 So, without much ado, I'd like us to go into our presentation for the day. Please welcome Leah, join me in welcoming Leah Brigante. Leah Brigante is a midwife with a decade of experience. She has been working in a series of roles including clinical leadership, research, policy, and advisory. Leah joined the Royal College of Midwives in 2017, contributing to improvement of maternity policy and midwifery practices across the UK and internationally, working with the European Midwifery Association and the European Forum for Nursing and Midwifery, and representing ICM on WHO guidance development groups. In her development role as consultant, midwife in public health, at Guise and St. Thomas NHS Foundation Trust in London, Leah led the Lambeth Early Action Partnership mid-maternity portfolio and developed an innovative social prescribing service for the prenatal period. Leah is part of the RCM expert clinical advisory group and has led a number of resources to support the pandemic response, including authoring the joint RCM-RCOG guidance on provision of midwifery lead settings during the pandemic. Leah has conducted research on midwife lead settings provisioned, the role of consultant midwives, and higher risk women's experiences of midwifery continuity of care as core investigator of the Popeye trial at King College London, as part of her MSc in implementation science, and Leah holds an affiliate research contract with King's College London and is a guest researcher for MSc programs in global and public health at King's College London and City University of London. Leah, over to you and welcome. So I'll give you presentation status, then we can continue from there. So welcome, Leah. Thank you. Thank you so much, Carol. It's great to be here and I'm delighted to start my IDM 2023 with you all. So for all of you that are midwives or aspiring midwives at the International Day of the Midwife. So I'm going to give you a bit of an overview of what I'm going to cover in this presentation. So we're going to talk a little bit about midwifery continuity of care models. Then we're going to move into the study ID as part of my MSc. So we're going to be looking at the aims and the methodology that he was used. I hope that's not the most boring part of this presentation. And then we will move on to the findings, the conclusion and hopefully recommendation that people can take on from this study. So what we know at the moment is that a lot of women and girls across the world don't have the right access to the right care when it comes to sexual and reproductive health as well as newborn and maternal health. And although there are international goals to reach universal cover, we know that it's very slow and midwives have been identified as a solution because midwives are incredibly cost effective and could meet the need of women and girls and babies by 90%. So we know that we can use this publication like the world's midwifery report in 2021 to make a case for midwifery globally. So some of the data from that report, they look at how midwifery could affect over 56 maternal neonatal outcomes. And those outcomes are improved by midwifery philosophy and practice, but also how almost 83% of all maternal deaths, silver, and also newborn deaths could be averted with high quality midwifery care. So I was very proud to co-author the position statement on midwifery-led continuity of care with Lise Lotte quickly from the Royal Dutch College of Midwives and also Sarah from the UNFPA we submitted a statement to the ICM Council and it was approved and published not very long ago. And the International Confederation of Midwives has this statement that basically encourages all country to advocate for the development of models of midwifery care, but also where those models don't exist to implement them, but where they exist to scale up and maintain such models and had an element of continuity. So what is the continuity of care? Because there have been a lot of definition and people seem to still be a bit confused of what he actually means. So we know midwifery on its own, so care provided in a midwifery model by a midwife will improve outcomes for women and babies. But those outcomes are particularly improved when there is a non-midwife caring for the woman and the baby across the pregnancy, birth and postnatal period. So what continuity of care is, is care provided by a non-midwife and a small team to support as a backup or often this is provided with a body or a partner midwife. And those midwives work in partnership with the women and they are able to lead care provision and care planning for these women as well as providing and delivering care. Obviously, those midwives don't work on their own. They are part of a wider, bigger network of multidisciplinary team and they are able to refer to specialists as necessary and make sure women receive the right care, the right time. And this data is based on the Cochrane Review that Jane Sandel and the team led. So I'm not going to go into all of the outcomes from the Cochrane Review but if you're not familiar with the Cochrane Review I would invite you to go and have a look because every time I look at it as a midwife I'm very proud that midwifery can make such a difference. So most of the outcomes that have been shown to be affected in the Cochrane Review have to do with baby loss. So there is a reduction in gestational loss by 19% before 24 weeks and 16% in general. Women are 16% less likely to lose their baby. They also have a reduction in preterm birth by 24%. And there are some outcomes that apply to intervention during labor so women are less likely to have an epidural or they're less likely to have an instrumental birth or an episiotomy. And they are a little 5% more likely to have a spontaneous vaginal birth and no difference in cesarean was identified by the review nor differences in adverse outcomes. So what we know about continuity is that it's a meaningful relationship that is formed over a period of time sometimes over location and over pregnancies because some women are looked after by the same team and by the same midwife across even pregnancies. And there is an opportunity for the midwife and the woman to form a reciprocal relationship. This relationship often extends to the family because women are often seen in their own homes and there is opportunity to involve siblings, partners and extended family. Obviously this is a complex intervention