Better Births and Continuity: Midwife Survey Results

Transcription

1 INSTITUTE OF APPLIED HEALTH RESEARCH Better Births and Continuity: Midwife Survey Results Beck Taylor Fiona Cross-Sudworth Christine MacArthur February 2018

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3 Table of contents Executive summary 4 1. Introduction 9 2. Method 9 3. Findings Participant characteristics Demographics Midwifery experience Current working hours Current patterns of work Current experience of intrapartum care Current caring responsibilities Midwives views on different ways of working: Quantitative findings Specific models of care Working in different settings Working across different organisations Different patterns of work Midwives views on different ways of working: Qualitative findings Barriers to changing the way midwives work: qualitative findings What would help midwives to work differently: qualitative findings Summary Recommendations Conclusion Acknowledgements About the authors References 46

4 4 Better Births and Continuity: Midwife Survey Results Executive summary About the survey In 2016 the National Maternity Review, Better Births, recommended that women have a named midwife, based in the community, who can provide continuity of care throughout pregnancy, birth and postnatal periods. 1 The 44 Local Maternity Systems (LMSs) across England are tasked with implementation of the Better Births recommendations, including continuity of care, by 2020/21. NHS England has provided detailed guidance to support this work, 2 which highlights the importance of engaging midwives in the development of continuity models. To explore midwives perspectives of different ways of working, and to inform implementation process, researchers at the University of Birmingham conducted an online survey of midwives in October midwives working across all seven NHS Maternity Early Adopter LMS sites 3 took part. Key findings (of all midwives who completed the survey): Continuity models: 35% Caseloading 53% 24% 32% 42% Team 35% of midwives were willing to work in a continuitybased model that included intrapartum care across all settings (either caseloading and/or team midwifery). 24% were willing to work in a caseloading model with intrapartum care across all settings, 53% were not. 32% were willing to work in a team midwifery model providing intrapartum care across all settings, 42% were not. Working Patterns: 83% 41% 24% 31% 12h 83% of midwives worked some unsocial hours (outside of Monday to Friday office hours). 41% stated that they were unable to work a different pattern to their current role. 24% said that they needed to work the same days each week. 31% currently worked 12 hour shifts only.

5 Better Births and Continuity: Midwife Survey Results 5 Night/On-Call Working: 37% 37% 48% 37% of midwives currently worked on-calls from home during unsociable hours. 37% reported that they would be unable to work any on-calls and/or nights. Two to four nights on-call per month was the most preferable frequency (48% of all midwives). Intrapartum Care: 88% 50% 88% had attended a birth in the past year. 50% reported being confident to attend a home birth as the primary carer. Working Across Settings: 47%? 53% 59% 19% 47% stated that they would be willing to work across settings. 53% reported that they did not have clinical confidence to work across settings (19% lacked confidence to work in the obstetric unit). 59% reported that they needed to update their clinical skills to work across settings.

6 6 Better Births and Continuity: Midwife Survey Results Barriers to changing the way midwives work Many midwives expressed concern about how their role might change, while a smaller number welcomed continuity based working. The barriers and facilitators to change are listed in the table below. Barriers to changing the way midwives work Practical barriers Caring responsibilities (64% had caring responsibilities, 46% for children) Transport issues Responsibilities elsewhere (eg, other midwifery roles, volunteering) Health conditions Wellbeing and work-life balance concerns Personal preference for particular ways of working Quality and safety concerns What would help midwives to work differently Concessions in how midwife roles are organised Adequate staffing to cover the work Financial/practical incentives: enhanced pay, assistance with travel Induction, support, training, and development Good leadership, management and organisation Continuity and quality as an incentive A change in midwifery culture Conclusion Recent policy and research has shown that women, NHS England, and the Royal College of Midwives welcome the focus on continuity of carer. 1 However, many midwives report barriers to being able to change the way they work to make continuity happen. Findings indicate that there may be a gap between the number of midwives required to deliver continuity plans, and the number willing or able to do so. In addition, midwives expressed concerns about what the change means for them in practice. Recommendations from the survey provide evidence to support many of the issues identified in NHS England s recent Continuity of Carer implementation guidance. 2 It is essential that NHS England and Local Maternity Systems listen to and address midwives concerns about the changes, evaluate the safety of midwives working across settings at scale, and evaluate the impact of the changes on midwives. In order to succeed midwives will need to support the plans. Midwives will also need support to change, and to sustain new ways of working while maintaining their own well-being. Many midwives expressed concern about how their role might change, while a smaller number welcomed continuity based working.

7 Better Births and Continuity: Midwife Survey Results 7 Summary of recommendations: For policymakers and NHS leaders: 1. Recognise that implementation of continuity models of care for all women is unlikely. 2. Prioritise continuity models for women with the greatest ability to benefit. 3. Encourage and support piloting and sharing of evidence. 4. Monitor the impact of continuity based models on quality and safety. 5. Monitor the impact of continuity based models on the workforce. 6. Support providers and current and future midwives to address the barriers to implementing continuity models. For Local Maternity System Leaders: 7. Work with your midwives to establish who is willing and able to adopt continuity based models. Team midwifery may be more acceptable than caseloading models. 8. Prioritise continuity models for women with the greatest ability to benefit. 9. Pilot and evaluate new models to test safety and unforeseen effects, and to show that models can work at scale for most midwives. 10. Listen to, acknowledge, and address your midwives concerns. 11. Ensure staffing is adequate to support models implemented. 12. Provide training, clinical and change management support. 13. Address practical barriers, though for some midwives they are likely to be insurmountable. 14. Consider making concessions in midwives working practices and rewards for those working in new models. For midwives: 15. Get involved with local activities to design, pilot and implement a model of care that delivers continuity of carer. 16. Get involved with national discussions regarding what is expected of midwives in terms of working patterns, being with woman, and work life balance.

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9 Better Births and Continuity: Midwife Survey Results 1. Introduction The 2016 National Maternity Review, Better Births 1 sets out the vision to improve quality, safety and efficiency of maternity services. NHS England highlights that, At the heart of this vision is the idea that women should have continuity of the person looking after them during their maternity journey, before, during and after the birth. 2 This means that the majority of a woman s care, including intrapartum care, should be provided by the same midwife, regardless of whether care is based in the community or hospital. Team and caseloading models of care are the primary routes by which NHS England envisage continuity will be delivered. Caseloading is defined as where each midwife is allocated a certain number of women (the caseload) and arranges their working life around the needs of the caseload, and team midwifery is defined as where each woman has an individual midwife, who is responsible for co-ordinating her care, and who works in a team of four to eight... This allows for protected time, during which the other members of the team will provide unscheduled care, and the lead midwife will not be called upon. 2 Implementing continuity models at scale will require significant changes to working patterns for the midwife workforce, and while maternity leaders welcome the plans, they have acknowledged the challenge.3 It is vital that the frontline midwife workforce is engaged in, and supports the change, and is able to adopt different models of care where required. This study was designed with midwives, and in collaboration with the Royal College of Midwives, to explore current working patterns, and perspectives on different ways of working. There are 44 Local Maternity Systems in England who must implement the Better Births recommendations by This study was undertaken in the seven Local Maternity System sites in England with Early Adopter status, tasked with implementing some or all recommendations by the end of Method In October 2017 the research team conducted an anonymous online survey of the midwife workforce working in Better Births Early Adopter sites in England. The survey included 49 questions, exploring midwife demographics, experience, current working practices and views on different ways of working. There were 33 quantitative questions and 16 qualitative questions. A peer-reviewed academic publication will follow on from this report which will describe the methods in detail. Research Questions 1. Where and how do midwives across Early Adopter sites work? 2. What settings and working patterns are in place at the present time? 3. Where and how would the current midwife workforce in Early Adopter sites be able or willing to work? All NHS midwives working in Early Adopter sites were eligible to take part, and were informed about the survey by manager, posters, and via social media. One of the 27 hospital trusts in Early Adopter sites declined to actively promote the survey. Electronic data from the online survey for women was collected via a secure survey hosting company, Typeform. Descriptive statistics were calculated for quantitative survey responses. Qualitative free text responses were analysed thematically. 9

