Women's experiences accessing continuity of care in Ireland: a qualitative study

Maternity care in Ireland is guided by the Irish national maternity strategy, ‘creating a better future together 2016–2026’ and is comprised of three care pathways (Department of Health (DoH), 2016). All pathways should support the physiological aspects of presence and childbirth, while also providing high-quality care that is in line with a woman's individual needs (DoH 2016).

Women should be offered a choice of care pathway based on three risk groups: normal, medium and high (DoH, 2016). The three pathways are supported care, assisted care and specialised care. Supported care is offered to women deemed to be of ‘normal risk’ in relation to their pregnancy status, with care offered by midwives working in the multidisciplinary team and shared with the general practitioner. Assisted care is for women deemed to be ‘medium risk’ associated with their pregnancies and for normal risk women who choose obstetric care, with care offered by obstetricians and midwives and shared with the general practitioner. Specialised care is for women experiencing a ‘high-risk’ pregnancy, with care offered by obstetricians and midwives (DoH, 2016).

In countries where continuity of care is given from the same registered midwife (such as New Zealand) or caseload midwifery from a small team of 2–4 midwives is established (such as Australia and the UK), there are fewer preterm births and interventions, and reduced fetal or neonatal loss (Bradford et al, 2022). Women also positively rate this more personalised maternity care experience, having greater trust and confidence in the service (Bradford et al, 2022), as well as feeling safe and confident with this relationship-based care model that supports normal physiological birth (McInnes et al, 2020). There is a sense of ownership and control over the pregnancy, resulting in a positive birth experience (Styles et al, 2020), and women describe higher levels of satisfaction from being involved in decision-making (Sandall et al, 2016; Hildingsson et al, 2019). McInnes et al (2020) and Bradford et al (2022) built on and supported findings from previous studies and systematic reviews of continuity of care models as being cost effective, having higher rates of spontaneous vaginal births, lower epidural and episiotomy rates, less preterm births and fewer rates of amniotomy (Sandall et al, 2016; Moncrieffe, 2018).

Advanced midwifery practice in Ireland is a relatively new concept. The advanced midwifery practitioner practises independently as part of the multidisciplinary team at an agreed extended scope of practice (Rohan and Johnston, 2018). They use clinical and critical skills to provide a complete episode of care from admission to discharge for a locally agreed caseload of women. Care giving includes physical and holistic assessments, therapeutic interventions, health promotion, education and care planning in partnership with the woman to empower her to make informed choices about her pregnancy and birth (Rohan and Johnston, 2018).

Prior to the introduction of the advanced midwifery practitioner service, the choices for pregnant women were hospital-based consultant care, private obstetric care or supported (normal risk) midwife-led antenatal care. In January 2017, an advanced midwifery practitioner service was introduced at the study site to offer choice and provide a pathway of care for ‘medium risk’ women. The advanced midwifery practitioner caseload, based on local service needs, was developed in agreement with the local steering group and agreed by the Nursing and Midwifery Board of Ireland. Box 1 outlines the inclusion criteria for the advanced midwifery practitioner service. The service aligns with the Irish national maternity strategy assisted care pathway and is guided by a regulatory framework providing a complete episode of individualised woman-centred care, governed by local guidelines and policies (Rohan and Johnston, 2018; Office of Nursing and Midwifery Services Directorate, 2020).

Box 1.Criteria to receive care at the advanced midwifery practitioner service

• Age: 16–45 years
• Booking blood pressure <140 mmHg and diastolic <90 mmHg
• Body mass index: 19–37
• One previous caesarean section and suitable for vaginal birth
• Singleton pregnancy
• No current history of illegal substance abuse or alcohol abuse
• Stable medical disorders or under the care of a consultant physician eg thyroid, anxiety, depression
• Gestational diabetes mellitus: diet-controlled
• Previous uncomplicated group B strep
• No fetal abnormality detected
• No underlying malignancy detected
• Care can be given in accordance with advanced midwifery practitioner policies
• Referred by consultant obstetrician for advanced midwifery practitioner care
• Previous pregnancy complications but not present this pregnancy eg pre-eclampsia, cholestasis

Formal feedback from service users reported that their maternity care needs were met and care was excellent, thorough, safe, respectful and professional (Lennon, 2022). Those who participated in the national maternity experience survey commented positively on advanced midwifery practitioner time for questions and their care giving (DoH, 2020). While these data are important, women's experiences have not been investigated. This study provided an opportunity to explore women's experiences of advanced midwifery practitioner care by having them compare this care with previous pregnancy care experience.

