Dr Marie Lewis, Consultant Midwife, Powys Teaching Health Board
'On average, 30% of women in Powys have midwife-led care in the community for labour; with 15% of that group (about 1 in 7) transferring to hospital for care during labour (intrapartum transfers)'.
Powys is a large rural county in mid wales spanning over 200 square miles. The county is made up mainly of farming communities and small market towns. It includes Welshpool, Newtown, Llanidloes, Machynlleth, Knighton, LLandrindod Wells, Brecon to Ystradgynlais and surrounding villages. Our borders join the English counties of Shropshire and Herefordshire and several Welsh counties surrounding us. We are a completely midwife-led service consisting of Head of Midwifery, Assistant Head of Midwifery, Consultant Midwife, Governance and Risk Lead, 12 band 7 midwives including two midwife sonographers, 20 band 6 midwives and two band 5 midwives - though exact numbers fluctuate over time as midwives move and those working full-time and part-time change. We are also fortunate to receive support from six maternity support workers. Powys doesn’t have any directly employed obstetric doctors within the service. We work closely in the community with our health visiting colleagues and the community paramedics.
Powys does not have any district general hospitals or obstetric units. We provide care from eight small midwifery teams based in the community or working from one of our six freestanding midwife-led units. We provide caseload midwifery to all women with good levels of continuity for women across the antenatal and postnatal period. We support women who choose to birth their babies in Powys to birth in a birth centre or at home. Not all women have a midwife they know in labour but we are currently piloting a new way of working to increase the chance of a woman having a midwife that she knows for birth, if she chooses to birth in Powys.
Continuity of midwifery carer
Our new pilot, commenced in April, involves midwives working in teams of four. They are buddied into pairs to provide all the routine care to women between two midwives and the pairs provide antenatal education, active birth workshops or hypnobirthing sessions to the women to ensure that all four are met antenatally. The on-calls are covered by one of the four midwives to ensure that women in labour have somebody whom they have met and they will have a 50% chance of being cared for by one of their primary midwives. We are using the pilot to explore midwives’ experiences of providing care in this way and to test sustainability for future services.
Midwife-led care and transfers
We care for approximately 1200 women per year in total with an average of 30% having midwife-led care for labour and an intrapartum transfer rate of approximately 15% of women who start labour with us. Transfer times from Powys to a district general hospital range from 30 mins to 2 hours depending on where a woman lives. Ambulance response time can also vary greatly depending on where you are and what is happening locally as many towns only have one ambulance sited locally. Powys does also have access to an excellent helicopter emergency response team when required.
For women who have additional care needs or who choose to birth in an obstetric unit, Powys families feed into one of eleven different hospitals that surround our county. Except for specific instances, generally Powys midwives do not follow women if they transfer to hospital during labour. For the most part, women transfer to the nearest hospital to where they live, but in some areas women do have a choice of more than one hospital. We work with providers in both England and Wales so have to ensure that our networks are wide and communication is relevant for all areas, in order to encompass best practice for families.
Caseloading service model supports birth centres and home births
Our birth centres vary in age and size matching the needs of the local population and we are currently committed to reviewing each of these birth environments with families and enhancing them to support physiological birth. We do not staff our birth centres with core staff; using the birth centre is an integral part of the caseload midwives’ remit and midwives move in and out of the birth centres according to the needs of the women. We staff women rather than buildings. If there are no women in the centre they are often not staffed.
We can offer women up to a 24 hour postnatal stay but do encourage women to return home as soon as possible as we feel this is the best place for families to get to know each other and settle into their new lives. Most of the women who birth with us return home within six hours. Our caseloading midwives continue to provide support to families through an on-call system 24/7 at home.
All our birth centres, except one, have birthing pools and many women choose to use water for birth. We also have a number of women who will choose to hire a birth pool for use at home. Our home birth rates vary between 8-12% which we are very proud of. We support women to choose place of birth at any point during her pregnancy or early labour. Each midwife has their own equipment, which they carry with them at all times, allowing them to care for a woman wherever she chooses to labour and birth. We offer all women without additional needs a home labour assessment in early labour which allows them to be seen in the comfort of their own home. It is unrushed and private, allowing them to decide where they want to birth their baby without undue pressure. Many women will decide at this point to remain at home for birth. They are usually coping well in labour, are comfortable and know that as they have the midwife with them and the necessary equipment, they might as well stay at home. We believe that providing all women with home labour assessment is one of our greatest achievements, and a significant factor in terms of our home birth rate and increasing uptake of home births.
Family-centred care and midwives’ time management
We are truly committed to family centred care and pride ourselves on working in partnership with women to ensure that their choices are respected. Midwives have a flexible system of working hours and on call provision, balancing the needs of staff with those of the families we care for. Appointments vary in length and, where possible, take place at home or in the birth centre depending on a woman’s preference. We do not structure routine care around fixed clinics or have fixed appointment times. We do not have fixed shift patterns and women and midwives can work together in planning appointments and care. Our midwives work a maximum of 2-3 on-calls per week which is incorporated into their annual contracted hours. On the whole, time is self-managed and midwives can balance their hours over the year, some weeks working less and other weeks working more depending on the needs of the service. As a management team we promote autonomy in the midwives and trust staff to work to the benefit of the families that we serve, while balancing their own needs and wellbeing.
Safety and quality improvement
We as a team are committed to always improving the quality of care we provide and being innovative in our ideas for providing care. We have been actively involved in developing community midwifery skills and drills training, through ASAP courses. We have run these for midwives from across the UK, in Jersey and in Kenya. We are always looking to get involved in quality improvement initiatives and have been working on several projects including Management of Obstetric Haemorrhage through the All Wales Obs Cymru work, development of an electronic hand-held record and woman’s app and, more recently, we have commenced a project to explore ways of measuring blood loss in birthing pools.
We have a passion for developing staff and encourage midwives to enhance their skills through further education, study days, peer reflection and attending leadership events. We provide as much continued professional development in-house as possible, In recent years this has included the opportunity for hypnobirthing training and this year we are offering our midwives the opportunity to train in aromatherapy. We are committed to incorporating both of these into standard midwife-led care in Powys.
In Powys we are passionate about supporting choice and enabling physiological birth in any way that we can. It is our privilege to work with families at such a special time in their lives and we strive to provide the best experience.