10 10 Better Births and Continuity: Midwife Survey Results 3. Findings 798 midwives participated in the survey. Some sites did not confirm their total number of employed midwives, but using submitted headcounts, and Royal College of Midwives national headcount data, we estimate that there were around 4000 midwives eligible to take part. Therefore the estimated response rate is approximately 20%. Most midwives provided free text comments (78%, n=620). In this section findings are presented as follows: Participant characteristics Demographics Midwifery experience Hours worked Patterns of work Intrapartum care experience, including continuity models of care Current caring responsibilities Midwives views about working in different ways Working in different settings Working across organisations Working different patterns 3.1 Participant characteristics Demographics Basic demographic information was requested in the survey: place of work (see figure 1), age of midwives (see figure 2), length of time since qualifying as a midwife (see figure 3) and current grade (see figure 4). The highest numbers of responses was from midwives working in Cheshire (23%, n=184) and Birmingham and Solihull United Maternity Partnership (22%, n=174). 6 midwives worked across 2 Early Adopter sites: BUMP, Cheshire, London and Surrey. The most common age of midwives was between 50 and 59 years (31%, n=245) which is representative of the English midwifery workforce 4 (33% aged over 50). 60% (n=480) were older than 39 years. 15% (n=118) were aged in their 20s. 56% (n=449) of the midwives had been qualified for more than 10 years. Most midwives were band 6 (66%, n=523). Figure 1: Current location/s of work EARLY ADOPTER SITE WHERE WORKED Cheshire and Merseyside % Birmingham and Solihull United Maternity and Newborn Partnership North Central London % 22% Dorset % Somerset 92 12% Surrey 67 8% Total responses: 804. Total responders: 798. Number is higher than 798 (participants were able to choose more than one answer.) North West London 45 6% NUMBER OF MIDWIVES

11 Better Births and Continuity: Midwife Survey Results years 15% (n=118) years 25% (n=197) years 26% (n=205) >60 4% (n=30) Figure 2: Age years 31% (n=245) NUMBER OF MIDWIVES Figure 3: Length of midwifery career Prefer not to say 1% (n=4) 0 5 years 24% (n=193) >10 years 56% (n=449) 5 10 years 19% (n=152) Band 9 0% (n=1) 0 Band 7 25% (n=201) Band 6 66% (n=523) NUMBER OF MIDWIVES Prefer not to say 1% (n=8) Band 8 5% (n=40) Band 5 3% (n=25) Figure 4: Seniority

12 12 Better Births and Continuity: Midwife Survey Results Midwifery Experience Midwives were asked about current (see figures 5, 6 and 7) and previous places of work (see figure 8 and table 1). The most frequently identified current place of work was community (36%, n=286), followed by the Obstetric Unit (OU) (34%, n=268). In the past year 56% (n=449) of midwives had worked in the OU, and 36% (n=287) in the community. When midwives were asked where they had spent most of the past five years working, the most frequent response was the obstetric unit (40%, n=321) followed by community (36%, n=291). 10% (n=81) of midwives currently worked in a home birth setting (ie attended women in labour at home as part of their job, not necessarily as part of a specific home birth team), and 30% (n=239) had worked in a home birth setting in the past year. 32% (n=255) of midwives from this sample worked in more than one setting. 44% (n=97) of those currently working in the community also worked in other settings. 24% (n=70) of those who reported working in community reported also working in home birth. 28% (n=81/286) of midwives working in the community were also working in intrapartum care in the hospital setting (ie OU, AMU, MLU). Most midwives had never worked in scanning (93%, n=739). 21% (n=165) of midwives had never worked in community and 34% (n=271) had never worked in a home birth setting. Figure 5: Settings in which midwives currently worked CURRENT SETTINGS WORKED Community Obstetric Unit (OU) Postnatal ward Alongside Midwifery Led Unit (AMLU) Antenatal ward Specialist Rotational/integrated Home birth Antenatal clinic Freestanding Midwifery Led Unit (FMLU) Other Scanning Prefer not to say % % % % % % 89 11% 81 10% 73 9% 39 5% 31 4% 7 1% 5 1% NUMBER OF MIDWIVES Total responses: Number is higher than 798 as participants were able to choose more than one answer. % for each setting provided as a % of all 798 participants.

13 Better Births and Continuity: Midwife Survey Results 13 Figure 6: Number of settings midwives currently worked in 6 1% (n=4) 7 1% (n=4) 8 1% (n=4) 9 0% (n=1) 1 68% (n=543) 2 14% (n= 112) 3 8% (n=67) 4 5% (n=43) 5 3% (n=20) Figure 7: Other settings worked for midwives who work in the community The following chart describes whether midwives working in the community were also providing care elsewhere, to understand how many midwives are already working across hospital and community, and how many of those working in the community are providing home birth care. ADDITIONAL SETTING WORKED Community only Home birth AMLU OU Antenatal clinic FMLU % 70 24% 41 14% 38 13% 25 9% 26 9% Postnatal ward Rotational/integrated % 9% Antenatal ward 16 6% Specialist Other Scanning 11 4% 6 2% 2 1% Total responses: 435. % calculated as % of the 286 midwives who worked in the community. Total responses higher than 286 as participants were able to choose more than one option.

14 14 Better Births and Continuity: Midwife Survey Results Figure 8: Where midwives spent most of their recent career (past five years) SETTING MOST TIME SPENT OU % Community % Postnatal ward % Antenatal ward Rotational/integrated AMLU FMLU Specialist % 12% 11% 11% 10% Home birth 60 8% Antenatal clinic 50 6% Other 18 2% Scanning 3 0% Table 1: Time since midwives worked in different settings Settings ever worked in In the past year 1 5 years ago 6 10 years ago More than 10 yrs Never Prefer not to say No. % No. % No. % No. % No. % No. % OU Postnatal ward Antenatal ward Community AMLU Home birth Antenatal clinic Rotational /integrated Specialist FMLU Scanning Total responses* *Number is higher than respondents: 798. Participants were able to choose more than one answer. % calculated as % of all 798 participating midwives.

15 Better Births and Continuity: Midwife Survey Results Current working hours Midwives were asked questions about their contracted hours of work (see figure 9) as well as the additional hours worked both paid (see figure 10) and unpaid (see figure 11). 52% (n=415) of midwives worked full-time and 48% (n=382) were part-time. 53% (n=422) of midwives did not work any additional paid hours. 10% (n=74) worked for more than 10 additional paid hours per week. 63% (n=503) worked on average between 1 and 4 unpaid hours extra each week. Figure 9: Contracted working hours Other 1% (n=12) Prefer not to say 0% (n=1) 37.5 hours 52% (n=415) 16 to less than 37.5 hours 44% (n=350) 0 15 hours 3% (n=20) Figure 10: Additional paid hours worked per week 20 1% (n=7) Prefer not to say 2% (n=14) None 53% (n=422) % (n=131) % (n=90) % (n=54) % (n=13) Occasional 8% (N=67) Figure 11: Estimated unpaid hours worked per week Prefer not to say 2% (n=13) <1 14% (n=110) % (n=243) % (n=260) % (n=127) >10 6% (n=45)

16 16 Better Births and Continuity: Midwife Survey Results Current patterns of work Midwives were asked about times of work (see figure 12) and length of shifts (see figure 13) as well as normal patterns of work (see figure 14). 83% (n=659) of midwives worked some unsocial hours (outside of Monday to Friday office hours). 37% (n=295) of midwives worked on-calls from home during unsociable hours. 63% (n=591) of midwives worked shifts of more than 8 hours while 35% (n=331) worked 8 hour shifts. 31% (n=246) only worked 12 hour shifts. 75% (n=596) of midwives worked a varied set of shifts each week. Figure 12: Current days/nights worked TIME OF WORK Weekday daytime Weekend/bank holiday daytime Weekend nights in hospital Weekday nights in hospital Night time on call from home Weekend days on call from home Bank holiday days on call from home Other Prefer not to say 34 4% 8 1% % % % % % % % Total responses: Number is higher than 798 as participants were able to choose more than one answer. % calculated as % of the total sample of 798. Figure 13: Current length of shifts LENGTH OF SHIFTS WORKED 8 or less 9 11 hours 12 or more hours % % % Other Prefer not to say 27 3% 0% Total responses: 950. Number is higher than 798 as participants were able to choose more than one answer. % calculated as % of the total sample of 798. Figure 14: Shift pattern PATTERN OF SHIFTS On a rota (varied shifts) Same shifts every week Other 56 7% % % Prefer not to say 5 1%