because it's a model of care that has a number of intervention offered within this model and we're going to go and look a little bit into the details of those. So we don't really understand what the mechanism is. Possibly there is an opportunity to pick up when things go wrong much sooner because of the relationship and because knowing the person in front of us. But also it could be that the relationship is therapeutic and allows also improve that advocacy and improve the care planning and navigation of systems. So I'm just going to set up the context for the puppy trial which is the context in which my study took place. So the puppy trial was a pilot study of midwifery practice in preterm birth including women experiences and it was a trial, a feasibility trial. So it was looking at whether a model of continuity of midwifery care with access to a specialist obstetric clinic. So those are not women that were low risk. Those are women with mixed risk and increased preterm birth risk. So women that were considered to have this increased risk would receive this model of care within an inner city UK teaching hospital. And obviously this was looking at pregnancy outcomes and women experiences but mostly looking at feasibility as it was in a feasibility trial. So a total of 334 participants were recruited in the trial. 169 were allocated to the puppy intervention group which is where my part of the study took place and I will go into the details of that and 165 received the standard care. So women were identified before 24 weeks and if they had increased risk of preterm birth they were randomized into the two trial groups. So the women in the trial intervention group they had anti-natal intrapartum and post-natal continuity from a primary midwife and they also were referred to an obstetric or other consultation, other specialists if needed, if they developed complication during pregnancy and if they needed any additional care. Also they received labor and birth care in their chosen place of birth. So they had an option of giving birth in a hospital setting in a midwifery unit setting or a home. Always provided, this care was always provided by the puppy midwives and they were also then seen by the primary midwife and the puppy team at home following discharge from hospital or after a home birth. The care was received mostly by this named midwife that each woman was allocated at the start of her pregnancy at the start of the journey but every named midwife also had a partner midwife so each woman was given a primary and a partner and also a small team of six was backing up 24 hours, 24-7, providing 24-7 cover seven days a week so that obviously those midwives could have some time off and the team was composed by six full-time midwives including a team leader and they were working very closely with the obstetric clinic as again those women allocated to the trial had some level of complexities and in order to maximize continuity and making sure that the women they were cared by the puppy team were also familiar with the six midwives in the team. The team was providing antenatal education classes and also monthly group session where women could drop in and meet the rest of the team and the rest of the midwives. I've put the puppy protocol there if anyone is interested in going and looking into the detailed kind of intervention description. So the aim of my part of the study which was set within the trial by was a small study was to look at the views and experience of women in the midwifery continuity of care intervention group and try to identify core aspects of continuity from the women perspective and possibly to use some of these findings on the core aspect to inform development of continuity of care in this specific setting but also more generally because some of these could be transferable. So the methods I used were qualitative interviews those were semi-structured in-depth interviews after the women had their babies so in the early postnatal period I had a topic guide so I had a bit of a set of questions I wanted to ask but it was more of a flowy conversation. All interviews happened in the women's home they were audio recorded they were then transcribed anonymized and uploaded on MVV12 which is just a software for analysis. The sampling was purposive it was the same criteria that applied to the trial participation applied to my study so obviously all the women I interviewed they matched one or multiple risk factor for freedom birth. I ended up contacting 20 women and 16 agreed to be interviewed and although there was an attempt to seek variation in socio-economic group ethnicity parity and obstetric history you will see my sample was diverse but not super diverse. So the data analysis was using Brown and Brown and Clark the sixth stage is described so it was all about familiarizing with the data generating codes then searching for teams reviewing those teams and then doing all the writing up. We were I had a team I had a supervisor because of my master and obviously the wider POPP trial investigators some of them were were involved with this part of the study supporting me so some of the interviews were double coded and although the analysis was inductive we then were kind of going back and making sure that the teams applied to the whole data set and they were not very dissonant teams and the recruitment kind of continued until we achieved the data that they were satisfying but also within the project timeline because they didn't have a lot of time for this study. So in terms of participants most women that were part of the study lived in a deprived urban area although the household incomes was above the median average UK income. Obviously we were in London so London also has a slightly different median income compared to the UK household. So in terms of demographic of the participants I had you can see here I had a good split in terms of age in terms of education it was a well educated group more than half were educated at a degree level of higher degree leg level. I had the ethnicity split the European kind of included UK and Eastern European or you know outside of the UK European and then I had two women from Africa or Afro-Caribbean ethnicity and one mixed and one Asian. So in terms of parity I had an equal split between Premiers and New Liberals women and I had one woman they had a previous freedom but and four they had a previous miscarriage or loss before 24 weeks. So