Methods

A qualitative study design was used to explore and compare the experiences of continuity of care advanced midwifery practitioner service users with their previous experience of at least one other model of maternity care.

Setting and participants

The study was undertaken in an Irish maternity unit; in 2020, 10% of women received midwifery-led care, 23% received care offered by the advanced midwifery practitioner and 67% received obstetric-led care (Saolta, 2021). The participants all received pregnancy care from the advanced midwifery practitioner service and had experience of at least one different model of pregnancy care. This was either in the traditional model of shared care with an obstetric team and the woman's general practitioner or midwifery-led shared care with the general practitioner.

From October 2020, all advanced midwifery practitioner service users with experience of at least one other model of maternity care were sent a letter of invitation to participate in the study one month postnatally. Recruitment continued until April 2021. A total of 77 service users were invited and 20 agreed to participate, 15 of whom met the inclusion criteria, with 11 finally consenting to participate and being available for interview. Participants had babies ranging from 2–5 months old at the time of interview. The pregnancy interval gap ranged from 1.5–4 years and 4 months old, with a mean age of 2.5 years.

Data collection

Online one-to-one recorded interviews were undertaken from January–May 2021 by two members of the research team. Both were university lecturers and qualitative researchers. One was a midwife and the other a mental health nurse, both with experience conducting research in relation to maternity care, and they were not involved in the maternity care offered to the participants. The participants were aware of the researchers' backgrounds.

A semi-structured interview guide was used for data collection. Four questions were asked during the interview:

• Tell me about the care you received from the advanced midwifery practitioner service in your recent pregnancy
• Describe what you liked about the service
• Tell me what you did not like about the service
• Describe any differences that you noticed between this service and other care you have had in a previous pregnancy.

Interviews were recorded, transcribed verbatim and anonymised using participant numbers to ensure confidentiality. The interviews lasted for 20–40 minutes.

Data analysis

The transcripts were reviewed and data were analysed by the researchers who undertook the interviews. Thematic analysis was used (Clarke and Braun, 2013) with NVivo (version 12.6.1) managing the data.

Rigour

Rigour was ensured by the researchers who undertook interviews, who completed initial independent thematic analysis and developed preliminary codes, which were then reviewed collaboratively by all team members. Themes were defined and redefined, and finally named to provide a theoretically informed understanding of the findings.

Involving the whole team in analysis contributed to the rigour of this study and ensured any biases held by researchers were challenged and discussed by the team, allowing for ongoing reflexive analysis. The team was guided by the four-dimension framework criteria of rigour relating to credibility, dependability, confirmability and transferability as developed by Guba and Lincoln, and adapted by Forero et al (2018), throughout this process.

Ethical considerations

Ethics approval was provided by the local service's research ethics committee (number: 820). Log numbers ensured anonymity and data were processed according to the terms and conditions of the research approval and in accordance with the data protection regulation pertaining to healthcare research (Health Service Executive, 2019).

Results

The participants' sociodemographic characteristics are outlined in Table 1. This study specifically asked participants to compare their experience of advanced midwifery practitioner care with their previous pregnancy care experience. Two themes were generated from the data. The first was positive comparison, which had three subthemes, while the second was access to an advanced midwifery practitioner, with four subthemes. The themes and subthemes are presented in Table 2.

Positive comparison

Participants were consistently positive about their contact with the advanced midwifery practitioner in comparison with previous experiences. They experienced this model as a new and welcome approach to maternity care and focused on issues around continuity of care and choice.

‘[Previous experience] The consultant said “oh I'll just have a look”…And then she did a sweep… without asking… it was really distressing because I was having the planned section and I just couldn't believe she done it without asking’.

Participant 1

‘[Experience with new service] So the advanced midwifery practitioner said to me “do you want a sweep?” And I said no….and she said…“we'll just leave it as it is” and I think that helped…[be]cause it happened so quickly that I think that might have changed how I felt’.

Participant 1

When making comparisons, participants were positive about previous care, but noted the contrast and positive experience of the advanced midwifery practitioner continuity of care service. They required experience of both approaches to make this informed comparison around continuity of care and choice. One participant made a direct comparison between her experience of the advanced midwifery practitioner service and her previous pregnancy.

‘I suppose it was so much smoother and it was so much more comfortable going in. Knowing that you were going into the one person, the same person, each time’.

Participant 6.

Supporting women's choice

All participants reported a positive experience of advanced midwifery practitioner service, and felt it listened to and supported women's choices and decisions in a manner that meant women felt empowered.