17 Better Births and Continuity: Midwife Survey Results Current experience of intrapartum care In order to understand current levels of experience in intrapartum care, midwives were asked about the number of intrapartum episodes attended in the past year (see tables 2 and 3). They were also specifically asked about their involvement in caseloading and team midwifery models of intrapartum care. n n n The majority (88%, n=704) of midwives had attended a birth in the past year. 44% (n=352) of midwives had provided intrapartum care for more than 20 births, and 27% (n=219) more than 50 births (more than one per week). Midwives working in the community only had most frequently attended between 1 and 10 births in the last year (68%, n=124). 11% (n=89) had not attended any births in the past year. 24% (n=195) of midwives reported that they worked in caseloading and/or team continuity models of care (16%, n=131 in team midwifery and 15%, n=119 in caseloading models). 7% (n=14) of these had NOT attended any births, 43% (n=84) had attended up to 10 births in the past year and 49% (n=96) had attended more than 10.While definitions of the models were provided in the survey, there may have been some confusion about the definition of team and caseloading models of care. On-call working was only reported by 60% (n=78) of those who said they worked in team midwifery models, though 70% (n=83) of the caseloading midwives reported doing so. Table 2: Number of births attended in past year Number of intrapartum episodes attended All places of work midwives Team and/or caseloading midwives No. % No. % None More than Prefer not to say Total

18 18 Better Births and Continuity: Midwife Survey Results Table 3: Intrapartum care episodes in the past year for midwives in different places of work Number of births attended in the past year Place of work Prefer not to say TOTAL f % f % f % f % f % f % f % f % Community Obstetric unit/ delivery suite Rotational/integrated midwife Specialist midwife Midwife-led alongside unit Postnatal ward Antenatal clinic Antenatal ward Home birth Midwife-led freestanding unit Scanning Other Total responses Table 4: Intrapartum care episodes in the past year for midwives in who work in more than one setting Number of births attended in the past year Place of work Prefer not to say TOTAL f % f % f % f % f % f % f % f % Community midwives who also work elsewhere CMW and home births only Intrapartum care eg, Obstetric unit, AMLU, FMLU Ward/Clinic based Total responses

19 Better Births and Continuity: Midwife Survey Results Current Caring Responsibilities Midwives were asked about their current caring responsibilities (see figure 15) and the support structures that enabled flexible working patterns (see figure 16). 64% (n=512) of midwives reported caring responsibilities of some sort. 46% (n=371) of midwives reported primary responsibility for children. Some midwives had more than one group of dependents: 8% (n=60) had caring responsibilities for both children and either grandchildren or adult relatives. 34% (n=286) reported no caring responsibilities. The majority of midwives utilised friends and family (52%, n=264) to support flexible working patterns. 33% (n=168) worked part-time in order to fulfil caring responsibilities. Figure 15: Caring responsibilities CARING RESPONSIBILITIES Children < % No caring responsibilities % Adult relatives % Grandchildren (not primary carer) 69 9% Other 12 2% Prefer not to say 10 1% Total responses: 889. Total responders: 512 (some midwives had more than one caring responsibility). % calculated as % of all 798 midwives in the survey. Figure 16: Sources of support for those with caring responsibilities SUPPORT TO ENABLE FLEXIBLE WORKING Relatives/friends % Part time Swapping shifts Knowing in advance Annual leave requests Flexible hours Other paid childcare % % % % % 93 18% Paid adult care Extra pay Employer childcare Other Prefer not to say 16 3% 7 1% 4 1% 33 6% 16 3% Total responses: Total responders: 512 (some midwives had more than one caring responsibility.)

20 Better Births and Continuity: Midwife Survey Results 3.2 Midwives views on different ways of working: Quantitative findings Midwives were asked to share their perspectives regarding different ways of working. The questions covered a range of models of care. However, in recognition of the complexity of this area, for example team midwifery can be implemented using different working patterns, midwives were also asked more specific questions about the possibility and acceptability of working in different maternity settings, organisations, and shift patterns Specific models of Care Midwives were presented with a list of models of care, including continuity based models, and asked which would be acceptable to them (see figures 17, 18 and 19). It is acknowledged that this is a complex area. The research team worked with the Royal College of Midwives, midwife leaders and frontline midwives to develop a comprehensive list of models of care that reflects how midwives work now, and may work in the future, and the list was accompanied by definitions of the terms caseloading and team midwifery. Key quantitative findings are presented below: n 35% (n=279) of midwives were willing to work in caseloading 35% of midwives were willing to work in caseloading and/ or team midwifery models that included intrapartum care across all settings. 20 n n n n and/or team midwifery models that included intrapartum care across all settings (24%, n= 190 caseloading, 32% n=253 team). 45% (n=359) were willing to work in a model which provides intrapartum care for home births. 40% (n=317) were willing to support home births as part of a community caseloading model, 37% (n=294) in a community team midwifery model, and 40% as a midwife based in a midwife-led unit (n=318). 53% (n=422) did not want to work in caseloading model with intrapartum care in any setting while 42% (n=337) did not want to work in a team midwifery model providing intrapartum care in any setting. 53% (n=426) were willing to work in the community models without intrapartum care (48%, n=380 caseloading, and 46%, n=370 team). The least popular roles were ward and hospital clinic work, rotational posts, scanning, and managerial posts which involved the hospital: antenatal ward work only (70%, n=556), antenatal clinic only (68%, n=539), antenatal and postnatal ward (64%, n=512), rotation (hospital based [50%, n=401] or hospital and community based [52%, n=417]), scanning (61%, n=483) and managerial roles (hospital based [56%, n=449] or mixed hospital and community managerial role [62%, n=492]).

21 Better Births and Continuity: Midwife Survey Results 21 Figure 17: Willingness to work in continuity models Caseloading &/ or team 3% 30% 35% 53% CONTINUNITY MODELS WITH INTRAPARTUM CARE IN ALL SETTINGS Team 2% 24% 32% 42% Caseloading 2% 24% 21% 53% Caseloading &/ or team 3% 28% 45% 46% CONTINUNITY MODELS WITH HOME BIRTH ONLY Team 1% 21% 37% 40% Caseloading 2% 21% 37% 40% Caseloading &/ or team 3% 24% 39% 53% CONTINUNITY MODELS WITH NO INTRAPARTUM CARE Team 2% 18% 34% 46% Caseloading 2% 17% 33% 48% NUMBER OF MIDWIVES Yes Caseloading and/or Team percentage total is greater than 100 as midwives could choose more than one option Maybe No Prefer not to say

22 22 Better Births and Continuity: Midwife Survey Results Figure 18: Willingness to work in hospital and rotational intrapartum roles AMLU and home birth 2% 26% 32% 40% Yes Maybe Obstetric unit only 1% 15% 34% 50% No Prefer not to say AMLU only 1% 26% 36% 37% FMLU only 2% 25% 25% 49% Any MLU 2% 28% 33% 38% Intrapartum and ward work acrross all hospital settings 1% 18% 33% 48% Rotational/integrated hospital and community 2% 19% 27% 52% Rotational/integrated hospital only 1% 19% 30% 50% NUMBER OF MIDWIVES

23 Better Births and Continuity: Midwife Survey Results 23 Figure 19: Willingness to work in other managerial, and non-intrapartum hospital roles Mixed hospital and community managerial role 1% 17% 20% 62% Yes Maybe Community managerial role 2% 19% 31% 49% No Prefer not to say Hospital based management role 1% 16% 26% 56% Scanning 2% 17% 21% 61% Postnatal and antenatal ward only 1% 17% 18% 64% Antenatal ward work only 1% 14% 15% 70% Antenatal clinic work only 1% 17% 15% 68% NUMBER OF MIDWIVES

24 24 Better Births and Continuity: Midwife Survey Results Working in different settings Midwives were asked about general willingness, ability and attitude to working in different settings (see figures 20,21,22,23 and 24). n n 26% (n=208) reported that they already worked across different settings (by definition willing to do so), and a further 21% (n=164 stated that they would be willing to work across settings. 34% (n=269) stated that they would not be willing to work across different settings. Midwives who were willing to work across settings were then asked about specific settings they would, or would not be willing to work in. The most popular settings were alongside midwifery unit (52%, n=417), community (47%, n=374), home birth (41%, n=324), obstetric unit (39%, n=311) and antenatal ward (39%, n=309). n n n 41% (n=324) would be prepared to work in a homebirth setting. 52% (n=417) agreed with the statement I enjoy working where I am now and do not want to move. 57% (n=462) agreed with the statement I have specific knowledge/skills in the area I work and I want to continue focusing on this area. 99% (n=791) disagreed with the statement I would work across all settings. Prefer not to say 1% (n=5) Figure 20: Willing to work across different settings No 34% (n=269) 0 Maybe 19% (n=152) 200 I don t currently, but yes, willing to do so 21% (n=164) 400 NUMBER OF MIDWIVES Yes, I already do 26% (n=208)

25 Better Births and Continuity: Midwife Survey Results 25 Figure 21: Midwives willing to work across settings by number of years qualified YEARS QUALIFIED /193 61% /152 43% > /449 42% Prefer not to say 2/4 50% NUMBER OF MIDWIVES Percentage labels indicate the proportion of midwives in each years qualified group who were willing to work across settings. Figure 22: Midwives willing to work across settings by age AGE /118 60% /197 49% /205 44% /245 41% 60+ Prefer not to say 12/30 1/3 33% 40% NUMBER OF MIDWIVES Percentage labels indicate the proportion of midwives in each age band who were willing to work across settings.

