 And I will ask Shauna Shenwell to come online. And Shauna is gonna be talking about evaluating women's and midwife's views of a midwife-led continuity of carer scheme. There we go, let's just give her a moment. Shauna, welcome. So Shauna has been a practicing midwife for eight years and currently works in Dundee, Scotland for NHS Tayside, supporting and caring for women on the postnatal ward. During her training, Shauna developed a passionate interest for research and since qualifying has always balanced working as a midwife alongside working on several research projects. Currently, she's seconded to the University of Dundee, mother and infant research unit as a clinical academic fellow. Shauna feels that both roles complement and inform each other and she highly values the importance of research in developing midwife-free practice and care for women and their families. Shauna's long-term goals are to continue to develop her research experience and complete a PhD. So Shauna, once again, welcome. The floor is yours, just give me one moment to hand you over the speaking and the control of this. Just bear with me here. And there you go, welcome. Thank you very much and hello, everybody. I'm Shauna and, as Alimea said, I'm a midwife and also a researcher with the mother and infant research unit at the University of Dundee and it's through my work at the university that I conducted this research with Dr Andrew Simon and Justine Craig, who was the head of midwifery at NHS Tayside at that time. So bear with me a second. So I thought I'd start by painting a bit of a picture for you. So midwifery care in Scotland, midwifery care in the United Kingdom is provided by the National Health Service and is free at point of access. Women contact their local midwifery team to arrange their care and normally meet with their midwife for the first time when they're around eight to 10 weeks pregnant. Midwives will be the lead health professional for women deemed as low risk during their pregnancy and provide care during the antenatal, interpartum and postnatal periods. Women are referred to a range of multi-discipline health and social care professionals as required or requested by themselves. And currently, most women will not be guaranteed to be cared for by the same midwife throughout their pregnancy journey, although that is something that is changing and I'll discuss that later on. So continuity of care. It's recognised that high quality midwife-led continuity of care improves outcome for both women and their babies. And continuity of care increases women's levels of satisfaction in the care that they receive as well. Likewise, midwives have reported in research that working within a continuity of care model finds that they have lower levels of work burnout, anxiety and depression when they compare to them at the time when they worked maybe in a more traditional model of midwifery care or when being compared to their colleagues that still work in that model. So as I said, continuity of care may not be something that women are party to just now with their midwifery care, but this growing bank of evidence combined with women expressing the wish to know their midwife is currently being reflected in UK maternity policy. So in 2017, the Scottish government published the new five-year plan that they have for maternity and neonatal services called the best start. And here you can see one of the recommendations within the study, sorry, within the report is that women experience real continuity of care and carer across their home maternity journey with vulnerable families, so women with additional needs being offered any additional tailored support that they may require. But what the best start also suggests and recommends that any new models of care offering continuity of care should be audited and evaluated, and that's what we did during this research. So setting the scene of where the research conducted and where I work. So NHS Tayside is one of the 14 health boards within Scotland in the UK. You can see I've highlighted it in green for you. It's quite central Scotland and has a mixture of regions from one of Scotland's largest cities to quite rural areas as well. Historically home birth rates within NHS Tayside were low. So in 2015, only 0.28% of the women cared for in NHS Tayside actually gave birth at home. In response, March 2016, midwifery management introduced a case loading continuity of care model which incorporated planned home birth. So a team was set up which women would join if they wished to birth at home and also they received then continuity of care. But in line with the English birthplace recommendations, the model initially offered this to Paris women, so women who were having, this wasn't their first baby, and they were also considered low risk. The NHS home births team, as I said, NHS Tayside, that area in green, it has three counties that become NHS Tayside. So there's Perth and Kenross, Dundee City itself, and again this area in green is Angus. Angus is sort of sandwiched between Dundee and Aberdeen, which are the third and fourth largest cities in Scotland. And Angus has an annual birth rate of around 1,000 women which approximately 30% at that time were considered would be eligible to join the home birth scheme if they wished. When it was set up, there was initially two part-time midwives who cared for women in the scheme. So booking when the women phoned to see a midwife because they knew they were pregnant, they would be asked if they would be interested in finding out about having a home birth, and then they would meet one of the two midwives within the worked in the scheme, and they would talk to them about their options of where to give birth, and then care for them throughout their pregnancy, and they split that workload equally. As the scheme progressed, the staffing went up from the two part-time midwives to three full-time midwives, and they cared for all women who then joined the scheme. They also had some women that they cared for that aren't choosing to have a home birth, but they still care for them in the same way. So the Angus home birth scheme had to be assessed to see if it was going to work and whether it was going to make a difference to the number of home births and also whether