Guidance

Care continuity between midwifery and health visiting services: principles for practice

Updated 19 May 2021

Applies to England

Executive summary

Care continuity between midwifery and health visiting enables safe, high quality, personalised care delivered in a timely manner. This continuity is an integral part of delivering the Healthy Child Programme (2009) and reaching the ambitions set in the National Maternity Review (2016) and NHS Long Term Plan (2019).

This document is designed to act as a tool to support local practice implementation and improvements in the care continuity between midwifery and health visiting services. It was developed based on a literature search of current research, an examination of current UK guidance and policy and interviewing midwives and health visitors working in Local Maternity Systems. The document provides evidence and practice examples to consider when improving quality of care through effective transition of information and collaborative practice between midwifery and health visiting services. This document will be relevant to providers of midwifery and health visiting services (including clinical staff and managers) and service commissioners working within integrated care systems and local authorities.

Care continuity between midwifery and health visiting teams can take different forms and be via joint working, sharing information and postnatal handover. Sharing information about women and their babies care also help provide consistent information for women and their families, and is in line with the Making Every Contact Count agenda.

To implement effective care continuity between midwifery and health visiting services, midwives and health visitors need:

• contact details of local midwifery or health visiting teams
• systems (ideally digital) to share relevant information about women and their babies in a timely manner
• protocols regarding when and how to share information and with whom antenatally and postnatally
• contact between midwifery and health visiting services at all levels of service; strategic and operational
• knowledge of each professional’s role and remit and each other’s informational needs
• opportunities to meet face-to-face, to build relationships and discuss care
• access to shared or aligned records that are accessible by both midwifery and health visiting teams as well as the wider primary health team (that is, Family Nurse Partnership (FNP) and GPs).
• the same tools and resources to share with women to ensure consistent information is provided

Through care continuity during the antenatal and postnatal period, a seamless service can be provided to women and their families. Other benefits include:

• provision of joint care for those women who need it
• earlier identification of women requiring targeted support
• improved care and consistent information for women and their families, leading to improved outcomes for women and their babies, an improved experience and increased care satisfaction through personalised care
• increased ability of midwives and health visitors to share relevant information in a timely fashion
• improved service pathways, standard operating procedures and information sharing documents such as notification of pregnancy and discharge forms
• better aligned service commissioning and pathways
• increased importance attributed to sharing of information between midwifery and health visiting services

Figure 1 shows a summary of factors contributing to effective care continuity between midwifery and health visiting services. These include:

• effective working relationships between midwife and health visitor
• consistent health and wellbeing message from midwife and health visitor
• ensure health and wellbeing information is evidence based
• consistent information sharing and record keeping
• effective communication between professionals and women and partner
• appropriate and seamless handover tailored to expectant women and partner
• ensuring services are universal in reach and personalised in response
• primary care and intensive family support
• peer support

Taken together these factors:

• ensure that women and their partners are given the same consistent and evidence-based information throughout their maternity journey
• support women and their partner to understand when and how their health information will be shared
• enable care to be tailored to each family’s individual needs

Figure 1. Factors contributing to effective care continuity between midwifery and health visiting services

Summary of actions for main stakeholders

Midwives, health visitors and their service managers

Recommendations for implementing effective care continuity between midwifery and health visiting services are to:

• create opportunities for midwives and health visitors to meet and discuss women’s care
• share relevant information about women and their babies throughout pregnancy and postpartum
• share lists of names and contact details of professionals in each service
• provide protected time for frontline staff to develop interprofessional communication and new systems for working
• form interprofessional health teams including health visitors, midwives, GPs and other professionals that meet regularly to discuss vulnerable families
• consider part-time secondments to develop interprofessional teams
• jointly develop templates for communication of women’s changing needs across the care pathway
• provide joint visits and appointments for women, particularly for vulnerable families, if acceptable to the individual woman
• provide joint training for midwives and health visitors on breastfeeding, safeguarding, perinatal mental health and other issues
• support collaborative working in maternity outreach hubs and community hubs

Commissioners of midwifery and health visiting services, local authorities and care commissioning groups

Recommendations for implementing effective care continuity between midwifery and health visiting services are to:

