Continuity of care is crucial to addressing perinatal mental health
Perinatal mental illness affects many new and expectant mothers, and if left untreated, can have a devastating impact on women and their families. 'Perinatal' covers the period of time from when you become pregnant, to up to a year after giving birth.
A wider campaign by Healthwatch England found that when mothers and birthing parents were asked what they would like to see improved in perinatal care and what could have helped their mental health, many said 'continuity in care'.
Mothers are more likely to have positive experiences when there was a continuity of care in place, ensuring mothers felt sufficiently supported and that any changes in their health or mental health may be picked up on. Unfortunately, not everyone experiences it. We spoke to five mothers who had given birth since April 2020 and had experienced a mental health issue prior to becoming pregnant.
What local mothers told us about continuity of care
"Having a midwife that you know and that’s followed you from a tiny little bean to a full baby helps with that. Having the same health visitor helps with that because you can let those walls down a little bit. It doesn’t matter if they see you crumble because they’ve seen you stand tall I guess. So that’s the difference of when you have constant care."
"It was different ones [midwives] every single time, which I was quite surprised about because every one tells you that you have one and you get to know them, but it was a different one every time."
Maternal suicides continue to be the leading cause of direct deaths occurring between six weeks and one year after the end of pregnancy. Two of the mothers we spoke to were Black. Black mothers continue to have the highest maternal mortality rates, and between 2018 and 2020, were 3.7 times more likely to die giving birth than white women.
The continuity of care model is important for those from Black communities. For Black mothers and birthers every interaction with a healthcare professional comes with a risk that your racialised identity will be a defining factor in your care. Anything that facilitates midwives and mothers and birthers to build a relationship based on individual needs will reduce risk and improve patient safety.
Why continuity of care matters
Continuity models of care have been shown time and again to provide emotional, psychological, and social safety for pregnant people and their partners. The Cochrane review found that midwife-led continuity of care led to birthing parents being less likely to lose their baby in pregnancy or the month following birth and that they were less likely to experience preterm births.
A systematic review published in the magazine Midwifery earlier this year also concluded that there is preliminary evidence that continuity of care in midwifery can reduce and prevent anxiety and depression in pregnant women during the antenatal and perinatal periods.
A crucial benefit to receiving care continuously from the same place is that the care team is able to get to know the mother, her history and her individual needs. In turn, the mother builds trust with her carers, leading to the possibility of maintenance of good care throughout pregnancy, during labour and in the postnatal period. This is paramount, given the length of time a mother is in contact with maternal health services during so many different stages and types of care.
When mothers experienced this, it made a huge difference to their confidence. Yet continuity of care didn’t seem to be the norm, but rather the luck of the draw, putting extra pressure on new mothers’ health and wellbeing. The testimonies below are from our own interviews with mothers and interviews conducted by three other local Healthwatch.
Burden on new mothers
When continuity of care was lacking, often the only link between each appointment or healthcare professional was the mother herself. It became the responsibility of the individual to get the care they needed rather than that of the healthcare system. This requires the ability to advocate confidently for oneself – a skill which is not simple for everyone. We will discuss this specific issue in a later blog.
So I had sort of standard midwife appointments, and each midwife I saw was different and which I kind of expected cause NHS you’re just not gonna get the same person, every single time, but there's downsides obviously to that and when you explain the same thing, over again. And then what I found was that each midwife kind of promised different things or didn't promise anything.
Having to repeat their history and needs to each new midwife became frustrating and a burden for mothers. As the mother below describes, someone already knowing this information takes pressure off them. They can then make the most of the healthcare that is being offered, as they are not re-hashing information that has already been shared.
"When you have to go through that every time with someone it can actually get quite draining and quite deflating. I found that having the same midwife alleviates that, because you might have that conversation once but you’re not going to have it every week and you can then build up a rapport." Interviewee
Labour stress
Not having the same midwife throughout meant that mothers sometimes experienced undue stress when it was time to give birth.