they were able to achieve continuity of care. So it was targeted to increase the planned home birth rate within Angus, just Angus, to 3%, and that women would receive 80% of their care from their primary midwife. So the objectives of our study was to meet one of the recommendations in the best start, and that was to audit and evaluate the scheme. The primary objective was to assess the extent to which low-risk Paris women in Angus opt for and plan a home birth with continuity care throughout the pregnancy childbirth continuum when they are offered this as a service. Secondary objectives were to evaluate the characteristics of those who opt for the service and achieve both a planned and home birth and continuity care. To evaluate the characteristics of those who opt for the service, but do not achieve both a planned home birth and continuity care. And finally, the last one was to assess using a quality care framework, the perceptions and experiences of service users and service providers concerning the pilot scheme. And this presentation that I'm giving to you today is going to focus on this last objective. So the methods that we used to carry out the research, women who joined the home birth scheme with an estimated due dates between October 2016 and March 2018 were invited to take part in the valuation study. Women who expressed an interest in the study were then invited to focus groups, either by telephone calls, text messages, or emails, and sometimes a combination of both, or all three. The focus groups were also advertised on a close Facebook page set up by the home birth scheme midwives. And that sort of gave the study a bit of kudos within the women as well, because they really had a trusting for the midwives and the fact that they were supporting the scheme probably helped with the recruitment. Midwives from the home birth scheme and also from the wider community midwife team were also invited to focus groups to share their own experiences of providing care or supporting the home birth midwives to provide care within the continuity scheme. So the data collection that happened, we ran four focus groups, of which 16 women attended. We had one face-to-face interview, because sadly for that woman, she was the only woman who turned up for that focus group. So she ended up with a one-to-one interview. We had one focus group that had six community midwives, and then the final focus group was a joint interview with two of the home birth scheme midwives, as the other home birth midwife was attending a birth, so she couldn't be at the focus group. As I said, we were planning on doing a quality care framework for the focus group, and we based this on the five components of the care, five components of care as identified in the Quality, Maternal and Newborn Care Framework, the QMNC. The framework has identified five categories that good maternal and neonatal care should comprise off in order to be quality care, and we asked questions around these five areas. So we looked at the practice categories, organization of care, the values, the philosophy, and also the care providers. And we asked a couple of main questions for each category, and then any additional questions that may have arised through the discussion in the focus groups. All of the sessions were conducted by the same researchers, and we shared the roles of facilitator and note takers. So the researchers were myself and Dr. Andrew Simon, who works as a at the University of Dundee, with also within the Department of the Maternal Mother Infant Research Unit. With the participants' permissions, all sessions were recorded. They were then transcribed and anonymized, and transcripts were analyzed by both of us using Richie and Spencer's method of thematic analysis and using the QMNC framework as a guide. So what did we find? Initially, we identified there was three principal themes that was coming out through the discussions from both the women and the midwives. And they were organizational structure and work culture, relationships, information and support. These were the things that were important to the running and the success of the home birth scheme. But what we also started to identify as we did more and more of our analysis of the transcripts were that these three themes were actually dependent and interconnected. They didn't stand alone. They weren't silos. They all relied on each other to be successful. So the organization structure and work culture, if that was in place and the midwives were given the time in order to see women, then that helped build relationships. The relationships helped build the information support, being able to feed back then into the system, help their organization and structure. And the information was vital and for, as you'll see later on, for the structure to actually work. So we started to realize that there was an interdependency between the themes. But what we also noticed was that there was a number of sub-themes that each of the three principal themes shared. And they also were related to each other. My slide seems to have lost words, sorry. So there was effective care, home birth, and then, my mind has gone blank, but the effective care used flexible, tailored, sensitive, safe, and family-centered. That's what effective care actually needed in the end. And it was that that we were looking at. So if we had any quotes that talked around those, then we put that down as effective care. Home birth was obviously a factor that was unique to the study. So if I take organizational structure and work culture, to start with, to develop a working partnership, the home birth midwives adopted a flexible working pattern which enabled women to choose appointment times to suit their family life. So in order for this scheme to work, the midwives needed to be working within a scheme that was flexible enough to give them appointments to suit the women. And Fiona and the midwife identified that women really loved the fact that we were able to see them at any time of day. So they would go out in the evening if that suited them and also suited the women and fit it in with her family life. So it was a far more flexible working pattern. Fiona also believed that flexibility removed the time pressures of traditional appointment systems