26 26 Better Births and Continuity: Midwife Survey Results Figure 23: Settings where midwives would be willing to work SETTINGS MIDWIVES WOULD WORK IN AMLU 8% 52% Yes Community 12% 47% Maybe Home birth 13% 41% OU 10% 39% Antenatal ward 10% 39% Postnatal ward 10% 37% FMLU 10% 36% Specialist 13% 34% Antenatal clinic 12% 33% Scanning 13% 17% Managerial 12% 24% Figure 24: Attitude to working in different settings ATTITUDE TO STAYING/ CHANGING SETTING OF WORK Did not answer 1% (n=7) I would work across all different settings Disagree 63% (n=505) Partly disagree 36% (n=286) Disagree 2% (n=15) I enjoy working where I am now and don t want to move Partly disagree 4% (n=32) Do not agree or disagree 4% (n=32) Partly agree 11% (n=90) Agree 41% (n=327) Did not answer 38% (n=302) I have specific knowledge/skills in the area I work and I want to continue focusing on this area Disagree 1% (n=5) Partly disagree 2% (n=12) Do not agree or dusagree 4% (n=28) Partly agree 14% (n=115) Agree 43% (n=347) Did not answer 36% (n=291)

27 Better Births and Continuity: Midwife Survey Results 27 Community work and home birth care Midwives were asked about confidence to attend home births (see figure 25) as well as confidence to run community clinics. Willingness to be responsible at home births was also assessed according to current place of work (see figure 26). 13% (n=107) of midwives did not feel confident to attend a home birth, and 10% (n=83) maybe felt confident. 50% (n=402) were confident to be first, or first and second midwife, 24% (n=188) were confident to be second midwife only. Confidence was highest in midwives who worked in the community currently. 70% (n=555) reported feeling confident to run their own community work and clinics. 62% (n=491) of midwives thought that there were specific things that would help improve confidence to attend home births with 36% (n=288) identifying shadowing opportunities, and 25% (n=203) suggesting that training and update sessions would help. Suggested activities to improve confidence to run community work were supernumerary shadowing (16%, n=128) and training/update sessions (8%, n=60). Figure 25: Confidence in attending home births MIDWIVES FELT CONFIDENT TO ATTEND HOME BIRTHS First/first and second midwife Second midwife only Maybe No % % 83 10% % Total responders: 780. % presented as % of 780 responding midwives Figure 26: Willingness to be responsible (first midwife) at a home birth for midwives working in different settings PLACE OF WORK Community % Obstetric unit/ delivery suite % Home birth 72 89% Midwife-led alongside unit 68 60% Postnatal ward 52 39% Specialist midwife Rotational/ integrated midwife Antenatal clinic Midwife-led freestanding unit Antenatal ward % 43% 49% 85% 31% Other 12 39% NB some midwives selected more than 1 category

28 28 Better Births and Continuity: Midwife Survey Results Barriers to working across settings Factors influencing ability and attitude to working across settings are explored in this section. Midwives were asked if they needed to update clinical skills and whether they believed that they had the clinical confidence to work elsewhere (see figure 27). Midwives were also asked if there were able to, or wanted to work different shift patterns, and about any settings in which they did not wish to work due to a different working environment/culture. Many midwives did not want to work in one or more setting for a variety of reasons: 53% (n=420) reported that they did not have the clinical confidence, 59% (n=467) needed to update their clinical skills, 54% (n=427) did not wish to work in the working environment or culture. 50% (n=401) did not want to work the shift pattern, and slightly fewer 41% (n=325) reported being unable (distinct from unwilling) to work the shift pattern in one or more settings. Of all settings, barriers were most frequently reported to working in the obstetric unit, with 35% (n=277) of the midwives identifying one or more barrier. 27% (n=215) did not like the culture, 25% (n=201) considered that they would need to update skills in order to work there, 24% (n=193) did not want to work the shift pattern, 17% (n=134) were unable to work the shift pattern, and 19% (n=148) stated that they did not have the confidence to work there. 17% (n=132) reported that they were unable to work the shift pattern in community and 22% (n=179) felt that they would need to update skills to work in community. 16% (n=126) considered that they were unable to work the shift pattern to provide home birth, and 13% (n=107) of midwives expressed a lack of confidence to work in a home birth setting. Figure 27: Barriers to working in different settings KEY Need to update my skills RESPONDERS: 467 RESPONSES: 1542 Lack of clinical confidence RESPONDERS: 420 RESPONSES: 672 Inability to work the hours/ shift pattern required RESPONDERS: 325 RESPONSES: 2205 Don t want to work the current hours/shift pattern required RESPONDERS: 401 RESPONSES: 1344 Don t wish to work the working environment/culture RESPONDERS: 427 RESPONSES: 1281 Total response figures are higher than numbers of participants as participants were able to choose more than one answer SETTINGS Obstetric unit/ delivery suite Community Antenatal clinic Home birth Antenatal ward Midwife-led freestanding unit Postnatal ward Midwife-led alongside unit 25% 19% 17% 24% 27% 22% 10% 17% 21% 18% 23% 10% 10% 16% 18% 19% 13% 16% 21% 15% 17% 8% 12% 19% 19% 16% 11% 11% 16% 15% 15% 5% 12% 19% 22% 12% 5% 11% 17% 11% Scanning Other Declined to answer 10% 14% 15% 2% 2% 3% 2% 1% 41% 47% 59% 50% 46% NUMBER OF MIDWIVES

29 Better Births and Continuity: Midwife Survey Results 29 Facilitators to cross-setting working Midwives were asked what factors would help them to work in other settings (see figure 28). Shadowing opportunities was the most popular practical way of increasing confidence to work in other settings (52%, n=415). Figure 28: Measures to facilitate cross-setting working THINGS THAT WOULD HELP MIDWIVES TO WORK ELSEWHERE Shadowing opportunities (supernumerary) More flexibility to organise my work/diary Training/update sessions (teaching rather than work experience) Different hours/ shift patterns % % % % Prefer not to say 89 11% Other 53 7% Working across different organisations Midwives were asked whether they would be willing to work across different organisations, specifically different hospital trusts (see figure 29). This question addresses the fact that Local Maternity Systems usually involve more than one hospital trust working together to deliver maternity care across boundaries. 50% (n=396) of midwives stated that they did not want to work across different organisations. Figure 29: Willingness to work across different hospital trusts WILLING TO WORK ACROSS ORGANISATIONS No % Maybe % Yes %

30 30 Better Births and Continuity: Midwife Survey Results Different patterns of work Midwives were asked about availability for work days, patterns of work, and if there was a need to work specific days of the week (see figure 30, 31 and 32). n n n 15% (n=122) of midwives were able to work all of the 6 different types of working times listed. The majority of midwives were able to work in the daytime (88%, n=702) and at weekend/bank holidays (70%, n=562). Fewer midwives were available to work on-calls at night (36%, n=285) than night shifts during weekdays (42%, n=334) or at weekends (40%, n=323). 25% (n=203) said that it was possible but that they didn t want to work on-calls from home at night. 26% (n=205) stated that it was not possible for them to work night shifts in the hospital on weekdays, and 23% (n=184) at the weekend. n n n n Figure 30: Midwives reported need to work on specific days of the week Prefer not to say 5% (n=40) Yes 24% (n=188) No 71% (n= 570) More midwives reported being able to work set shifts (70%, n=555) and rotas (69%, n=548) than annualised hours (caseloading 27%, n=219; team 34%, n=271). 24% (n=188) stated that they need to work on specific days of the week while 71% (n=570) did not need to. When asked how many night time on calls was acceptable, the most frequent response was 0 (31%, n=245). The median acceptable number of nights was 2. 37% reported that they would be unable to work any on-calls and/or nights.

