A continuity of care project with two on-call schedules: Findings from a rural area in Sweden

Background: In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare. Aim: To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden. Method: A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth. Result: One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14–4.22) and the emotional (aOR 2.05; 1.09–3.86) aspects of intrapartum care, regardless of the model. Conclusion: This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives’ working conditions and women’s access to evidence-based care.


Background
Midwifery continuity models of care are highly recommended [1] and growing in many countries [2].These models may differ for midwives and organisations, e.g. as a result of being privately or publicly run [3][4].Two studies [3,4] compared either standard public care with standard obstetric private care and Public Midwifery Group Practice (MGP) / caseload care.This latter model uses terms MGP, caseload, or continuity of care interchangeably, and equates to continuity of midwifery care of no more than 3 or 4 midwives working in partnership across 7 days and 24 h a day but carrying an individual caseload of no more than 40 women each per annum.Midwives have two days clear off call each week with agreement of their midwife-colleagues to provide the backup clinical care required of women within their caseload.
There is strong evidence for the benefits of continuity models as shown in the large Cochrane review by Sandall et al. [1], which included 15 randomised controlled trials with more than 17,600 participants.The studies came from countries like Australia, Canada, Ireland and the UK.The trials included in the Cochrane review were conducted in alongside midwifery units, and obstetric units, with antenatal care usually provided in community settings.Four of the included trials offered caseload care, whereas the rest provided team midwifery or group practices of different sizes.Continuity was offered during antenatal, intrapartum and postpartum care.The prevalence of having a known midwife during labour and birth was 63-98%, and the corresponding figures for standard care were 0.3-2.1% [1].
Few studies have focused on the sustainability of continuity models, although one example is the Midwifery Group Practice model in a rural city of Victoria, Australia, with more than 20 years of success [5].The group practice has been modified over the years both in terms of number of women in the practice as well as the number of midwives and the on-call schedules [5,6].
Continuity models of midwifery care are rare in Scandinavian countries, with the exception of Denmark.Jepsen et al. described in a study from 2016 [7] that caseload care is increasing in Denmark, with 61% of the hospitals offering continuity models.The midwives usually work in pairs, and each midwife takes care of 60 women annually.They provide antenatal care in small clinics and attend the births, usually at hospital.Half of the antenatal visits are provided by medical doctors.The midwives are on call for seven days in a row and have six days off after the on-call period.Thereafter, one day is based on the antenatal clinic.If the midwife is attending a birth, she needs to be replaced, usually after 12 h and by a ward midwife [7].
Midwives are the primary health providers during pregnancy, birth and the postpartum period in Sweden.Prenatal care is most often provided in the primary health care setting and continuity of care is generally good during the 8-9 basic visits.However, continuity between antenatal, intrapartum and postpartum care is rare since midwives either work in the Primiary health care setting or in the specialized care setting in hospitals.There are two completely different managing systems and there could be many small antenatal clinics incorporated in the health centrals and midwives are in those cases employed by the central together with general practitioners, nurses, physiotherapists etc.These professionals (including GPs) are rarely involved in the care of pregnant women.
During a normal pregnancy the majority of women meet 1-2 midwives [8].For intrapartum care, midwives work in collaboration with obstetricians in hospital-based labour wards.The midwife has an autonomous responsibility for normal births, but stays present in case of instrumental or surgical births.In small and middle-sized hospitals, it is common that midwives rotate between assisting women during labour and birth, postnatal care and taking care of gynaecological patients.The trend in Sweden is to close smaller labour wards and the centralisation of maternity services often implies long distance to hospitals with labour wards.Currently, there are no existing birth centres in Sweden, and homebirths are rare [9].Previously, one randomised controlled trial named the Stockholm birth centre trial was conducted in the mid-1990s [10].Despite good outcomes, this birth centre was closed and replaced by a modified birth centre [11] that also was closed after some years.Currently, there is a general shortage of midwives in Sweden [12].
Recently, there has been a call from health authorities [12] to strengthen intrapartum care and women's health.Several attempts have been made, such as increasing the number of midwives, focusing on problems with perineal ruptures and correct suturing, increasing team work, developing obstetric skills and providing continuity models of care [12].In this paper, we present one of the initiatives taken to provide continuity of midwifery care.

Aim
To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden.