in terms of birth outcomes this was quite an interesting sample because a majority majority of the women planned to give birth in a midwifery led settings and these included the option available to them as alongside and home births but as you can see from the birth outcomes table actually not all of them ended up in their favorite place of birth and two participants experienced preterm birth although their babies were alive and healthy at the time of data collection and yeah as you can see we had a split in vaginal birth 10 out of 16 and then one elective cesarean and four emergency cesarean. So this is the most interesting part and those are the teams that emerged from the interviews and I've linked that the full paper if you're interested into into reading about it so those are the five teams and now I'm going to go through each of them and give you some details and some quotes. So the first team was accessibility so this was described as women really enjoyed having this direct access to a name midwife and a team this this meant they had a mobile number they could call this number was obviously a 247 number that was split between the team in terms of covering those 247 hours but what it meant in practice is that women didn't have to call the hospital switchboard introduce themselves give their data they they had a real responsiveness but also somebody that knew them was picking up the phone and they didn't need to repeat their medical or obstetric history. So one of the quote here is this woman say if I needed anything she was there I could text her you know I could speak to her it was completely different she was there all the time this is where I actually took the title of my paper because it was this idea of this woman had a baby before and she didn't have the kind of constant presence in the background of this midwife that she knew. The second team was time and this might be a concept that seems a bit odd but often in very busy maternity services and midwifery clinic women don't really have much time with their midwives and they come with a lot of questions with a lot of things they would like answered but they don't necessarily have the time and the space and this was very different in the poppy team care because women said the midwives were extremely generous with their time they never felt they were rushed they never felt the midwife had somewhere else to go or something else to do they just felt the midwife was there for as long as they needed it. The midwives were providing antenatal and postnatal home visits and they also had they also had the clinic and providing antenatal care for example in the women's home as well as postnatal meant that often the partner or older siblings could get involved with the care and that kind of gave a different dimension of this appointment with the midwife. The third team was building relationship and I found a beautiful description in the data of the women describing their midwives as being like a friend, being like a mother, being like a sister you know this kind of really emotional connection and relationship with the midwives. They also spoke about knowing them and of them so it wasn't just about I know the name of the midwife I really got to know the midwife I really understand her as a person and they received social and emotional support in fact I think a couple of women saying how it was then difficult to say goodbye at the end of the care when you know they've been in these close relationship with this person for nine months plus and then you know the discharge they arrived and this person that they'd seen so regularly was kind of walking out and again this this is a very nice quote of a woman that described them as friends with lots of skills. Advocacy was another team that was identified and kind of it was it took place across three main streams so there was they advocate I do in the advocacy for women autonomy and I will go into that with some of the stories he also meant supporting free choice including women making the so-called outside guidance choice and also he meant navigating complex healthcare systems for the women and making sure that women were not lost or falling through the gaps so those are two very different stories but I just wanted to go into into them given that we have time and so there was the first one is the pink quote at the top I'm not going to read it out but this was a woman that had a very traumatic first experience with a with a forceps birth and a long induction of labor and she was told that she couldn't give birth in the midwifery led unit this time because she had a complication and the midwife the puppy midwife attended the appointment with a consultant obstetrician to make sure she had this personalized birth plan and she didn't need to go to the labor ward you know the obstetric unit but she could go in a midwifery unit and and this is exactly what happened she then ended up having a beautiful water bird and I will pick up a quote from her laser on his presentation which is I think one of the most powerful quotes I've got and the and the other quote here in in the green this is a different you know a different story this is a woman that had an emergency cesarean but she really wanted an elective cesarean this time and she you know I don't know if you are aware but there have been kind of national drivers to reduce the unnecessary cesarean so obviously she wasn't offered an elective cesarean she was encouraged to look at her option including a v-buck heavy virginal birth after cesarean but for this woman this really was not what she wanted and the midwife did the advocacy for her to make sure she had the elective cesarean and this kind of removed all the anxiety that she had in the pregnancies and she felt very confident about it and about the midwives and the midwives really respecting her choices another team was trust and trust obviously developed as alongside their relationship and women you know it was having the time having the advocacy all of those things then led to a relationship of trust so women felt they could speak to their midwives they felt respected they did not feel scared and this improved disclosure especially in one case of of a woman they had some social complexities and you know there was involvement of other agencies and she was confident that the midwives would support her despite all the social complexities this also enabled the midwives sometimes to