31 Better Births and Continuity: Midwife Survey Results 31 Figure 31: Days and times available for work/ability to work different shift patterns 34% 13% 22% 28% 3% 3% 32% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Annualised hours as part of a team Annualised hours in caseloading model buddy system Rota Set shifts Night time on-call home Weekend nights in hospital Weekday nights in hospital Weekend/bank holiday days on call from home Weekend/bank holiday day time Weekday day time 23% 27% 14% 69% 0% 20% 8% 4% 70% 12% 11% 6% 2% 1% 25% 25% 13% 36% 2% 23% 26% 8% 40% 2% 26% 22% 42% 8% 3% 14% 25% 14% 43% 2% 4% 12% 12% 70% 1% 3% 3% 5% 88% KEY Not possible Prefer not to say Possible but don t want to Maybe in particular circumstances Yes SHIFT PATTERNS WORK DAYS AND TIMES

32 32 Better Births and Continuity: Midwife Survey Results Figure 32: Number of nights on call acceptable to midwives per month 0 31% (n=245) 1 11% (n=91) 2 26% (n=207) 3 8% (n=62) 4 14% (n=112) 6 2% (n=16) 5 2% (n=15) 7 1% (n=4) >7 4% (n=31) Prefer not to say 2% (n=15) Facilitators for different patterns of working Midwives were asked what would help them to work more flexibly on different days each week and during unsocial hours (see figure 33). There were 127 suggestions regarding what would help midwives to work on different days of the week, and far more (2337) suggestions for what would help them to work more nights, weekends and bank holidays. Measures to enable midwives to work more nights, weekends and bank holidays included knowing rota well in advance (56%, n=444), being able to swap shifts (51%, n=406), have flexible working (44%, n=354) and accommodate annual leave (43%, n=344). Figure 33: Facilitators of different ways of working Knowing well in advance when expected to work 24 3% % Ability to swap shifts 8 1% % Flexible working hours 0 0% % Ability to accommodate annual leave requirements 1 0% % Part time working 16 2% % Help with caring responsibilities from relatives/friends 31 4% % Fixed working hours 0 0% % Pay to assist with childcare 13 2% % Employer-provided childcare Other paid childcare Paid care for adult relatives Other 12 2% 80 10% 5 1% 61 8% 3 1% 40 5% 14 2% 49 6% Measures to facilitate working on different days each week Measures to facilitate working more nights/ weekends/ bank holidays NUMBER OF MIDWIVES

33

34 34 Better Births and Continuity: Midwife Survey Results 3.3 Midwives views on different ways of working: Qualitative findings Barriers to changing the way midwives work: qualitative findings In the qualitative free-text responses, the midwives described a range of challenges to working across settings, organisations, and in different patterns (shifts, days and hours). Responses referring to settings, organisations and patterns were analysed separately, then reviewed as a whole. The barriers to changing the way midwives work were organised into four cross-cutting themes: Practical barriers Wellbeing and work-life balance Personal preference Quality and safety concerns Over the following pages, examples are provided of quotes illustrating the different barriers. Often midwives reported several overlapping barriers in the same statement, such as the practical issue of caring responsibilities plus concern for personal wellbeing. I did enjoy being on call when I was younger, when I had no commitments and wasn t responsible for others. It was extremely fulfilling. Practical barriers to working differently Practical barriers are defined as relatively fixed circumstances in midwives lives which made working differently challenging. They included the following sub-themes: Caring responsibilities (for children, grandchildren and adult relatives) Transport issues Responsibilities elsewhere Health conditions Caring responsibilities Caring responsibilities were frequently reported as a barrier, particularly concerning children, but also adult relatives, and in a few cases pets. The need for predictability to accommodate carer responsibilities, and the inflexibility and cost of childcare were reported by a large number of midwives. A lack of local family support, partners who were shift workers, and being a single parent were further exacerbating factors. Because I have children, I wouldn t organise my childcare to end up not being called into work, and then have to reallocate more child free time to earn my wages. It is challenging enough to sort childcare for days I am definitely in. If I am allocated a shift, I sort childcare, turn up and get paid. If hospital midwifery became a on call role, I would leave the profession. I love my job but my family come first. Childcare responsibilities, if my children are expecting me to pick them up from school and I don t because I m called to a labouring woman, that would put them under stress. My husband works shifts also and we do not have a lot of family support. If I had varying days every week I would have to pay for all 5 days at the nursery and it wouldn t be worth me coming to work. I do not have family I can rely on. I have tried a childminder and nanny, however, I have to leave so early for shift that this is not possible. When working nights, I would have to have someone to sleep over in my house which just isn t possible on a regular basis. The profession does not accommodate single parent professionals with not a lot of family support. Nurseries are available at a significant cost to already stretched parents. Would LOVE!! to work [in continuity based models] in the future as is the ideal way I would like to practice and the care I want to be able to provide, however just not possible at present [due to childcare responsibilities]. I ve been there and done that [continuity based models] in the past. At this stage in my career, I want to work a rota system. I want stability as do my children. I did enjoy being on call when I was younger when I had no commitments and wasn t responsible for others. It was extremely fulfilling Having my rota completed three months in advance allows me to plan ahead, to ensure I have another adult in my house to oversee my teenagers and ensure their safety etc. (no all-night parties for example or the house being burnt down etc.)

35 Better Births and Continuity: Midwife Survey Results 35 My honest answer is nothing [would help me to work across organisations] - as I would if I could. Family commitments are not a luxury option, and as much as I love the job my elderly father has loved me longer- it s my responsibility to him. But that could change. I m no good to anyone if I have burnt the candle at both ends. As midwives we have to have insight into keeping ourselves physically, psychologically and emotionally well - to be excellent midwives. I have learned this the hard way. At one stage was trying to juggle care needs of elderly relative with dementia and special needs grandchild. Had to take early retirement from senior role to facilitate this. On call from home would be difficult as I live more than 30 minutes away. Transport issues Some participants also reported difficulties in travel arrangements to accommodate more flexible working patterns, including living too far away to cover on call, difficulties travelling at peak times, need to be close to children, not being able to drive, and concerns about driving after night working. On-call from home would be difficult as I live more than 30 mins away. I live 50 miles from work therefore I like the hospital environment and 12 hour shifts. Being in a location where I can quickly travel back to my children if an emergency rose would also be necessary, so moving from one location to another is not acceptable I believe midwives deserve [to] be able to plan in advance, without having to constantly stress about where they will have to travel. Some midwives may not own cars, and travelling from one side of [the city] to the other especially during rush hour is not feasible, and shouldn t be acceptable. This system being proposed will not work for the majority. I don t feel safe anymore to drive a car after so many hours. Responsibilities elsewhere In addition, many midwives had additional responsibilities elsewhere which limited their availability to work different days and hours, such as management of specialist clinical duties, volunteering, study, other roles elsewhere (specialist clinical or management), and bank midwifery shifts. I feel a couple of on-calls at night are ok but more than this is detrimental to my life away from my career (I do voluntary work). I chose my current specialist role to ensure that I could have more flexible working arrangements. When working fully clinically within the hospital there is no flexibility at all. I work bank to accommodate my children s needs. Work life balance. I like to live my life and enjoy activities outside work which enhance my effectiveness within work. I do not want to resent work. Health Conditions A smaller number of midwives described medical conditions, eg diabetes, musculoskeletal problems, or depression, which meant that they would find it hard to work in different settings, or in different patterns: I have done this [worked across settings] before and now due to medical reasons and age I no longer wish or feel I can work at my best in these areas. Many staff are now affected by medical problems/disabilities that affect their working conditions and environment. Unfortunately many staff are now unwell as a result of poor health that is or was contributed to by working conditions and hours. We have no protection on hours worked as a profession and it s ridiculous watching others health failing due to demands. I like to live my life and enjoy activities outside work which enhance my effectiveness within work I struggle with driving around in the community and night driving. You can t even park in the different work sites without a parking permit for each site.