Method
Design: This study builds on a participatory action research from a rural area of Sweden.The principles of democracy, participation, reflection and change are applied [13][14].Participatory action research in the present context aimed to develop a continuity of care project and collate action and reflection, theory and practice.The model was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period.Questionnaires were collected from participating women, in mid pregnancy and two months after birth.
Setting: The study was performed in a rural area in a northern region of Sweden.The region includes 275,000 people.Shortly before the project started, the labour ward in the small town in the rural inland area, with an annual birth rate around 300-350, had closed down.The consequences of closing the labour ward implies long journeys to the other hospitals, often in difficult weather conditions with lack of mobile coverage following these roads.The remaining two labour wards in the region are situated in two other cities along the coastline and have an annual birth rate of 1,600-1,700 in the largest hospital and 6-700 in the smaller hospital.The hospitals with labour wards are situated 100 and 120 km away from the study site.
Development of the project: Initially, four midwives were recruited to the continuity of care project, which started on February 1, 2017.Prior to beginning of the on-call services, the midwives worked with the recruitment of participants.They provided antenatal care for women in the project and offered parental education classes and information meetings.They also arranged all practicalities for the project such as mobile telephone contracts with special coverage (similar to those used in the mountains where mobile coverage is sparse), leasing of a four-wheeled car and arranging equipment for emergent births.They also participated in introduction programs at the two labour wards.Sometimes, the project midwives had to cover standard antenatal care, in addition to the project.This was mainly due to the overall shortage of midwives.From August 1, 2017 to June 30, 2019, the on-call service was offered, during which the midwife on-call would follow the woman to the hospital where she had chosen to give birth.Antenatal care was provided on site at the local hospital (where the labour ward was closed) and all births occurred at the other two hospitals.
On-call service: During the study period, two models of continuity were offered to pregnant women.The first model was offered from August 1, 2017 to April 30, 2018, with four midwives providing on-call services from 7 a.m. to 12p.m.One of the midwives was on call four days in a row on weekdays every fourth week (Monday to Thursday) and three days every fourth weekend (Friday to Sunday).The midwives were usually at home during the on-call hours, if not away for birth services.If they attended a birth, they usually stayed until it was completed but no longer than 12 h in total (Model 1).
From May 1, 2018 to June 30, 2019, the model was subjected to changes (Model 2).First, only three midwives worked on the project.The midwives spent their on-call hours at the rural hospital 7 a.m. to 5p.m.If there was no birth, the on-call midwife helped the other midwives or spent time with administration.When being on-call the midwives could provide antenatal care at the clinic sporadically , if they were not away for a birth, but they did not have fully booked days with antenatal care during their on-call periods.When they were not on-call the midwives provided antenatal care with fully booked days.
After 5p.m., the midwives did not follow women into the labour ward, but they were available to perform clinical assessments when needed until 11p.m.The other notable change was that the three midwives rotated the on-call services and were on call every third day during weekdays.On the fourth day, there was no on-call service available, due to the long-term sick leave of one midwife.A general lack of midwives made it impossible to replace her.
The third change was that if the midwife was away to assist a birth, she handed over the birth to the hospital staff at 9p.m. in order to get home within the on-call working hours.The reasons for not providing on-call services around the clock were lack of midwives, sick leave and working hour restrictions of no more than 12 h.During summer holidays, only two midwives worked, and some weeks the on-call service was closed.
Recruitment of participants: Women who called the antenatal clinic for a booking appointment were informed about the study and offered to participate.All Swedish-speaking women were eligible for the project, although initially, younger women, those expecting their first baby or were classified with fear of childbirth (FOBS score greater than 60) [15,16] were prioritised.The basis for the priority came from earlier research that shows that these women prefer continuity to a high degree [17].It is also known that it could be important to invest in a woman's first birth [18]; such a prioritisation could help avoid a negative birth experience.A negative birth experience could subsequently result in childbirth fear and a preference for a caesarean section in a the next pregnancy [19].Another inclusion criterion was to have a due date from August 1, 2017 to September 30, 2019.Women born outside Sweden who understood the Swedish language well enough to communicate by telephone were also invited to participate.During the booking visit, the women received written and oral information about the study and signed a consent form with contact details that was forwarded to the research team.
Process: Women who consented to participate were assigned a primary midwife who carried out all antenatal visits.The project participants also met the other project midwives at the visits during pregnancy, at information meetings or in parent education classes.At the onset of labour, the midwife on-call was contacted, either directly by the woman or, in the case that the woman had been admitted to hospital during the night, by the staff at the labour ward.Depending on the course of labour and the woman's needs, the time and place were determined for the assessment of labour onset.A plan was thereafter made about going to hospital directly or waiting at home, in the case that the woman was in the latent phase.
Sometimes the midwife could travel in the care behind the couple, sometimes she turned up after a while.When arriving at the hospital, the midwife on-call was responsible for the intrapartum care and followed the routines at the hospital.The working time regulations required that after 12 h of work, the care was handed over to the hospital staff.A few days after discharge from hospital, the responsible midwife arranged for paediatric examination at the local rural hospital.
Data collection: Data were collected by two questionnaires, in mid pregnancy and two months after birth.The questionnaires were sent to the woman's home address with a prepaid response envelope.Two reminders were sent by text messages.Women who did not respond to the second questionnaire after three months were invited to complete the follow-up questionnaire online, using the platform Netigate.The platform could be reached from a computer, mobile phone or tablet.
From the first questionnaire, socio-demographic background variables were collected (age, parity, country of birth, civil status, level of education).In addition, self-reported physical and mental health and questions about fear of childbirth were addressed.Fear of birth was assessed using the Fear of Birth Scale (FOBS), [15,16].FOBS is a validated instrument for identifying fear of birth [20,21].Women assess their levels of worries and fear on two 100 mm Visual Analog Scales, that are average to give the FOBS-score.The cut-off point of 60 or more was used to classify women with fear of birth [16].All women in the region are subjected to a screening procedure in mid pregnancy, using FOBS and there are guidelines for referral in case of FOBS > 60.The Cronbach Alpha value in the present study of 0.93 corresponds well to the original study [16] of 0.91 and the validation study [20], where the Cronbach Alpha value was 0.94.
The questionnaire delivered two months after birth evaluated the women's experiences of the care received during labour and birth.Specific questions about satisfaction with the medical and emotional aspects of care, as well as an overall assessment, were investigated using 5-point Likert scales ranging from 1 = Very satisfied to 5 = Very dissatisfied.In the analysis, these questions were dichotomised into 'Very satisfied' versus 'Not very satisfied'.The women's birth experience was also assessed on a 5-point Likert scale ranging from 'Very positive' to 'Very negative'.In the analysis, the responses were dichotomised into 'Very positive' versus 'Not very positive'.The reason for the dichotomisation was based on previous literature suggesting that answers less than 'Very satisfied' entails that there are areas that could be improved [22].We also investigated the presence of a project midwife during labour and birth, how long she was present and the women's experience around continuity.The women also had the opportunity to comment.
Analysis: Descriptive statistics were used to present the data.Chisquare test was performed to study change over time in women's assessment of intrapartum care, divided into three-months periods.Crude and adjusted odds ratios with a 95% confidence interval were calculated between the women who had or did not have a known midwife for the assessment of intrapartum care.The project was approved by the Regional Ethics Board in Umeå, DNR 2017 / 120-31.

