Continuity of Carer: Summary for CCGs and the National Maternity Review

The hardworking, well informed and  persistent midwifery campaigner and strategist Brenda van der Kooy has once again helped us all by providing a useful summary of the research on continuity of carer and the financial and health advantages to the NHS.  She balences this against the higher cost of this care compared to the fragmented/factory model maternity/midwfery care as we have it now.  She says that for those who want continuity of carer and its benefits for themselves, their friends and their family – this, basically is what you need to tell the National Maternity Review.

Implementing Continuity of Carer

Since the recognition of the importance of ‘continuity of care’ in the Changing Childbirth Report 1993, many case loading pilots have been undertaken. Although virtually all have not continued and national rollout has not occurred, their evaluations have added to the robust evidence that ‘continuity of carer’ improves outcomes for mothers and babies and the women who experienced this care valued it very highly.

Improved outcomes that were measured include:

  • higher normal birth rates,
  • lower intervention rates,
  • reduced preterm births,
  • reduced admissions to Special Care Baby Units, and
  • increased breast feeding rates which leads to:
    • reduction of necrotising enterocolitis in babies;
    • reduction of otitis media and lower respiratory infections in babies, and
    • reduction of breast cancer in mothers.

These provide significant direct financial savings for the NHS. It has been suggested that many other medium and long term health and social benefits will also result from the outcomes of an optimal pregnancy, birth and early weeks experience for mothers and babies.

The reasons for cessation of the case loading pilots were:

  • withdrawal of or inadequate funding;
  • midwife burnout from carrying too large caseloads, and
  • difficulty recruiting further midwives into an underfunded, overstretched model.

Case load midwifery care is the only model that can provide ‘continuity of carer’ and it does cost more than the fragmented care provided by the current shift pattern model. This is in order to pay midwives appropriately for the significant on call commitment required for when their caseload of women give birth and to cap their caseload to a sustainable and safe number of women. This investment is also required to reap the ongoing life time savings from the improved health and wellbeing of mothers and their children as identified in the NHS Five Year Forward View.

The simplest way to provide this investment and for it to act as a lever for maternity providers to innovate and provide continuity of midwifery carer is to introduce a national ‘continuity tariff’. This paid to any provider who can prove that a woman was attended throughout her pregnancy, labour and the early weeks by her named midwife (or her back up).

The implication of not addressing this resource shift at national level to implement ‘continuity of carer’ will be that the opportunities for improved physical, mental health and well being for mothers and their children will continue not to be realised along with the failure to reap the significant potential ongoing financial savings.

Brenda van der Kooy RGN, RM, PGCEA, MSc Advanced Midwifery Practice

Midwifery Consultant


DoH (1993) Changing Childbirth: Part 1: Report of the Expert Maternity Group, London: HMSO

Sandall J, Soltani H, Gates S, Shennan A, Devane D.; Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.

Sandall, J., Davies, J., & Warwick, C. (2001). Evaluation of the Albany midwifery practice: final report, March 2001. Florence Nightingale School of Nursing & Midwifery, King’s College. Available online at

Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study BMJ 2009;338:b2060

Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK; 2012. Available from:

Building Great Britons Conception to Age 2: First 1001 Days All Party Parliamentary Group

February 2015

NHS Five Year Forward View October 2014

Wesson N, Carter N.; The Search for Continuity. AIMS Journal Vol: 26. No: 3. 2014