"Again it’s about that continuity - who you saw in labour you’re not going to see on the ward. So, they haven’t experienced what you’ve just been through so then you, who’s just given birth and been in labour for however long, has to kind of relay about it and how you’re feeling. Sometimes if you’ve just been in labour for, I think it was 13 hours let’s say, I didn’t want to have to say, 'This is how I’m feeling. I’m really shaken, I can’t really hold my baby very well.'" Interviewee
Mental health risks
When speaking to the new mothers it became clear that continuity of care can have a significant impact on maternal mental health by increasing the level of emotional support available. By contrast, a lack of continuity of care can significantly increase pressure on expectant and new mothers.
Mothers with pre-existing mental health problems reported being offered mental health support at the beginning of their pregnancy but not throughout and not during the postnatal period.
With me already having mental health issues - I do know at the time when I found out I was pregnant, they did say to me did I need additional support, but that was at the very beginning, and I was never offered it again.
One mother, who was on antidepressants, reported her mental health was flagged up, but only so that staff could look out for potential problems the baby might have as a result of the mother’s medication.
"I know how stretched the NHS is. And those midwife appointments, I'm sure they have loads of people to fit in per day, so it's not necessarily the individual that I'm frustrated at. It's the system and the process - it's flagged up in one sense for the health of the baby and the alarm, just in case the baby isn't okay when they're born - you know on my notes? So it's like a big 'ooh, this person's on antidepressants, we've got to double check stuff,' but it's not flagged up enough to double check with me that I'm okay. So yeah, I do feel like there was a lack of... support." Interviewee
For other mothers having continuity of care would have had a direct impact on their mental health care.
"I think what they could do to improve would just be to link to link all the services together, so that the midwife can contact the Mental Health team for you to make that jump because I don't even know I had some sort of strength to make that call but actually I can imagine that a lot of people wouldn't be able to pick up the phone and look like referral themselves." Interviewee
Lack of continuity of care during COVID-19
During the COVID-19 pandemic, the negative effects of a lack of continuity of care were exacerbated due to lockdown measures. This meant reduced staff availability and an overall reduction of maternity and mental health services. These measures had an impact on the continuity of care new mothers received during their postnatal period, as it affected the services health visitors were allowed to carry out.
We saw the health visitor once and then they were told they weren't allowed into people's houses because of COVID. So we didn't have any health visitors come to visit, we didn't have any contact from anyone.
Women also reported continuity of care suffered when it came to mental health support during COVID. Existing services were suddenly no longer allowed to continue appointments, leaving women without any support during a crucial time.
"I was told that I would have daily visits because of my mental health. And then they weren't allowed to do any home visits at all because of COVID. We were in full lockdown. So, it was literally just essential appointments only. Sorry, my voice is cracking." Interviewee
Policy context
The 2016 Better Births report of the National Maternity Review set out an ambition for every woman to have continuity of care – including a midwife and an identified obstetrician - throughout their pregnancy and birth. The 2019 NHS Long Term Plan also set out further ambitions to improve continuity of care for most mothers.
In 2021, all local maternity systems were asked to agree a local plan to roll out Midwifery Continuity of Carer (MCoC)for all women, with a target of making MCoC available to all women by March 2023.
However, in September 2022, NHS England removed the national target date for continuity of care in light of the unprecedented workforce challenges faced by maternity services.
While those trusts that were able to meet minimum staffing requirements across the service were encouraged to continue rolling out their MCoC plans, NHS England acknowledged that some Trusts did not have the staff resource to expand MCoC for all women.
The recent national Maternity Delivery Plan encourages trusts to continue to roll out MCoC where possible, in line with the principles around safe staffing set out in 2022. It also emphasises that the NHS approach to improving equity of maternal health outcomes involves prioritising delivery of continuity of carer for women from minority ethnic communities and the most deprived areas.
Healthwatch England's call to action - support for midwives and maternity workers
While it is positive to see the ambition to make MCoC the default model of care for all pregnant women, the delay in achieving this highlights the urgent need for a properly resourced national workforce plan. We need to address how education and retention of clinical staff will be improved in the coming years to ensure that there are enough staff to continue rolling out the commitments of the NHS Long Term Plan and the Maternity Delivery Plan.
NHS England should re-introduce a target date for the full roll-out of MCoC whenever staff levels make this realistic. In the meantime, midwives and maternity support workers should be supported to deliver continuity of care where possible and personalised care for all women through appropriate tools and guidance, including issuing the revised Continuity of Carer Deployment Tool as soon as possible.