Study participants
During the study period, 314 women expressed an interest in the continuity project and consented to participate.Twenty-three women had a miscarriage, and 13 withdrew participation during pregnancy.The follow-up questionnaire was sent to 278 women and returned by 236 (85%).Ten questionnaires were excluded from further analysis.These questionnaires belonged to four women who went into labour before the on-call services started, four who chose to give birth in a hospital outside the region and an additional two who did not complete questions relevant for this study.The 42/278 women who did not respond to the follow-up were more likely to be born in a country outside of Sweden (p 0.000) and also more likely to not have completed the questionnaire in mid pregnancy (p 0.000).No other background differences were found between respondents and non-respondents.Continuity with a known midwife during labour and birth was achieved by 86 women according to the midwives' notes, but only 77 of those completed the questionnaire.Seven of the nine women who had a known midwife during labour and birth, but did not return the questionnaire, were born in a country outside Sweden.

Background characteristics
Table 1 shows the background characteristics of women in the project.The majority were aged 25-35 years, born in Sweden and lived with a partner.The most common level of education was high school, 41% were expecting their first baby, and only a few had infertility problems prior to the pregnancy.The women in general rated their physical and mental health as good, but one in three scored high on the FOBS, indicating fear of birth.The mean FOBS was 46.56 (SD 28.57).The majority of the women belonged to Model 2 (141 vs 85) and had a normal vaginal birth, with the total caesarean section rate being 15%.

The continuity models in relation to the women's background characteristics
Table 2 shows the comparison of the two models in relation to the women's background characteristics.More women born in a country outside Sweden were found in Model 2. Women with fear of birth and women who had a known midwife during labour and birth were more likely to belong to Model 1.There was a statistically significant difference between the models, with 49% continuity with a known midwife in Model 1 and 25% in Model 2 (OR 2.93; 1.65-5.19).There was no difference in Model 1 regarding women's background characteristics and having a known midwife.In Model 2, more primiparous women had a known midwife (OR 2.62; 1.18-5.83).No other differences were found in the women's background characteristics.