‘Yeah, she was really good…I was adamant that I wanted to try and give birth naturally this time…I didn't get the opportunity the last time and…she kind of talked through both scenarios’.

Participant 4

Central to this experience was women being involved in their care planning in a manner that they had not always experienced from other care models.

Providing comfort

The participants all described the overall comfort experienced when working with the advanced midwifery practitioner as different to their previous experiences of maternity care.

‘She's very relatable…she doesn't use medical jargon…if you had no medical knowledge, you'd understand what is going to happen…at the end of it, “have you any questions? Is there anything bothering you?”’.

Participant 3

It made me feel more comfortable…through the relationship we'd built’.

Participant 7

Advanced midwifery practitioner's clinical competence

While clinical competence was not questioned in the participants' previous experiences of maternity care, they had overall positive experiences with the advanced midwifery practitioner, who offered comfort and support that allowed empowerment. This confidence in the practitioner's clinical competence resulted in a relationship where participants felt that their concerns were addressed in an inclusive and confidence building manner.

‘I felt really safe in [the advanced midwifery practitioner's] hands, that she was taking really good care of the baby, whether she had to go to all that trouble of ringing a few numbers in the hospital… she made sure that I got seen’.

Participant 1

Access to the advanced midwifery practitioner

Participants understood that they were able, and indeed encouraged, to make contact without planned appointment times.

Continuity: one-to-one contact

Continuity and one-to-one contact were deemed central to the participants' overall experiences, relating to previous experiences and contributing to overall satisfaction with the service.

‘The advanced midwifery practitioner…if there was a problem…“ring me…just email me”…knowing that, that you could speak to somebody…it was really reassuring’.

Participant 2

All participants valued accessibility as a fundamental improvement on previous experiences. Central to access was appreciation of continuity and one-to-one contact with the advanced midwifery practitioner.

‘With [the advanced midwifery practitioner]… the same person all the time and she did remember what you had said the previous time and…I never felt rushed and I nearly felt like I'm taking up her time but she never made me feel like that at all… and she really seemed to take an interest and care… you weren't just like a patient’.

Participant 6

‘She was so consistent…and seeing the same person all the time’.

Participant 8

In previous pregnancies, the participants had not had the same level of one-to-one care and had to repeat their stories to different staff.

Postnatal support

The participants were aware that the advanced midwifery practitioner service did not extend to labour, however they valued consistency of contact and the relationship that had been formed.

‘I had to go back…because [the baby] wasn't feeding…I emailed [the advanced midwifery practitioner]…[who said] “just pop over to me”… it only took about 10 minutes but still, it was really important to me’.

Participant 6

The participants expressed a desire for a scheduled postnatal visit at the advanced midwifery practitioner service, similar to the 6-week general practitioner postnatal appointment.

‘Your 6-week visit with your doctor, I would nearly have preferred to have had that with [the advanced midwifery practitioner] instead…far more approachable than my doctor’.

Participant 2

‘Looking back on it, if there were a couple of midwife appointments postnatal, I think that would have been really helpful’.

Participant 6

Reason for referral

The participants did not know about the advanced midwifery practitioner service in advance, with the suggestion and referral being made by other professionals.

‘And I just said I wasn't going to go private and to refer me into the hospital…when I went to my booking…they offered me that, so I accepted it then’.

Participant 3

While the participants indicated that they were given a choice, the choice was not informed by knowledge about the service or clarity about the reason for referral.

‘[I was asked] would I be happy to go with the advanced midwife and I said definitely, because I found the midwives easy to talk to’.

Participant 1

‘I don't know [why I was referred]…I did have mental health issues with my previous pregnancy so maybe that's why, but there was no clarity why I was sent there’.

Participant 2

Service sustainability

Participants being unsure about why they were referred to the advanced midwifery practitioner demonstrates a lack of service awareness and participants linked sustainability with service awareness and access.

‘In hindsight, it probably would have been easier if I could have just gone straight to [the advanced midwifery practitioner], but I didn't know that’.

Participant 4

Participants indicated that they would like the advanced midwifery practitioner service to be extended to more women, even if expanding the service meant seeing more than one practitioner. They felt that this would still be a better service than previous non-advanced midwifery practitioner options.

‘If there was one or two or even three [advanced midwifery practitioners]…you're not seeing like six or seven different people’.

Participant 2

Participants consistently commented on the ability of a sole practitioner to maintain the service, voicing concerns over sustainability and an understanding that more resources would be preferable.