• support infrastructure to enable sharing of information
• develop shared electronic platforms for local care records that are accessible by all healthcare professionals involved in a woman and baby’s care
• implement service level agreements for information sharing
• provide midwifery and health visiting service in the same locations such as maternity outreach hubs or community hubs that are easy for women to access
• consider a dedicated co-ordinator or liaison roles to oversee information sharing, transfer of care, arranging visits and referrals
• engage with the local community, including Maternity Voices Partnership, to co-develop information sharing procedures taking into consideration the needs of minority and vulnerable groups
• commission interprofessional training events to develop understanding of practice areas as well as each other’s roles and responsibilities
• monitor outcomes such as breastfeeding monitor the number of antenatal contacts and new born visits within 10 to 14 days postnatal

Introduction

This document sets out the strategic context and research evidence for delivering effective care continuity by midwifery and health visiting services. Care continuity is understood in this context as planned and sustained delivery of high quality support and includes providing consistent messages, effective handover of care, joint working and good working relationships.

This document can be used as a tool to support local practice implementation and improvements in the care continuity provided by midwifery and health visiting services. It provides evidence and practice examples to consider when improving quality of care through effective transition of information and collaborative practice between midwifery and health visiting services. As such this document will be relevant to providers of midwifery and health visiting services (including clinical staff and managers) and service commissioners working within integrated care systems and local authorities.

The expected outcomes from the implementation of these practice principles are:

• more personalised, safer and effective care for women and their families
• consistent information for women and their families, leading to an improved experience and increased care satisfaction
• increased ability of midwives and health visitors to provide a seamless service
• earlier identification of and response to vulnerabilities which may impact on the health of the woman and her baby
• improved service pathways, standard operating procedures and information sharing documents such as notification of pregnancy and handover forms
• better ability of the commissioners of midwifery and health visiting services to support their workforce with care continuity during the antenatal and postnatal period
• more shared visits when clinically appropriate
• more women receiving an antenatal visit by their health visitor

How this document was developed

The development of this document was led by Justine Rooke and Monica Davison (Public Health England) and Dr Ellinor Olander and Dr Patricia Moran (Centre for Maternal and Child Health Research, City, University of London). The document was systematically developed using 3 strands of evidence; academic research, current UK guidance and policy and the experiences of those working in Local Maternity Systems.

Firstly, a literature search was conducted using Scopus and PubMed to identify UK-based empirical studies published since 2015 on care continuity as provided by midwifery and health visiting services. Relevant journals not included in these databases (such as Journal of Health Visiting) were hand searched. Search terms included midwifery, health visiting, collaboration, joint care and partnership and variations of these. Good quality evidence was ensured by only including peer-reviewed research. To be included studies had to provide information regarding care continuity or on factors influencing this. Women’s views and experiences were also included. To be included research could be randomised controlled trials, surveys, service evaluations and qualitative studies with either women or healthcare professionals. These inclusion criteria were used to ensure focus was on practical suggestions. The included research is based on qualitative evidence.

Secondly, the websites of Institute of Health Visiting, National Institute for Clinical Excellence (NICE), NHS England, Royal College of Midwives (RCM) and Public Health England (PHE) were searched to identify relevant and current guidelines as well as practice examples. The database OpenGrey was also used to identify practice examples. Examples were deemed appropriate if they were in line with current guidelines and provided information on positive outcomes for women. The most recent MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) reports were also checked for relevant information. Further, an email was sent out to all Local Maternity Systems to ask for practice examples. To be included, a practice example had to focus on one of the factors influencing care continuity such as information sharing, joint working and so on.

Finally, 25 interviews were conducted with staff working within the midwifery and health visiting services in England. Participants were recruited via an email to all Local Maternity Systems and the PHE network, and were interviewed between July to September 2020. Participants worked in 13 different Local Maternity Systems and included 15 participants working as midwives, 9 as health visitors and one participant was a service commissioner. Interviews were transcribed verbatim and analysed thematically. Findings confirmed previous research findings, participants viewed care continuity as important, reported different systems of sharing information and supporting families. Participants also discussed how practice had changed during coronavirus (COVID-19).