Women's experiences of having a known midwife
In all, 77/226 (34%) of the study sample had a project midwife present some time during labour and birth.The majority (71%) had an unknown midwife present, but some women had the opportunity to meet the labour ward midwife previously (17%).Such an encounter could be due to circumstances such as the women having attended the hospital for some kind of health assessment or having seen the same midwife on several shifts (shift work means change of staff three times a day).In the group of women who received continuity (n = 77), the primary midwife was present in 50 of the births and another project midwife in 32 of the births.Five women reported that they met both their primary midwife and another project midwife during labour.The average time of the project midwives' presence was six hours.Most of the women who had their primary midwife present reported that they believed her presence facilitated the birth process (77%); this was also the case among most of the women who had a project midwife other than the primary (61%).The majority of both groups of women who had a known midwife ranked the experience of the midwife's presence as 'Very positive' (73 vs 76%).
The women's comments revealed that they were fully aware of the limited chance to have a known midwife.Some women (n = 56) commented on the importance of continuity.The comments were often around the travel distance, where they stated that the most important thing was to have a midwife in the car behind theirs during transport, but also that they were informed that it was only by chance they would have a known midwife.Those who had a known midwife (n = 36 comments) wrote mainly very positive comments about the midwife and the birth, and they emphasised the safety and security as the most important factors in continuity.Some women made neutral comments, and one woman made a negative comment.

Intrapartum care
The majority of the women were satisfied with all aspects of intrapartum care (Table 3).There was a statistically significant difference in women's assessment of the medical aspects of intrapartum care over time (Chi square 18.179 (df 7), p = 0.011) and the overall assessment (Chi-square 19.535 (df 7), p = 0.007), but not for the emotional aspects (chi-square 10.392, (df 7), p = 0.167).
In Fig. 1, the proportion of women being 'Very satisfied' with the aspects of intrapartum care is shown.There was no statistically    significant difference in the assessment of intrapartum care in relation to the two models.Table 4 presents the medical and emotional aspects and the overall assessment of intrapartum care in relation to having a known midwife present during labour and birth.The adjusted odds for being 'Very satisfied' with the medical and the emotional aspects of intrapartum care were almost doubled when having a known midwife.The overall assessment only bordered on significance.The results remained quite similar after adjusting for background characteristics, mode of birth and model of continuity.