‘I did ask her once or twice like the work that she had, like how did she manage…I think two or three [advanced midwifery practitioners] would be ideal’.

Participant 6

‘But it was COVID-19 time, so it's kind of a hard one…now I was never rushed but you always felt like the nurses were…kind of stressed’.

Participant 4

Discussion

Previous studies have investigated continuity of care for normal risk women (Sandall et al, 2016; Perriman et al, 2018; McInnes et al, 2020; Bradford et al, 2022) but few have explored continuity for women on the assisted care pathway (Fox et al, 2022). This study aimed to provide insight into the experiences of women using a continuity of care advanced midwifery practitioner service compared to a previous care experience in obstetric or midwifery-led models of care. Although the findings are specific to the study participants, several aspects of care delivery were identified that differed from previous pregnancy care. Continuity of care with the advanced midwifery practitioner was described favourably and could be useful to inform the development of future advanced midwifery practitioner models of care in Ireland and other countries.

The consistent positive findings of these participants' experiences of advanced midwifery practitioner care, including a comparison to previous care, adds to the evidence indicating that midwifery-led care, specifically when it is associated with continuity of care, is valued and increasingly chosen by women when the option is available to them (Lazzerini et al, 2020; Rayment-Jones et al, 2020; O'Brien et al, 2021; Shahinfer et al, 2021; Roxburgh et al, 2022; Prussing et al, 2023). Annual reports from the study site show a year-on-year rise in the number of women attending for advanced midwifery practitioner care in the study unit (Saolta, 2021; Lennon, 2022). Feedback from service users shows that they rate the service favourably, with many stating that they would recommend it and suggesting that there should be a continuity of care advanced midwifery practitioner service in every unit (Lennon, 2022).

However, evaluating continuity models is difficult. The variation of pathways offered by advanced midwifery practitioners in Ireland must be acknowledged, and the nuance of their development is often influenced by the service needs of the specific unit. This makes it difficult to translate this care option to other health service jurisdictions (Rayment-Jones et al, 2020). The model offered in the present study is unique and differs to midwifery-led caseload services based on the inclusion criteria for women accessing the service and the continuity of care that the service provides (Lennon, 2022).

There are few studies exploring the benefits and outcomes for women who do not meet the criteria for midwife-led continuity of care. This study was undertaken to inform the advanced midwifery practitioner service by providing women with an opportunity to compare advanced midwifery practitioner continuity of care with other models of care that they had experienced. It was also based on recommendations for research to investigate different continuity of care models to inform the organisation of future maternity care (Sandall et al, 2016).

All women attending for care in the study site received information about the different care pathways with the booking in appointment letter. The pathway most suitable for each woman, as per the national maternity strategy (DoH, 2016), was identified by their named obstetric consultant at the booking in appointment, discussed with the woman, and subsequent antenatal care is provided in this pathway. Despite this, some participants were unclear as to why they were referred to the service. Prussing et al (2023) described how a lack of understanding that a midwife can be the lead caregiver affected women actively seeking out this proven safe option of care. This finding, along with the finding that women did not actively ask about their pregnancy care choices, was striking.

The Irish national maternity strategy (DoH, 2016), with a particular emphasis on having maternal choice in the three care pathways, has been in place since 2016. The continuity of care advanced midwifery practitioner service started in January 2017, to offer choice to women in this catchment area, yet the present study highlighted the need to promote not only the availability of the care pathway options but also the benefits of midwifery-led and continuity of care services available locally. The discussion of the long-term sustainability of the advanced midwifery practitioner service and it being available to more women demonstrates how once women had experience of the service, they wanted others to be aware of its existence and ensure its sustainability and accessibility. This sustainability and future proofing services has been demonstrated in other continuity of care studies (Butler et al, 2015; O'Brien et al, 2021).

Information that enables informed decision making is paramount to a woman being satisfied with her care (Dahlberg et al, 2016; López-Toribio et al, 2021; O'Brien et al, 2021; Turienzo et al, 2021; Roxburgh et al, 2022), and this was discussed as being important to the participants of the present study as well. Being listened to, never rushed, and having conversations that were tailored to and based on the needs of the individual not only enhanced trust in the advanced midwifery practitioner service but also led the participants to feel involved in their own care. The value and importance of individualised caregiving involving a woman has been replicated in several other studies (Forster et al, 2016; Perriman et al, 2018; Krausé et al, 2020; Dharni et al, 2021; Mathias et al, 2021; Fahlbeck et al, 2022).