36 36 Better Births and Continuity: Midwife Survey Results Wellbeing and work-life balance concerns Many midwives expressed concerns about personal wellbeing and stress, and work-life balance, with a small number stating that they would leave midwifery if asked to adopt particular ways of working. Continuity-based models, cross-setting working, cross-organisational working, and flexible and unsocial patterns of work were all described as impacting on midwives wellbeing and stress levels. I am not keen on caseload midwifery as I am aware that research has shown that there has been a high rate of burnout amongst midwives who work in this way. Some suggested that as they were getting older they were less suited to working across settings, organisations, or unsocial/flexible hours. I have worked many years in different areas but my body is ageing and I don t think I would manage the high pressure on a busy obstetric unit! As an older midwife I find working nights more difficult now, my sleep is already disrupted by menopausal symptoms! [I m] unfamiliar with other Trusts ethos, at my age I am not willing to change - I would find it stressful. Have been employed in [a continuity-based] model previously. Exhausting, demoralising, finically at a loss, never feel like a team, little communication. Difficult to achieve deadlines unless work, unpaid overtime! This [continuity based model] idea is wonderful for women that their midwife will follow them wherever they choose to birth. What about the impact on midwives? A service needs to be created to support women but it also has to support the midwives who care for the women. Midwives are already leaving the profession. A continuity model will no doubt see more midwives leaving or suffering from stress disorders due to no work/life balance. Colleagues who currently combine hospital with community settings seem to have little continuity with either and have a worse work life balance than I do. [Cross-setting working] makes many people who have worked in one area very uneasy and nervous. The same as a paediatrician wouldn t then do cardiac surgery or eye surgery. By doing this it makes many midwives myself included think of leaving. I will leave before I do shifts and labour ward again. I don t think it necessarily makes for a better service. You will just have more midwives go off sick with stress. Not knowing staff that you are working with [is difficult]. Difficult to establish bonding if constantly changing staff. Unfamiliar environments increase in stress. Each organisation has their own way of doing things. Expecting such flexibility from the staff I feel would result in a very unconfident workforce. Constantly on catch up, never feeling like you know what you re doing. If the women in our care deserve continuity, do the workforce not deserve some too? I have worked over 8 years doing nights, weekends, [bank] holidays and different shift patterns. I do not feel I am able to cope with the demands anymore during the nights and weekends, I need routine in my life. Shift work has affected my personal life, mental health and wellbeing. This idea is wonderful for women... what about the impact on midwives? Midwives also commented on the impact of different ways of working on their work life balance: Being able to provide continuity of carer during births is an incredibly rewarding experience and I would do it as much as possible. However, I deserve to have a life too and for that reason the current pattern I work of 4 nights on call a month is just insane. I do not want to work in a continuity of carer model as I value my work/life balance. I ve been qualified many years working in several different hospital and community settings, working all shift patterns including permanent nights for several years. I ve worked my way up to the specialist role I am in now and do not wish to return to shift work/on-calls. I do not want to be on call/work as part of a team of midwives who provide continuity of care. This may be perfect for the women but I am not sure how the midwives will withstand this. I feel that even with the buddy system, your working week would be all over the place [in a continuity-based model], and would still mean you had inconsistency in your week for childcare/planning etc. It s too difficult to juggle work and home life. I NEED routine and stability. I can and do work fully flexible but am finding it difficult to maintain a good work life balance and find the change in shifts due to short staffing is impacting on my health. For example: Night, night, sleep day, early, day off, night, night. [12 hour] shifts are popular as they have improved the work life balance for midwives.

37 Better Births and Continuity: Midwife Survey Results 37 Some midwives described work-life balance, and how they perceived that their needs were not adequately considered, and how they did not feel valued. Will midwives be expected to work according to the woman s needs with no regard for the midwives needs? As a practising midwife in the NHS I already work weekends, bank holidays including Easter, Christmas and New Year and also cover on calls often working all day then the majority of the night supporting home birth. I have done this for over 25 years sacrificing and missing out on numerous personal family moments to fulfil my role. I am now horrified that the service I have offered and sacrifices I and my family have made is now not enough... The service/clients expect more! I am now going to be required to be available to work community days with an increase in on calls, plus late, early, long days and night shifts at a variety of venues. I will be expected to work any one of the shifts with little control over when or where. There is no thought for the needs of the practitioner... I have never felt so worthless. For some midwives, there was a desire to separate private life and work, to be on or off duty. Do not want to work any on calls whatsoever. I m either at work or not and don t want a grey area in between that totally dominates my life I have seen this with colleagues and it would not be acceptable to me. Do not want to be available to women at all times, need time when I can be off and have a glass of wine etc. without worrying that I am going to be called. It s too difficult to juggle work and home life. I NEED routine and stability. Personal preference for particular ways of working Midwives reported how they liked where they currently worked and how they did not think they would enjoy working in other settings, sometimes following previous negative experiences. Personal preference was expressed for working in (or avoiding) different settings, organisations and shift patterns. Many simply expressed that they simply did not wish to work differently without providing a reason. Some provided further detail, describing liking where they worked or not liking the prospect of change. I think all midwives have a personal preference of where they would like to work based on their strengths and you will get the best out of the workforce if staff are working where they want to work. Naturally we are all better at different things and are able to perform better in those areas. I want to specialise in community care. I am not a clone, I do not want to rotate or work on labour ward. I would leave midwifery rather than work back in a hospital. It sounds awful to say this but I actually do not want to work anywhere other than a Labour Ward/ Birth centre environment. I have found my place in midwifery. I have, over the years, experienced and worked in all areas but enjoy working in this environment the most. Nothing [would encourage me to work at another trust]. I applied to work in my hospital for a reason. It s in a good area, the midwives are friendly and it s a short distance to home. I don t want to work in another organisation. Do not wish to work interchangeable shift patterns. Quality and safety concerns Some midwives reported concerns about quality and safety of care that may result from changing the way they work. The most commonly reported concern was a need to have setting-specific expertise, and not be a Jack of all trades working across settings. Midwifery has changed so much it is impossible to be a master in all areas; the different areas are so specialised. Even low risk midwifery encompasses areas that before were under medical care. You can t be an expert in all areas and all settings. You can t provide continuity of care in all settings. It s better for women and midwives if they provide the expert care they have to the women as much as they can when on duty or within a small team. However it s also safer for the women if other midwives provide expert care when required if that is there expert field. Feel that a core group of staff is important to keep the skills and experience in each department. Feel that it can be difficult to be good in every area/department when rotating around due to high volume of knowledge and expertise and experience you would need.

38 38 Better Births and Continuity: Midwife Survey Results Having worked across different settings in the past I became deskilled as I became a Jack of all trades and lost some of the confidence which I had gained when working as a rotational midwife. I think that there is a danger especially where labour ward is concerned that midwives become jack of all trades and do not have all the necessary skills to look after women in acute episodes. Some of the midwives had specific concerns about the quality and/ or safety of cross-organisational working, moving between different NHS trusts: National recommendations are that staff who work together should train together. This cannot happen if I am working with different people all the time. This is not safe practice. Because of the lack of confidence - no one can just walk into another hospital and pick up the reins and work as they do in the area they know well. When a midwife comes to work in the antenatal clinic it takes ages before they are up and running and not missing important things. I need structure at work and stability. I don t think I would get that across trusts and I want to be able to give continuity where I am, not spread so thin Following a lady across trusts to give continuity would mean more women miss out on continuity for the sake of the one getting it. Having worked cross site previously it is my belief that a lot of time is wasted travelling from one site to another, it is difficult to be in 2 places at once, service and efficiency suffers. I think that there is a danger especially where labour ward is concerned that midwives become jack of all trades and do not have all the necessary skills to look after women in acute episodes. I would welcome working in a caseloading model inclusive of intrapartum care, preferably with a buddy having a small caseload. Fatigue and safe working were concerns with respect to working different shift patterns and unsocial hours. Reasons for fatigue included: age; working the day after night duty; working a mixture of days and nights in quick succession; long hours; having insufficient work-life balance to feel rested. Note in the final quote the midwife also suggests that continuity based models may reduce continuity as midwives are less available during the daytime. I would not be able to function waking from sleep to travel and then have to coordinate myself to work. It would be detrimental to me and the service users. I find it hard to work daytime be on call and being called out and continue to work in the morning. I don t feel safe anymore to drive a car after so many hours. Consideration of how this [continuity based models] affects negatively affects continuity of care is important as it potentially pulls midwives from their daytime duties. It also potentially impacts on a Midwife s ability to do her job safely due to long hours and limited sleep. Current pay is inadequate for the impact that on call shifts have on midwives lives, even if they are not called. A couple of midwives suggested that their current way of working was a good way of delivering continuity to women, highlighting the various interpretations of continuity. The first quote describes continuity throughout labour, the second describes ante- and postnatal continuity, distinct from Better Births which describes continuity across the entire maternity pathway. 12hr shifts already give continuity of care especially during the labour. I love providing continuity as I do now. I get to know the women and are there for them throughout pregnancy and postnatally. Of course intrapartum care is important but other research has discussed how women mainly want the midwife looking after them in labour to be caring and competent. This push to freestanding [midwife led unit] with caseload model feels more about money. How will our breast feeding rates fare when women are sent straight home?