take a a role a birth there was almost letting women do their things and just giving them the confidence and this was described by a few of the women as this feeling when their midwife walked in the room as they were in labor or they were in second stage that you know the middle midwife didn't do anything she just walked in and sat next to them and just said hi i'm here and this kind of made a big difference for them and this quote at the top is exactly the quote i was saying earlier about this woman they had such an healing birth experience with the second time because the midwife advocated for her to give birth in the every unit and and for her to use the pool that she said my my view on birth was completely changed and now i'm able to pass a positive message about birth to friends and to my daughter you know this this daughter that she had birthed six weeks i think before i interviewed her the last team was the emerge from this present from from my study was the reduction of stress and anxiety and this this is quite an interesting team because women felt they were in control of the whole process and knowing how the care was going to be organized and delivered and having been planning the care alongside the midwives meant there was no uncertainty and this applied to all sort of things even things that i've never really thought about as a midwife myself having been providing continuity for years in my own midwifery experience and it was things like being very clear of you know the midwives is coming to me so i don't have to get into the car and drive in traffic you know i don't have to look for parking i don't have to you know it was this kind of being clear on what to expect how how to expect it when to expect it it was it was a very interesting findings and also they had this kind of almost background presence of the midwives 24 7 this was a real big difference because they sometimes were not even calling the midwives out of hours sometimes they were emailing the midwives or texting the midwives but they were not texting a hospital you know hoping someone would pick it up they were texting this particular person and this person would get back to them with blood results chasing appointments so they felt they had this kind of you know they were in this bubble they were being held someone was held in their pregnancy and their space and this applied to postnatal care and two of these women had pre-term births and those babies were in Nico and and and the midwives did step in and support them even when they were discharged from the hospital and the babies were in Nico and you know really going the extra mile and making sure they were not being they were not losing any kind of postnatal care because their babies were in hospital and this is such a beautiful quote there as well it was this this woman say as soon as midwife be arrived I stopped feeling fear and the body obviously relaxes so in terms of this is just to say that because the context of this trial was looking at the feasibility of implementing such a model for women with obstetric complexities and the higher risk of preterm birth in the in the in my interviews I was trying to look at you know if there is anything that we could identify that would have made a difference in terms of preterm birth but you know this is a very small study there is no causation there is some literature out there that if you are more calm and confident and there is less stress and anxiety and and this is provided by having a social support this can buffer the mechanisms to stress but obviously and there is some some evidence out there the stress can be a predictor for preterm birth but really I can I can only say I can only conclude from this study that because they had continuity they had management and relational and information continuity they had accessibility to the team they were they described as you know those are the things that made us feel safe and in control and obviously because they were in a continuity model they had very consistent care they didn't miss appointments they had very prompt referral things were spot very quickly and they had the the referral that they needed but there is no kind of causation or or association either I don't think so the key conclusion I draw from the study is that recognizing that if women are cared by non-midwives and those midwives are accessible all the time these support women feeling listened to but also to be actively involved in clinical decision-making and obviously these also then contributes to to women feeling less stressed and anxious during pregnancy and birth but also during the early parenthood so I think it's very important when we look at implementation of development of midwifery continuity models of care for women with obstetric complexities that we look at those teams and make sure that we have access in place and when I mean when I say access is this 24-7 access to advocacy to have time built in so it doesn't matter if you see the same midwife but for 10 minutes you know it needs to be within a model of care that has all those core elements and those core components that will allow the relationship to flourish and to build so then trust and advocacy and all those other things can develop from their relationship so this is very important because it will improve outcomes it will improve women experience of care but also it will reduce anxiety levels so those are all the co-investigator and the people that have been part of the puppy trial journey as well as the funders and I wanted to acknowledge them all my co-investigator but also the Royal College of Midwives that supported me to do my master and King's College London my university and the NIHR that funded the trial and obviously a very heartfelt thank to all the women that let me in their homes and told me their stories you know very emotional at times and as the midwives had been generous with their time towards the women the women were very generous with their time towards me giving me their whole although they all had you know small babies and more important things to do then talk to me so thank you so much those are my contacts if you want to get in touch and I will link the full paper if anyone is interested and wants to go in and find out more and I'm obviously here to take questions now thank you very much Leah very interesting presentation very engaging and I especially like the quotes from the women it felt like