Discussion
The main findings of this study were that Model 1 resulted in a higher amount of continuity, especially for women with fear of birth.Women who had a known midwife present during labour and birth reported that this facilitated the birth process, and the women appreciated the midwife's presence.Having a known midwife was associated with higher satisfaction in the medical and the emotional aspects of intrapartum care.
The background characteristics of the sample are quite similar to all women living in the area, with the exception of foreign-born women, which was expected due to the inclusion criterion of mastering the Swedish language well enough to be able to participate.The foreignborn women who responded to the questionnaire obviously did master the Swedish language, but language problems might be the reason for the over-representation of foreign-born women not returning the follow-up questionnaire.The inclusion criterion was to be able to communicate in Swedish on the telephone, which could be different from responding to written questions.Cultural and language barriers in the interpretation of survey questions have previously been reported [23].Another important difference from general populations is the higher proportion of women with fear of birth.Generally, around 20% are identified with fear of birth when using FOBS [15,16,20].The comments from women, however, made it obvious that when they answered the questions about fear of birth, many women were anxious about the long distance to the hospital, not the birth itself.Similar results have been reported from an Australian study conducted in a rural area after the closing of the labour ward [24].
Based on the information provided in the follow-up questionnaires, the proportion of continuity with a known midwife was 34%.This is similar to another Swedish study where women with fear of birth had the opportunity to have their counselling midwife also attend the birth [25].That study showed comparable results, with a better birth experience and high satisfaction with care [25].In addition, 29% of those who had a known midwife reported that their childbirth fear had disappeared [26].One can only speculate if it is "enough" to have met the midwife on 2-3 occasions [25] to develop a relationship.In the present study, the majority of women who received continuity were taken care of by their primary midwife, but all women had had the opportunity to meet all project midwives.We have no information, however, if women met the other project midwives only once or at several occasions.
There are currently only a few initiatives in Sweden that offer continuity with a known midwife, and, similar to other countries [2], it could take time to change a system.However, offering continuity of the most vulnerable groups, such as those with fear of birth, could be a good start for hospital managers to inspire midwives to work to their full scope of practice and deliver evidenced based care.Organising the care to fit the needs of women is valuable, even if the proportion of continuity does not yet reach the figures of 63-98% reported in the Cochrane review [1].
Model 1 created the highest proportion of continuity.It sometimes implied that the midwives stayed for a long time at the labour ward, and sometimes women met two of the project midwives, mainly during births that lasted a long time.Similar to the Danish study by Jepsen et al [7], the midwives were usually replaced by the ward midwives after working for a maximum of 12 h.The first months with on-call at home and the enthusiasm of the midwives to work in a novel model of care might have forced them to stretch their willingness to stay until the baby was born.In Model 2, the midwives were hospital based, instead of being based at home, during their on-call days, with a start at 7 am.One could assume that they got tired during the day, and the motivation to travel long distance to attend a birth might have diminished.The balance between work and social life has been acknowledged as a major issue when it comes to the on-call aspect of caseload care [27][28][29].In most studies, however, the positive aspects of the relationship with the women and the flexible work outweigh the negative aspects of being on call [27][28][29].
In most studies about continuity models in rural areas, there is a health facility nearby where women can give birth [5,30].This was not the case in the present study, where midwives had to travel long distances to provide continuity.Travelling a long distance several times a week in often bad weather and snowy roads during wintertime could be exhausting.It is likely that the level of continuity in this small hospital would have been higher if the labour ward were to open, at least for low-risk women.One example from rural Australia [30] is a descriptive study of how a collaborative team approach with midwives and general practitioners (GP) with a diploma in obstetrics developed, offering birthing services to women after the closure of a maternity ward.Midwives and GPs thought a small caseload model offered to around 200 women per year might be safer compared to unassisted births, which were increasing in occurrence.The health facility did not have access to perform emergency caesarean sections, electronic foetal monitoring or epidural anaesthesia, but it had access to two larger hospitals within a 40 to 50 min' drive [30].Similar arrangements would be likely to work in rural areas of Sweden for low-risk women, if women and midwives would tolerate being without direct access to medical doctors.The problem in Sweden is that in most areas, GPs are not involved in the care of women who give birth, which could make it difficult to develop similar models.Consumer activists and women were driving the changes in the Australian rural study [30].Consumer activists are also engaged in the Swedish rural hospital under study, where the entrance has been occupied for more than three years, with people from the community protesting until the labour ward re-opens.
The results showed that women in the present study were satisfied with all aspects of intrapartum care, with more than half rating all aspects as 'very satisfied' (57.9% very satisfied with the medical aspects, 54.8% with the emotional aspects and 57.1% very satisfied with the overall assessment of intrapartum care).In a previous national survey performed in 1999-2000 [31], the corresponding figures were 52.5% (medical aspects), 48.2% (emotional aspects) and 53% for the overall assessment.The same questions were also asked in a regional study in the same area as the current study in 2007-2008 [32].In that study, 54.6% were very satisfied with the medical aspects, 47.5% with the emotional aspects and 55.9% with the overall assessment of intrapartum care.Comparing these measures, there seems to be a slight increase in satisfaction over time.The doubled odds for satisfaction when having a known midwife when giving birth, as shown in this study, adds to the growing literature on the importance of relationshipbased care.
This study is compromised by its non-randomised design, the small sample, the self-reported questionnaires and the fairly low proportion of women who actually received continuity with a known midwife.Despite this, the results point in the same direction as the international literature [1], with higher satisfaction when having a known midwife.The detailed information of the two models could also serve as inspiration to others interested in introducing, developing and evaluating midwifery models with continuity.
Another issue to consider is the action research approach as a novel initiative in continuity models.A randomised controlled trial would have been the 'golden option'.However, such a design was not feasible due to the shortage of midwives and the novelty in starting the first continuity of care model in a rural area of Sweden.Participatory action research makes it possible to involve the staff that will work in the model and modify the continuity model.It was important to develop a model that would suit the midwives' work situation but also follow the work time regulations suggesting that the midwives could not work for more than 12 h in one shift [7].That came at the cost of less continuity.It is, however, important to be aware of the problem with the recent closure of the labour ward.The project started the day after the closure, when the midwives, women and people in the community bemoaned the loss of the labour ward.The women's comments also mirrored that this loss created the fear of birth, mainly concerning the long distance and being afraid to give birth on the road.

Conclusion
This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth.Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied.Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

Fig. 1 .
Fig. 1.Proportion of women being 'Very satisfied' with the medical aspects, the emotional aspects and the overall assessment of intrapartum care over time.

Table 1
Characteristics of the participants.

Table 2
Women's characteristics in relation to the continuity models.

Table 3
Women's assessment of intrapartum care.

Table 4
Experience of intrapartum care in relation to having a known midwife at birth.Adjusted for background characteristics, mode of birth and model of continuity. #