A draft of this report has been reviewed by representatives from PHE, RCM, NHS England and service managers and local Maternity System staff. Based on this feedback the document was finalised. This document benefitted from many people giving up their time to share their experiences and providing feedback, and we are very grateful for their time and input.

Main drivers, policy and strategic context

The National Maternity Review (Better Births, 2016) outlines a clear vision for maternity services across England to become safer, more personalised, kinder, professional and more family friendly. Maternity services should also enable women to make decisions about their own care and provide support centred on individual needs and circumstances. The review also recommends staff to be supported to work in high-performing teams and deliver care that is women-centred.

Implementing the vision set out in Better Births will support the Secretary of State’s ambition to halve the number of stillbirths, neonatal and maternal deaths and brain injuries by 2025.

The Maternity Transformation Programme seeks to achieve the vision set out in Better Births by bringing together a wide range of organisations to lead and deliver across 11 work streams. There are a number of initiatives implemented as part of the Maternity Transformation Programme which will aid care continuity between midwifery and health visiting services. The Better Births 4 Years On: A review of progress report (2020) presents data on how over 100 community hubs have opened nationally. Community hubs where midwifery and health visiting services are co-located will help provide care continuity for women and their families. The same document reports that over 10,000 women had been booked on a continuity of carer pathway provided by midwives by March 2019. With improved continuity from a named midwife sharing of information with health visiting services will become easier.

By 2023 to 2024, all women will be able to access their maternity notes and information through their smart phones or other devices. This will help women share their maternity notes with their health visitor.

The NHS Long Term Plan (2019) promises to implement an enhanced and targeted continuity of carer model to help improve outcomes for the most vulnerable mothers and babies. By 2024, 75% of women from ethnic minority communities and a similar percentage of women from the most deprived groups will receive continuity of carer from their midwife throughout pregnancy, labour and the postnatal period. Continuity of carer during pregnancy benefits women, and is implemented to reduce health risk and decrease health inequalities (1). Continuity of carer has also been found to particularly benefit women with complex social factors and ethnic minority women (2, 3). Ethnic minority women have been found to have increased risk of maternal mortality. Compared to pregnant non-ethnic minority women, pregnant ethnic minority women were more likely to be admitted to hospital with confirmed SARS-Co-2 infection (4).

The NHS Long Term Plan discusses increased support for mental health for women and their partners and for breastfeeding. Perinatal mental health services will be improved to enable more women access evidence-based support. All maternity services should be working towards delivering an accredited, evidence-based infant feeding programme. This provides another great opportunity for midwives and health visitors to work collaboratively to provide consistent breastfeeding messages and support to women.

COVID-19

Midwifery and health visiting services had to change rapidly when the COVID-19 pandemic happened in early 2020. The pandemic also impacted on care continuity and new processes had to be introduced. For example, services now had to share information on whether women or anyone in their family had suspected or confirmed COVID-19 or if they were in a shielding category. When midwives and health visitors were co-located information sharing was more readily and easily available but due to home working as a result of the pandemic, online meetings were introduced in many areas. This way of working could facilitate future collaboration between midwifery and health visiting professionals due to its ease and convenience, including cutting down on travel time.

At the start of lockdown, areas with strong established working relationships were able to work quickly to change support and care for women and their families. In practice example 1, Cambridgeshire and Peterborough Local Maternity and Neonatal System share their experiences.

Practice example 1. Changing practice during COVID-19 (Cambridgeshire and Peterborough Local Maternity and Neonatal System)

As professional relationships were already formed between midwifery and health visiting services, when the COVID-19 outbreak happened we were able to rapidly come together as senior leads to plan collaborative support and care for antenatal and postnatal women in our localities. A joint care pathway was developed and shared with all midwifery and health visiting teams across our services within the first weeks of the COVID-19 outbreak. This has been continually updated to reflect the rapid changes in service that resulted from the pandemic.

In other areas, the pandemic reinforced the need for robust information sharing between services. In practice example 2, a new communication and handover process was implemented during the pandemic.