you know very personal you got really relational with the women and which was a good thing they developed confidence with you and indeed I love the quotes from that that came from the women makes it so real and very engaging thank you very much there's a comment here in the public chat the 24-7 can be overwhelming for the midwives it's great for the women to have access at any time but does this not sometimes push reasonable boundaries of a valid relationship and then there's also another comment thank you Leah wonderful work and we have just a few minutes to take in a couple of questions and yeah the presentation did very well so I don't know whether you would want to respond to the comments and thank you Leah will you take this forward and make this a permanent feature of care in terms of scaling this what sort of case load would be carried by a midwife so kindly respond to those questions and comments Sheila that's a great question so maybe I wasn't very clear but the 24-7 was not provided by a single midwife it was provided by the 24-7 team backup so the midwives were never working you know here in the UK we still follow the european directive when it comes to working hours so the midwives cannot exceed a certain number of hours per day or per week so that the in the same way you would roster you know if you're working on a shift pattern so you would cover a shift a road that we shift they were covering on calls so yes the the women get these 24-7 access but it's not to a single individual it's to a team of six to a team of six that is splitting their availability across the week and the months so they can all go on holiday they can all take study days they you know obviously they can go off sick if something happens so it's not as overwhelming as in my sound because they're not working in an independent midwifery models they're not on call 24-7 themselves is the team that is sharing this this this load so often you know the midwife would do seven and a half hours or 12 hours a day as she would do on a normal shift based on how the road that was organized for that week and the women you know this is provided within the national health care system so they know they have access to midwives but they were they are explained very clearly from the beginning that the the continuity is provided by a team of six and they have one in six chances of getting their midwife and that kind of doubles to one in three because they are given two midwives so they have a partner and a primary midwife so yeah I agree the model needs to work for for midwives as well as he has to work for women and that's why it's a team based model rather than a one person doing doing it all I think Linda is asking if these should be a permanent feature of care so this team is still going on they still exist they were set up as a team for the trial in a hospital that didn't have any continuity of care at all and everything was made in place so those midwives didn't get a temporary contract they got a permanent contract and they are they are staying on and working in this model although obviously I know that every team has been moved around and restructured because of the pandemic but it's still going strong and as you know I'm sure you know Linda but there is a commitment to scale up those models but obviously we need to have the right resources the right number of midwives you know and all of the things to take this forward and what sort of caseload so yeah so I guess the caseload varies of based on the complexities of the women so those women here in the trial they had some complexities in terms of they had a high risk of freedom but a lot of them were in MDT care so they were cared by a specialist clinic for Prid and Bert as well as the midwife so the midwife carried and reduced the caseload they had I think 24 women a month so it was it was a small caseload but I know it has been done in when I definitely did the caseload it was between 30 and then 32 women a month so it really depends of your population where you are and everything else so I hope that answer well so we got Carol in terms of question oh joy joy camp is my lovely colleague at the Royal College I hope she says how do you hope your finding will change practice well I really hope that because we have all the quantitative data and we know how it changes those are kind of obstetric outcomes and you know and and and women outcomes and intervention but I really hope that when the the Coggin review has been taken and implemented without sometimes looking at those things that you know we have the numbers but do we know what the women say about those models and I hope you know my side is just one but there are so many others the kind of say this advocacy and the relationship and the trust but also the time and the access so I hope that when people look at implementing a continuity model they they look at those core aspects and don't dilute the model you know I shouldn't be a tick box yes you have the same midwife but this midwife has a caseload of 50 because that's not never gonna work I hope that it will affect practice as in people will look at making sure those elements are in those models as they get implemented and scaled up and thank you Magda for your thank you and Linda and Sonya so she says I was about to ask how would you manage if there is more than one client who refers to a specific midwife based on her comfortability with a specific midwife yeah so I mean that's I have to say that kind of happens sometimes that women prefer one midwife maybe because they've been cared by the person before in the past or maybe because they're not happy with a midwife and usually you know with a team of six those teams are usually between six seven sometimes even eight midwives if they are part time it can be accommodated and you know people can move around they still it's not a private service so you know if someone doesn't like seven midwives it's we can't find new ones but you know within a team I'm sure it can be accommodated and people can be moved around but I have to say it does happen rarely it happens but rarely and yeah thank you Leticia thank you so thank you thank you very much Leah thank you audience for the many questions and she has given her contacts there maybe this conversation can continue offline after this and Leah once again thank you very much for your presentation very enlightening a lot of learning it's been great thank you