which improved information sharing and relationship building. So we can go out and visit, maybe you would have 20 minute appointment here, but we would go there for an hour and discuss anything we wanted. So the fact that they had the flexibility and they weren't stuck to sort of, as she says, 20 minutes appointments knowing that the next woman would be waiting outside to see her, they could spend time and discuss information that the women wanted to share and that helped them build the relationship. They didn't feel rushed, they didn't feel time pressured and neither did the women. So the relationships could build and be more fluid. Women echoed to the midwife's thoughts on the benefits of the scheme's flexibility. Nancy also recognized this enabled the midwives to form relationships with their other family members. So it was a far more holistic approach to the family care. It wasn't just the women going through this process herself, her whole family were involved in the care of her pregnancy. So Sophie was really good at fitting it in my family life around about when she was coming in. Jessica, her daughter was full of questions and Sophie would answer them with doubts thinking about it. Jessica I think was about three or four at the time. And Nicole felt that the appointments in her home empowered her and left her feeling in control and that her views were respected more than in the medical care settings. So all care in the home birth scheme was done in the women's home as far as possible. She obviously had to come into hospital for any scans, any unplanned care or so, any triaging and any medical care. But care from the home birth midwives was done all in the home. And she felt that because we're inviting the midwife into our home, they're kind of more respectful of your space and what you're wanting to do. So because she was in her home, she felt that the midwife, there was a power shift between them and that she was more empowered to be in control of the situation because she was in her home environment somewhere where she was comfortable and somewhere where she didn't feel that that power setting was maybe with the midwife more than with her information and support. So Rebecca developed a trusting relationship with her midwife, Kate, and due to the continuity of care, her information was shared easily. She just makes you really feel comfortable because if you've got any questions that you might have felt a bit, I don't know, silly or intimate or whatever, it felt comfortable. You didn't have to keep re-explaining things to new people. So she just was able to build that relationship and then because she had the relationship and the women spoke about friendships as well with the midwives, she felt more relaxed and maybe before she wouldn't have asked questions, she felt with Kate she could ask anything. And then it then meant that Kate was able to build more information and able to tailor Rebecca's care to her needs. For Nicole, continuity was also a positive experience. I had met the other two midwives as well, but having Sophie come every week just made me feel more confident. So again, Nicole's talking about the confidence that this continuity being in her home and the continuity care gave her. The scheme was set up so that the three midwives would meet all women who were in the scheme. So if, for example, Sophie wasn't able to attend Nicole when she was in labor, then she would have met one of the other two midwives so it wouldn't be a stranger coming into her home. So there was still a relationship building happening. Information and support again, sharing information effectively and efficiently between the team members was vital for women to receive safe tailored care and the women believed this was achieved. So Tanya had the experience that Dr. White, one of our consultants in NHS Tayside, she's very supportive of home birth. However, she recommended that I don't birth at home on this occasion, but after every appointment I would speak to Sophie about it and she would then in turn speak to Dr. White. And so I always felt like everyone was in the loop. So this was important for the system and how the information and supports feeding back into the organisation and the organisation, the fact that these referral pathways and the relationships between midwifery staff and medical staff were in place before the scheme started and allowed the scheme to function without the women feeling their care was interrupted. And relationships. Earlier Nicole had recognised the benefits was receiving care in her home environment. The advice also felt that being invited into a women's home promoted relationship building. So Kate identified that I think women are a bit more relaxed and like a bit more honest, more of a relationship in their own environment where they feel comfortable and they feel control in their home. So she's echoing what Nicole had said. She recognised that because the women were relaxed and in their own environment they were more comfortable and in more control and probably opens up a bit more to her. She also then went on to say that so when you're in somebody's house you're seeing how they live and issues perhaps of this and that and you can discuss specific areas if you know public health. So she identified that because she was seeing how the women lived she could tailor her conversations while she was there in order to meet the needs. She maybe saw something in the women's house that she thought I need to speak to her about this. She maybe wouldn't have told me that if I had come to the hospital she'd come to the hospital but because I'm here then I'm able to have this conversation. So the midwives felt the home-invited environment provided a deeper understanding of the women and how she lived in her family. Elaine valued the relationship she's developed in the effective individualised care she received from the midwives in the scheme. Here she describes how her care this time had differed from her previous experience which had been a birth in the hospital. So they're really of... They're obviously really passionate about home birth. They really made you feel safe, secure and valued. Sometimes you just don't get the same value in hospital. You know, you're just another number and for your