Practice example 2. Implementing a new communication process during the COVID-19 pandemic (Humber, Coast and Vale Local Maternity System)

A midwifery handover document was created to allow midwifery discharge information and requests for future support to be shared between the midwives and the health visitors. This information sharing has ensured a better communication of needs, transparent discharge information, care continuity for the client and a platform to sense check antenatal and baby loss notification knowledge. In addition, the health visiting services set up a single point of contact by telephone facility to receive any midwifery handovers so any concerns could be easily communicated.

The immediate outcome is that health visiting services receive midwifery handover information for every mother and baby which allows the health visitors to attend the new birth visit with up to date knowledge of the baby and family. This allows them to be fully informed about the families care needs and ensures that all services are fully informed about postnatal care. The handover information has also allowed us to identify families who were not known to the health visiting service in the antenatal period and to understand why this was.

Through collaborative working across a geographical system we have been able to improve the care given to all parents by improving our channels of communication.

Joint home visiting and discharge or handover planning are especially important for families with complex needs so that assessment and appropriate referrals can be made to maximise support available to women (5).

Practice example 3 provides an example of joint working between health visitor, midwife and GP that enabled appropriate care planning and support for a new mother experiencing mental health issues.

Practice example 3. Joint working to support women during the COVID-19 pandemic (Norfolk and Waveney Local Maternity System)

During the COVID-19 pandemic, a health visitor making a new birth contact via Attend Anywhere video calling with a Universal service user identified low mood in the mother directly relating to her traumatic birth experience. The mother disclosed that she had not shared her feelings with her community midwife or any other health professional. The health visitor sought her consent to speak to other health agencies – midwifery and GP services – this was given. The health visitor then liaised with the community midwifery team to ensure a referral to the debrief service was offered and that the allocated community midwife for this woman was aware.

The community midwife directly contacted the health visitor and together they made a joint plan to provide support via video and midwifery home visiting contacts. Midwifery contacts were extended beyond the usual postnatal period and support was provided for the mother to access her GP. A virtual triangle meeting took place between the midwife, health visitor and GP to share information to support the care plan.

Excellent communication and liaison between agencies have provided a robust care plan for this service user and ensured handover of care will be fully informed when it takes place.

Why care continuity is important

Benefits for women and their families

Care continuity helps midwives and health visitors tailor the best care possible, which will have a positive impact on women’s and their babies care and satisfaction with services.

More and more women begin pregnancy with health risks, such as older age, a high body mass index (BMI) or with a long term condition. Further, more babies are born into care than ever before: approximately 1 in 200 in 2018 (6). This is a sharp increase from 2008 when 1 in 400 babies were taken into care within one week of birth. This number is higher in deprived areas: in Blackpool 1 in 47 babies was born into care. Providing joint care is especially needed and important for these high risk women and is likely to benefit these women the most.

In line with Making Every Contact Count, midwives and health visitors can share information to promote positive changes in health behaviour. Midwives and health visitors sharing information will also ensure women receive consistent messages, which in turn can have positive effects on breastfeeding, maternal mental health and child outcomes. Women identify issues especially important to share as mental health concerns or chronic health conditions (7). Receiving inconsistent or contradicting information on the other hand cause women unnecessary anxiety (7). An example of early intervention and positive outcomes resulting from the timely sharing of information between midwifery and health visiting services is the smoking relapse prevention pilot carried out in Sheffield, described in practice example 4.

Midwives and health visitors sharing information will also ensure women do not have to repeat information and their experiences every time they see a new healthcare professional. Women report frustration having to repeat the same information to different healthcare professionals, leading to dissatisfaction with care and not feeling heard (7).

Practice example 4. Smoking relapse prevention pilot in Sheffield (South Yorkshire and Bassetlaw Local Maternity System)

Sheffield implemented a pilot programme of smoking cessation support which integrated the role of health visitors to encourage post-partum follow-up and relapse prevention.

Pregnant women’s smoking status was ascertained at booking with referral of all smokers to the stop smoking service. Training was provided for health visitors in using carbon monoxide monitors and identification of health visitor champions to provide ongoing support to women who quit during pregnancy. Information was shared between the midwifery service and champions on their caseload’s smoking status. This information helped health visitor champions to visit women still smoke free at 30 to 34 weeks and followed up at their birth visit offering ongoing support up to 6 to 8 weeks after birth. Health visitors also referred fathers or partners to the stop smoking service.