The participants also described how the language used during appointments facilitated understanding of their pregnancy care, as opposed to the medical jargon and interactions that they had experienced in previous pregnancy care. This has been shown to be central to midwifery-led care and highly valued by women (Perriman et al, 2018; Rayment-Jones et al, 2020; López-Toribio et al, 2021; O'Brien et al, 2021; Turienzo et al, 2021), resulting in a feeling of being respected (Lazzerini et al, 2020) and supported (Sword et al, 2012; Shahinfer et al, 2021), as well as enabling informed choices, further increasing satisfaction (Yuill et al, 2020; Dharni et al, 2021). The women participating in the present study also felt that they could discuss and explore any issues with the advanced midwifery practitioner, which was not possible in previous models of care. This concept has been noted across studies by Sword et al (2012), Krausé et al (2020) and Dharni et al (2021).

The present study's findings mirror previous studies that reported how the relationship formed between a healthcare professional and the woman meant that the woman was comfortable accessing the service with any concerns, knowing that she would be treated as an individual with referral to other services as needed (de Wolff et al, 2021; Fahlbeck et al, 2022). Access to the women's obstetric team without scheduled appointments is not always possible based on specific clinic times and days and other clinical commitments. However, access to the advanced midwifery practitioner service is possible during weekdays via mobile phone or email, and this was highly valued by the participants. This meant that the participants felt comfortable accessing the service with questions or concerns between appointments and described the service as being safe, thorough and competent. The sense of never being rushed for time to address specific needs, as well as having access to the service without scheduled appointments, even when discharged postnatally, was viewed as positive and has been replicated in other continuity of care or caseload studies (deWolff et al, 2021; Mathias et al, 2021; Turienzo et al, 2021; Roxburgh et al, 2022). However, this is not traditionally available in obstetric-led models of care.

Most continuity of care models involve the midwife providing antenatal, intrapartum and postnatal care. The advanced midwifery practitioner service, as offered in the present study site, does not provide intrapartum care; however, this was not described as a gap in the service by any of the participants. Forster et al (2016) showed that satisfaction results from consistent advice, physical and emotional support and safe competent care and not by having a known midwife during labour (Forster et al, 2016). Postnatal review prior to discharge from the hospital was rated highly, with some women not being aware that this was part of the service. Several participants expressed a desire for the advanced midwifery practitioner service to provide postnatal follow up. This need was also identified by service user feedback and a postnatal clinic has been in operation since June 2022.

Strengths and limitations

A key strength of the study is that all participants had experience of at least one other model of pregnancy care. The semi-structured interview guide enabled them to compare this care with the continuity of care model and discuss aspects that were important to them, providing an in-depth individual insight into different models.

Recall bias needs to be considered, as continuity of care with the advanced midwifery practitioner was received most recently, with some participants comparing this to experiences from several years ago.

Conclusions

This study provides insight into the experiences of women attending a continuity of care advanced midwifery practitioner service who would not traditionally meet the criteria for midwifery-led care. It compared the advanced midwifery practitioner service with previous models of maternity care. The findings show that the relationship formed from an approachable healthcare professional with access without scheduled appointments was highly rated. Having time for questions and discussions with care based on individual needs using terms and language that were understood was also described positively, with women wanting to future proof the service. This demonstrated the value that they placed on the service. The sustainability and expansion of the service was raised by the participants.

Women want continuity of care, the ability to make informed choices and to be involved in their care, as shown by the findings of this study. There is a need to ensure Irish maternity services offer care pathway choices, including midwife and advanced midwifery practitioner continuity of care. This needs to be at the forefront of future service development.

Key points

• Continuity of midwifery-led care and advanced midwifery practice is in its infancy in Ireland.
• Continuity of care has been shown to be central to high-quality maternity care. This model improves maternal satisfaction and provides important benefits to women, with no increase in adverse outcomes for normal risk pregnancies.
• Little is known about women's experiences of continuity of care at an advanced practice level for women with underlying medical disease.
• This study builds on previous studies into continuity of midwifery care and provides insight into the experiences of women using a continuity of advanced midwife practitioner service, as compared to previous experiences of obstetric or midwifery-led models of care.

CPD reflective questions

• How would a continuity of care model work in your unit and be of benefit to your service users?
• How would an advanced midwife practitioner continuity of care model work in your unit?
• What caseload of service users would benefit from continuity of care?
• How would you obtain data to develop a business plan to support a continuity of care service?
• What training, resources, support and supervision would you need to introduce continuity of care into your unit?
• If you implemented continuity of care in your unit, how would you evaluate the impact of this intervention in your service?