39 Better Births and Continuity: Midwife Survey Results What would help midwives to work differently: qualitative findings Midwives provided a range of suggestions for what would help them to work differently, in addition to the quantitative findings (see page 29). The main themes were, in order of prominence: Concessions in how midwife roles are organised Adequate staffing to cover the work Financial/practical incentives: enhanced pay, and assistance with travel Induction, support, training, and development opportunities Good leadership, management and organisation Integration of policy, practice and culture Ability to provide continuity and quality care A change in the midwifery profession Concession in how midwife roles are organised Midwives suggested that predictability, and/or concessions in their working patterns would encourage them to work differently, with a wide range of suggestions including: increased flexibility in hours; autonomy and choice about working patterns; limiting number of on-call shifts; part time working; choice over annual leave; shorter shifts; fixed shifts; ability to caseload own women; and having a buddy to work with. Predictability was mentioned most frequently. With enough notice I can work almost anything. I would need notice and an ability to do requests to facilitate childcare. Choice of when and where to work, self-roster or plan well in advance [would encourage me to work across organisations]. I would need notice and an ability to do requests to facilitate childcare. A small number of midwives suggested measures that would encourage them to consider caseloading midwifery specifically: annualised hours, provision of a buddy, manageable-sized caseload, and quarterly caseload. I would welcome working in a caseloading model inclusive of intrapartum care, preferably with a buddy having a small caseload and work annualised hours. I would need to understand the expected size of the caseload [to consider continuity-based models] - there needs to be a work/life balance so that I don t burn out! Quarterly caseload, I m happy for brief period of time but not all year. Adequate staffing Midwives described how sufficient staffing for models of care would encourage them to consider change, and some contrasted this with current gaps in NHS midwifery staffing. Would be very enjoyable and rewarding if staffing was better which would enable easier and more realistic working patterns for all staff to work. Whilst managing a work life balance and being able to see family. It requires effective communication with colleagues, support from management and adequate staffing. Guarantee you will get rest between your shifts. Good support and adequate staff to provide good care to women. I would not want to go and work in another trust where staffing was inadequate. Financial incentives: enhanced pay and assistance with travel Many midwives stated that additional pay would encourage them to work differently. More money, better hours, continuity of carer [would encourage me to work across organisations]. Proposed support for travel included covering costs, reliable parking provision, pool car, courtesy bus/taxi, travel time included in paid hours. Free parking, accessible guaranteed parking space, payment for fuel and other expenses. Induction, support, training and development opportunities Midwives reported how they would require support to work across organisations and settings. Familiarisation opportunities [would encourage me to work across organisations]. I already work as a bank midwife at another trust but on occasions the staff are less than friendly, which would make huge difference. Staff feel threatened when either working in a different place, or having others coming in from another trust. Support to integrate and become familiar with environment, workforce, systems and culture of a different organisation [would encourage me to work across organisations]. Am happy to work in any setting but need the time and space to be allowed to come back up to speed with all the changes and not just pulled in and made to take over in short staffing situations where the senior back up is non-existent.

40 40 Better Births and Continuity: Midwife Survey Results I am not sure if I will enjoy to work as a case loading midwife. I have never tried. But it may be a good opportunity to challenge myself. But I would do only with buddy midwife (experienced) and not on my own. At least until I feel confident. Some midwives stated that the opportunity to develop in a new role or organisation would help them to consider working differently. Opportunity to learn different approaches and methods of working, to learn from different clinicians in different trusts. Leadership, management and organisation Leadership, management and organisation of maternity services were reported to be a facilitator for working across organisations and settings, and a couple of midwives related how they had seen this working well elsewhere. I was involved in a project in the past that included cross border working- successful if well organised. It s simply the best way to work. On-calls are much less onerous when you know the lady you are going to. Morcambe Bay there were three trusts who were supposed to work together. They were very suspicious of each other and dysfunctional as a team. Medical staff had no respect for each other and resultantly families were affected. I am aware things have started to change but how long has it taken and to what cost. I know of other trusts who work between two sites and obstetricians and midwives have worked closely together to avoid disparity in the services but this requires a lot of collaboration. One midwife offered a range of suggestions for activities to encourage integration. Mixed training, social events, networking, pooling of resources, shadowing and a zero tolerance to bullying [would encourage me to work across organisations]. Many midwives focused on a specific aspect of cross-organisational working: significant variation in policies and practice (something which Local Maternity Systems are aiming to address), therefore it was implicit that this variation would need to be addressed, though only a few explicitly recommended standardising across the system. If the policies and protocol were standard across all trust it would give me more confidence to work in different trusts. Also if all staff were accommodating to none trust midwives. Different Trusts/organisations use different paper work/guidelines which can be very confusing. I am aware that the networks are trying to make regional guidelines but they are very difficult to implement as different Trust use different methods/equipment/ medicines etc. Continuity and quality as an incentive Some midwives suggested that they would be happy to, or are already working in continuity based models, and that they found the way of working, and the continuity they could offer, attractive, suggesting that this would incentivise them to change the way they work. To improve continuity of care to my own patients. I would love to caseload and be in call for my own women. It s simply the best way to work. On-calls are much less onerous when you know the lady you are going to. Currently by providing continuity, I technically work any/all shift patterns but would rarely work through a whole night, and if I did it would be at the birth of a family I have a relationship with. This is vastly different (and preferable to me!) than working a hospital night shift. One midwife acknowledged that it would be hard to do, but that she could see that it was worthwhile. This is going to be really difficult but I can see the benefits to women. A change in midwifery culture A couple of midwives suggested that a significant change was required in the midwifery culture as a whole, and the NHS systems and structures that support it, in order to change the way midwives work. There needs to be a wholesale shift in the culture of the midwifery management to allow midwives the autonomy to work in a caseloading model rather than the current micromanagement. There also needs to be a radical rethink of the skills midwives needs to work in this way the current NHS structure has eroded skills like clinical reasoning and decision making midwives have a pass the buck attitude to decision making. To be truly autonomous in practice within midwifery Clinical skills such as advanced history taking and physical assessment need to be incorporated into post registration education as midwives move towards non-medical prescribing. We need to move away from the majority of midwives working shifts and towards working flexibly to follow women and support women s and midwives needs and lives with the relevant support and remuneration. Caseloading and annualised hours cannot work for a large organisation. Midwives with care responsibilities need to plan care for their family which relies upon having regular shifts. With 150 midwives who takes responsibility for ensuring that their hours have been worked?

41 Better Births and Continuity: Midwife Survey Results 41

42 42 Better Births and Continuity: Midwife Survey Results 4. Summary Midwives in the survey were experienced, and appeared representative of the general midwife population The midwives who took part in our survey had broadly similar characteristics to recent national workforce data and survey reports. 4 5 Midwives were experienced (over half had been qualified for longer than 10 years), and many (a third) were over 50 years of age. Over a third currently worked in community with a quarter reporting utilising team or caseloading models of intrapartum midwifery care (though these terms may have been misinterpreted). Many had worked in an obstetric unit in the past year and it was the most frequent overall place of work. Most had attended intrapartum episodes over the past year (over a quarter had attended one birth per week). Midwives are used to working flexible, unsocial hours Three quarters of midwives worked on rotas with different shifts each week. Four out of five midwives worked unsocial hours and almost two out of five already worked on-calls. A third worked 12 hour shifts only. Nearly two thirds of midwives worked between one and four hours extra unpaid each week. Many midwives have responsibilities outside of work Nearly two thirds of midwives had caring responsibilities. Nearly half of the midwives worked part-time, and some reported working fewer long days to manage their responsibilities. Further challenges included being a single parent, having a partner who also worked flexibly, and having little or no family support. While a reasonable proportion of midwives are open to changing the way they work, many feel that this would be difficult or impossible A third of midwives were willing to work in caseloading and/or team continuity models where they provided intrapartum care in any setting, and just under half were willing to do so for home births only. A range of barriers to change were reported. Two out of five midwives reported being unable to change their current shift patterns, and half did not want to. Around a quarter reported that they were unable to work nights at any time, and a further quarter did not want to work on-call at night. Nevertheless many felt that some night working was acceptable. There were more (over two thirds) reporting being able to work set shifts and rotas than annualised hours (approximately a third). A quarter already worked across some settings but a third was not prepared to do so. Half were not willing to work in particular places of work or working environments, with one third unwilling to work in the obstetric unit. However, many midwives were willing to work in an alongside midwifery led unit (half), in community (nearly half) or in a home birth setting (two out of five). These findings suggest that some midwives will find it a challenge to provide continuity of care including the intrapartum period as defined by NHS England, though recent guidance suggests that hospital setting continuity should be provided where possible. 2 A range of barriers to working differently were described Confidence was assessed quantitatively: half of midwives did not feel confident to work across settings. Nearly three quarters felt confident to run their own community work and half felt confident to be primary carer at home births. Barriers to working differently reported in free text responses included: practical barriers (caring responsibilities, transport and proximity to work, responsibilities elsewhere, health issues); wellbeing and work-life balance; personal preference to work in particular ways/places; concern about quality and safety of certain ways of working. Midwives provided suggestions regarding what would help Facilitators to working differently included: concessions in how roles are organised; adequate staffing; financial/practical incentives (enhanced pay, assistance with travel); induction, support, training and development; good leadership, management and organisation; integration of policy, practice and culture across organisations; ability to provide continuity and quality care; a change in the midwifery profession. Shadowing was the most frequently recommended intervention to increase midwives confidence to work in community and home birth. There will always be midwives who are unable to adopt continuity based models of care Implementing flexible, continuity based models across the entire population of women and babies in Local Maternity Systems in the NHS is unlikely at the current time, due to the number of midwives reporting that they are unable or unwilling to change the way they work, and the complexity of some of the barriers they describe. However, a proportion of midwives are willing and ready to adopt new ways of working. It may be necessary to implement continuity based models incrementally, ideally targeting populations with greatest ability to benefit, and working with midwives most able to adopt new models of care. It may never be possible to provide continuity based models at scale if the pool of midwives willing and able to work in this way is too small. There may be additional unforeseen consequences to implementing continuity based models at scale Midwives expressed concerns about working across settings and organisations, working with different people, equipment, and in different places. There is a role for core midwives with setting-specific expertise to support those moving between settings. The safety of working patterns and support for safe working will also be an important consideration if more midwives are required to work flexibly across the week, and the day and night, as the impact of flexible working and long hours have been documented elsewhere. 6 7