The integration of health visitors led to 54 women (49%) accepting a referral from the midwifery service for postnatal smoking cessation relapse support with the health visitors. Among these women, 47 new birth visits were completed with 67% of women still smoke free, by 6 to 8 weeks post-partum 34 visits were completed with 25 women still smoke free.

Benefits for midwifery and health visiting services

Effective care continuity between midwifery and health visiting will improve midwifery and health visiting services and help services run more smoothly. For example, midwives sharing information about pregnant women will help health visitors deliver the mandated antenatal contact and New Birth Visit. Effective information sharing and joined-up services are also a priority in the revised Healthy Child Programme commissioning guidance (2021). Sharing of information is likely to extend the many benefits associated with continuity of carer as provided by midwives. Collaborative working will also help developing local services and effectively use resources. This includes streamlining support such as antenatal education or breastfeeding clinics and providing joint training for midwives and health visitors. For example, applying for Baby Friendly Initiative accreditation can be a good opportunity for joint training. This accreditation is based on a set of linked evidence-based standards for maternity, health visiting, neonatal and children’s centres services.

Training can also be delivered by one healthcare professional group to another to support workforce development. In practice example 5, a problem with avoidable Newborn Bloodspot testing repeats was identified within the health visiting service, and training was developed and delivered by midwifery services to help reduce these repeats.

Practice example 5. Workforce training: Newborn Bloodspot Testing (NBS; South East London Local Maternity System)

A problem with avoidable NBS repeats amongst health visitors was identified within the health visiting team. Avoidable repeats cause anxiety for parents and delayed identification can lead to delayed treatment of an affected baby.

To reduce the number of avoidable repeats, the Lambeth Early Action Partnership Health Team (LEAP) provided a 1-hour midwifery-led NBS training session to 23 local Lambeth and Southwark health visitors and practice nurses. The team also set up a system for local health visitors to work with their local Guy’s and St Thomas’s NHS Foundation Trust and Kings College Hospital community midwifery teams to have their practical skills signed off.

The training increased the attendees’ confidence and knowledge of NBS. After the training, the LEAP Health Team’s health visitor worked with the local health visiting screening lead to support ongoing internal training for health visitors. The health visitor avoidable NBS repeats went from 23.5% to 7.5% across both trusts. This suggests an improvement in health visitors’ knowledge and skill in undertaking the NBS.

Benefits for midwives and health visitors

Care continuity between midwifery and health visiting will help midwives and health visitors provide safe and tailored care for women and their families. Through collaboration and sharing information, midwives and health visitors can jointly discuss personalised care plans and support. This is more important than ever due to the pregnancy population increasing in health risk and vulnerability. Sharing of information can also lead to informal learning from other healthcare professionals, sharing of resources and job satisfaction knowing safe high quality care is provided to women and their families.

The need for these practice principles

These practice principles are needed for 3 reasons.

First, the Health visiting and midwifery partnership – pregnancy and early weeks document which promotes care continuity between midwifery and health visiting services through the perinatal pathway was published in 2015. Since then, the Maternity Transformation Programme has been implemented, the NHS Long Term Plan published, and the Healthy Child Programme is currently being revised. It is therefore time to provide recent evidence and examples on how to implement this pathway.

Second, there are inconsistences in care continuity as delivered by midwifery and health visiting services across England. Approximately 35% of health visitors report that collaboration with midwives has decreased. Some Local Maternity Systems have clear care pathways and standard operating procedures for how to deliver care continuity, other areas are still developing their procedures. In this document, we have used examples from areas who deliver care continuity between midwifery and health visiting services to share with those areas still developing their local practice.

Third, as previously mentioned, the needs and circumstances of the pregnant population are changing. For example, more and more women with long-term conditions have successful pregnancies. The proportion of deliveries complicated by diabetes mellitus has increased from 5% to 8% between 2013 to 2014 and 2018 to 2019.

Based on these health needs, the pregnant population of today and tomorrow are likely to need more care continuity throughout the perinatal period than previously. Local Maternity Systems may need to revise their current procedures to accommodate this increase in need. Care continuity may be delivered differently depending on the local context, including population and resources.