appointment, blood's routine, everything and away you go. The midwives always took more time to get interested and you genuinely were interested. And this feeling of you're not just another number was quite a common theme that came through from the women that they really felt that they were a person. She was Elaine. She wasn't that part of two that was needing to come and get some bloods done. She was the women and the midwives really understood each other. And I think for a woman to feel safe and valued and secure in her pregnancy is what we're all aiming for. So the scheme was really benefiting that and aiding it to happen. And one of the outcomes that we noticed and has become apparent through some of the quotes that I've said is the home environment helped empower women to establish control of their pregnancy and birth. So Mia, I love the fact that when they came into the house it made a big difference. I don't know. It just may be a lot less, not stressful, but you just made it feel like you had ownership of your birth rather than being some medical procedure. So here again, there's this talk about, I'm not just the number, this is my birth. This and being in her home gave her the power and empowered her. And she felt she had an autonomy over her, the decisions that were made. And so it gave her the agency to be able to do that. And although the home environment was important, she continued to care and the relationship that midwife also empowered women. So Nicole again has said, I had Fiona and it was just great to have her at every appointment. Yeah, she made me feel so comfortable right from the very start. And yeah, I went on a birthday anyway. So that positive relationship and that ongoing relationship with her had built her confidence and made her feel more enabled to birth the way that she wanted to. So it empowered her to continue to care, not having to tell her story over and over again and just being able to talk about issues that really were important to her at that time gave Nicole, empowered Nicole to birth the way she wanted to. So I've just, so in this discussion, we identified the three principal themes and how the success of continuity care scheme was dependent on the correct management of each theme and the interaction between the themes and sub themes. For example, without the supportive infrastructure, midwives not have the flexibility or time to ensure continuity care for the women in the scheme. Continuity care and flexible appointments helped mutually trust in relationships to develop and consequently fostered two way information sharing. Information sharing enabled tailored, sensitive and safe care to be provided and knowledge transfer which in turn enabled women to feel empowered and in control of their pregnancy and birth. To see in the chat, somebody's asked, is this only impossible if related to home birth? Why not envisioning this and why not envisioning this as a character to the whole profession? So in this research, the study was done in relationship to home birth and since then in NHS Tayside, we have introduced in continuity of carer and Angus, everybody now receives continuity carer whether you are birthing at home or whether you are birthing in the hospital or in the midwife leg unit. And I do think and we feel that continuity of carer was important, the home birthing, but the home birth definitely helped but it wasn't the only factor. And as I'm just going to say some points to consider, unique to the scheme was the home environment which was believed to aid the relationship building. Therefore, anyone wishing to establish a similar scheme within the traditional clinical setting will have to overcome the potential barriers of the clinical environment need to try and move away, women not feeling that they are just another number. Midwives also must be allowed to take the time away from work and therefore it's important that boundaries and expectations are set and agreed by all parties at the start of the relationship. I think what had happened with the two midwives who had started in the scheme, they never really switched off their mobile phones and they would answer text messages from the women in their care at any time, regardless they were part time, so they did have, but even on their days off they were sort of squeezing in an appointment to see someone. So the midwives who work in the scheme now really have for their protective time off and it's recognised that they need to be able to have time off and with their family. And effective communication is vital between multidisciplinary team members to ensure safe care and this must be supported with a robust referral system when there is a need to escalate care. So in Angus, they were supported by the consultant, Dr. White, who was supportive of home birth, but also the ambulance service of transfers where needs, the labour suite of transfers were needed. The home birth midwives spoke about that if they did need to transfer the women, they would stay with that women when they were in labour suite in order to continue that relationship and make and help that women feel safe rather than feeling abandoned that she's been handed over to staff in the hospital. And that's real continuity care. That's continuity care, isn't it? It's making sure that women feels she's been built up this trust and relationship with you and the midwives felt that you couldn't just turn around and hand over to a labour suite midwife, although the care would be the exact same, that women had that relationship with them. And I just thought I'd finish with some birth stories. So overall, all of the women interviewed were positive about their experiences, even those who did not manage to birth at home. Women have gone on and are sharing their stories with family and friends, thereby they've normalising home birth in Angus. Angus does now have a high number of home births. Hannah said, I have a friend who's pregnant just now and she's actually now planning a home birth because I told my story. I had a few people who had gone on to home birth app or had spoken to Vivian. And Mia said, yes, I've told everyone. I can't stop talking about it. There's seemingly a village in one of the villages in Angus which most women are now having home births