43 Better Births and Continuity: Midwife Survey Results 43 Working with, and supporting midwives, is crucial There were many reports of midwives feeling stressed, under pressure, and undervalued, which align with other recent work exploring midwife wellbeing 5, and this is likely to be a key factor in midwives receptivity to change. At a time when the NHS is short of midwives, it is vital that the workforce is supported and retained, and for some continuity-based models may be a step too far. Midwives described personal experience, word-of-mouth, or research which shed a negative light on past continuity-based models. This history and midwives fears, need to be acknowledged. Midwives need to be supported to understand how current plans are different. Some will need to see it to believe it, through piloting and evidencing the benefits for women, babies and midwives. Pilots will need to demonstrate that continuity models are possible for most midwives, not simply those who find it relatively easy due to personal circumstances or professional confidence. Implementation at scale is likely to involve exploring how continuity models can be adapted and implemented to incorporate the facilitators and address barriers that midwives have identified. The future of midwifery and how it aligns with continuity based models of care Implementing continuity based models at scale represents a shift in expectations of the midwifery profession, reducing separation of life and work, and making working life more reactive and less predictable. For many midwives, this is not be what they signed up for when they became midwives. While the Royal College of Midwives supports the NHS plans, 8 current and future frontline midwives will need to be engaged in debate, to agree and accept the role of a midwife in the twenty first century. In order to support implementation of continuity, the Royal College of Midwives has produced detailed guidance that managers can use to explore the issues with midwives at a local level. 9 Recent work by Health Education England 10 has highlighted differences in expectations from career for midwives, and it is not clear whether continuity models will align with the needs and motivations of staff. NHS England acknowledges many of the challenges In December 2017, NHS England produced additional guidance to support LMSs implementing continuity of carer. 2 This guidance acknowledges that there are a number of challenges which align with the findings of our survey: Different systems will require different approaches, depending upon the local situation It will always be necessary to have core staff working in different settings. Not all midwives will be able to do caseloading, that this would be difficult to upscale and sustain, and as a model it is likely to remain a small-scale option, with team midwifery being more feasible. Caseloading suits some midwives more than others, and burnout can be a problem for some, and evidence suggests that autonomy shown to be protective. The impact of part time working on how continuity models work needs to be considered Midwives work life balance is a challenge in implementing continuity models. For some midwives, working in continuity-based models or core teams may be more suitable at different stages of career. In terms of planning and implementing the change, the NHS England guidance highlights that midwives need to know what the models are in order to make decisions, and that LMSs need to work with midwives to establish what their local models should be. The guidance states that some staff will need training, for example refresher courses to provide epidural care.

44 44 Better Births and Continuity: Midwife Survey Results 5. Recommendations For policymakers and NHS leaders: 1. Recognise that implementation of continuity models of care for all women is unlikely, as many midwives face significant, fixed barriers to working in this way. 2. Prioritise continuity models for women with the greatest ability to benefit. 3. Encourage and support piloting and sharing of evidence regarding what is possible, what works in practice, what helps, and whether expected benefits are achieved. 4. Monitor the impact of continuity based models on quality and safety, including whether there are any negative or unforeseen consequences, eg due to a reduction in setting-specific expertise in midwives. 5. Monitor the impact of continuity based models on the workforce, and ensure that midwives are not burning out or leaving the profession. Consider what new models are expecting of midwives, and ensure that what is being asked is acceptable to a modern workforce. Team models may offer more predictability for midwives than caseloading. 6. Support providers and the midwifery profession to address the barriers to implementing continuity models of care, including future recruitment and training of midwives to be continuity-ready. For Local Maternity System Leaders implementing continuity based models of care: 7. Work with your midwives to establish who is willing and able to adopt continuity based models of care, as it is likely that there are those who will welcome this way of working for some midwives it will be the wrong time in their career, or wrong model of care for them, or they will need support to change. Team midwifery may be more predictable and acceptable than caseloading models. 8. Prioritise continuity models for women with the greatest ability to benefit, ie those with increased social and clinical risk, as it is highly unlikely that all midwives will be able to adopt continuity based models of care. 9. If continuity based models are to be rolled out at scale, first pilot and evaluate new models locally with midwives with a variety of professional and personal circumstances - not just those who have no practical barriers or support to overcome them. Use pilots to test safety and unforeseen effects of continuity based working. It is likely that core staff with setting-specific expertise will always be required, eg in the obstetric unit. Use pilots to show your midwives that new ways of working and the lifestyle changes required are possible/worth it. 10. Listen to, and address your midwives concerns about continuity models. 11. Ensure staffing is adequate to meet the requirements of the new model of care to avoid short staffing and burnout, and to provide safe care. 12. Provide training, clinical and change management support before and during the change 13. Address practical barriers such as transport and childcare, though for some midwives they are likely to be insurmountable. 14. Consider making concessions in midwives working practices and rewards for those working in new models of care, eg some degree of predictability, flexibility, autonomy, development opportunities, or enhanced pay. For midwives: 15. Get involved with local activities to design, pilot and implement a model of care that delivers continuity: collaboration and making your voice heard will ensure that plans are doable and acceptable to you. 16. Get involved with national discussions regarding what is expected of midwives in terms of working patterns, being with woman, and work life balance.

45 Better Births and Continuity: Midwife Survey Results Conclusion Recent policy and research has shown that women, NHS England, and the Royal College of Midwives welcome the focus on continuity of carer. 1 2 However, many midwives report barriers to being able to change the way they work to make continuity happen. Findings indicate that there may be a gap between the number of midwives required to deliver continuity plans, and the number willing or able to do so. In addition, midwives expressed concerns about what the change means for them in practice. Recommendations from the survey provide evidence to support many of the issues identified in NHS England s recent Continuity of Carer implementation guidance. 2 It is essential that NHS England and Local Maternity Systems listen to and address midwives concerns about the changes, evaluate the safety of midwives working across settings at scale, and evaluate the impact of the changes on midwives. In order to succeed midwives will need to support the plans. Midwives will also need support to change, and to sustain new ways of working while maintaining their own wellbeing. 7. Acknowledgements We extend our thanks to the 798 midwives who made time to share their views. We are extremely grateful for the advice and support from the Royal College of Midwives (RCM), NHS Maternity Early Adopter sites, our University of Birmingham CLAHRC team colleagues, and individual midwives and managers who supported the development and promotion of the survey. Many were involved in this work, too many to name everyone, but in particular we thank Jon Skewes and Amy Leversedge from the RCM, and Trixie McAree and Justine Jeffrey from the Birmingham and Solihull United Maternity and Newborn Partnership. This research was funded the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.