because their friends have had home births and it's escalating and rolling and it's just become, we don't actually have a home birth team now. It's just become the norm in that area and they continue to care and that they are able to, the women are told their options for where to birth if they want to birth at home, they birth at home, if they want to birth in the midwife unit or if they want to choose to come into nine wells to the labor space, that's their choice. But it's far more open conversations now. And I mentioned that this was only one of the outcomes. So there are two papers that we have written from the study and that's the references for them that discuss the findings for the main outcome, the primary outcome and the other secondary outcomes in the study. And I'd just like to take the opportunity to thank all the women in midwives who took their time out to take part in our study. And that's our references. And thank you very much. I'm just, Amina, do you want me to look at the chat? Yes, thank you, Shauna. There's some of this continuity, Royzen says continuity is the key to building the relationship and open and honest conversations. Even better if in the home but can translate to the hospital setting too as certainly feedback from my caseload is the same person leading out on care and access in between appointments with capacity to fit in extra visits if it requires. So yes, continuity is really the key in building these kinds of relationships. But for this study, it happened to be a home birth scheme as well. So we can't, so that has fed in to the outcomes. But yeah, absolutely. Continuity care was equally as important in building those relationships without the continuity. I don't know what happened to that slide but continuity was the third. The main thing that I forget. But without continuity, that relationship wouldn't have built. It wouldn't have mattered if a different midwife was going out to the women's home every time. That continuity, that relationship wouldn't have been there. It was a fact that the midwife was the same midwife going out and building the relationship. Yes, and relationships are so key when it comes to care during the pregnancies, right? Okay, great. Now there's another question here that says you refer to weekly visits as well as having freedom to have longer visits. Now how sustainable is this and what sort of midwife resources do you require? Example, what is the caseload per midwife? How many boots per midwife per annum? Yeah, so their caseload, I think they were set up to have roughly 35 women on their caseload at any one time. Angus is quite a rural area, which means that they are, if you, Scotland has quite substantial hills and we can have women in very rural locations. So perhaps that would reduce the number of caseloads because of the travel that some of the community midwives would be doing. So yeah, 35 was the number of the caseload that they had. I think in the year after we did the research, they had increased the number of births to over 50 at home in the year, which doesn't sound a lot, but when you've been 0.28% of all the births, it was a substantial increase. So they did manage to increase, but in our findings, they did manage to increase from that 0.2% up to 3% of births when we're at home. We worked out the percentages of those who booked and obviously some of those pregnancies don't continue. So that 3% is including anybody who booked for pregnancy. It's not just looking at those who birthed in Angus, it's those who booked for pregnancy. Yeah, how sustainable is this? So they had a flexible working theme that meant that they could be sustainable. The midwives themselves spoke about it that because of the home birth element, if they were called out for a home birth, the women were flexible enough with them that they could phone up and say, like I was out last night, I didn't get in until whatever time in the morning is it okay if we push your appointment back? And they said, because the women could potentially be having their own birth at home, then they were quite happy to do that because one day they knew it could be them that had the midwife out in the middle of the night. So they were quite happy to do that. Great. But yeah, there has to be, and that's where the organization in care comes into. The organization in care has to support it and it has to be that there's enough midwives to allow a caseload of a practical number that midwives can work in that way. No, of course. And I'm so, so glad that you brought up the point that they are actually, they have protected time because I know what it's like to be pregnant and wanting that constant support. So that's so, so important that that's being given to them. I see Roshin trained in PRI. Hi, Roshin. Yes. Great. So I don't see any more questions. I think if there are any more questions, please do drop them in the chat box. Shauna, this was so, so enlightening. And I want to say thank you so much for sharing this incredible knowledge. I see a few people are typing, so we might have a few questions. Mary says, it sounds like such a wonderful way to work. I'm a student midwife and looking forward to working this way. Thank you very much. So there you go. This is a great, great inspiration for a lot of people who are getting into this field. Yes, we're definitely, it's being introduced with the best start. The NHST side are moving towards working in the best start model. So with continuity care, Angus is fully continuity care. Perth midwives, where Roshin is talking about, and they are in the process of working continuity care. So they are all on call for there. So they work on call for the women to come into the midwife-led units to give birth. So it's not necessarily at home. This is the scheme is set up that if the women go into, they're on call for the women on their caseload if they're going to birth in the midwife-led unit or at home. So yeah, it's being introduced and Dundee is sort of getting there. But it's a much bigger area. So it's harder to put into place. Of course, of course. Brilliant, okay. So thank you everybody who has been here. We have learned so much from each other and the work that the midwives are doing. We have just dropped some links for our VIDM as we go forward.