Main communication points

It’s important that care continuity between midwifery and health visiting services is provided both during and after pregnancy. There are certain important communication milestones, but this should not exclude information being shared outside of these times.

There are 4 communication points where midwifery and health visiting could share information:

Antenatally

1. Booking 8 to 12 weeks
2. 16 to 28 weeks
3. 32 to 36 weeks

Postnatally

4. Birth visit to 10 to 14 days postnatal

Information sharing should consider women’s circumstances, for example for low risk pregnant women, the information shared could be less and at fewer timepoints compared to a woman who lives with complex needs and where ongoing collaboration may be necessary.

After birth, the health visitor will also share information with the woman’s GP ahead of her 6 to 8 week postnatal check with her GP.

Care continuity during and after pregnancy

The appropriate timing and detail of information shared during pregnancy depends on local systems and resources and women’s needs and circumstances. Information sharing and early intervention planning are vital to support women. For example, for pregnant women living with complex social factors midwives could consider a multi-agency needs assessment or refer to a multi-agency team, including health visiting services. Within the community setting, midwives and health visitors may deliver joint antenatal classes (8), share information about and refer women to community services.

Important for all women is to receive information antenatally about the health visitor’s role. This is particularly important for first time mothers and women who have immigrated to the UK (8, 9) to make them aware of the importance of the health visiting antenatal contact. Other important information to provide women during and after pregnancy is provided in the Health visiting and midwifery partnership – pregnancy and early weeks document as well as the High Impact Area documents breastfeeding, parental mental health, smoking, alcohol and healthy weight.

All women

After booking, the midwifery team can notify the health visiting team of the pregnancy. They may also notify the FNP if appropriate. This notification can include assessment of social and health need, including needs of the partner or father, and referrals to other agencies such as mental health or social services (see below for examples of information that can be shared by midwifery services with the health visiting team antenatally). The health visiting team should aim to inform midwifery services of a named health visitor for every woman during this time if possible or at least contact details to the health visiting team.

As the pregnancy progresses, the midwife is to communicate any change in the pregnancy status or changes in risk to the family or child to the named health visitor or health visiting team. The midwifery team should aim to notify the health visitor in a timely manner of identifying any significant changes to maternal or child wellbeing.

Important information

The following is a list of the types of information or issues affecting a mother, parent or parents which can be shared between midwifery and health visiting services ahead of the mandated health visiting contact:

• first-time mother
• parents under 19 years
• child protection or social welfare concerns
• domestic abuse
• safeguarding referral
• drug, alcohol or substance misuse
• anxiety, depression or previous post-natal illness
• previous history of stillbirth, neonatal or cot death or baby in NICU
• smokers living in the home
• late notification of pregnancy
• single parent in need of support
• parent chronic physical or mental ill health or disability
• learning difficulties
• mother needs an interpreter (and which language)
• ambivalence regarding pregnancy, low self-esteem or relationship difficulties
• unemployment or financial difficulties
• multiple births
• housing concern
• maternal BMI, below 19 or above 35
• asylum seekers or refugees
• care leavers or history of being in care

An individualised postnatal care and support plan could be developed with the woman in the later weeks of pregnancy. The care and support plan could include:

• relevant factors from the antenatal, intrapartum and immediate postnatal period
• relevant information on family context
• details of the healthcare professionals involved in her care and that of her baby, including roles and contact details
• plans for the postnatal period including infant feeding and physical and emotional wellbeing

After the birth of the baby, the midwifery services should update the health visiting services on the health of both mother and baby. The midwife can explain the purpose of the parent-held personal child health record and how it will be used by the midwife, health visitor and GP. At discharge from community midwifery care, the midwife could complete appropriate sections of the parent-held personal child health record to facilitate transfer of care to the health visitor. A child and family needs assessment, including partner or father’s needs may also be needed.

The New Baby Review is done by the health visitor and should ideally occur within 14 days after birth. However, in some circumstances, this is not possible. Ahead of this review, health visitors should have received information from midwifery services about the woman and the baby they are visiting.

Vulnerable women

An action plan could be a particular consideration for women and partners or fathers with complex social factors. Where a woman or father or partner is identified as vulnerable (for example, maternal mental health, learning disability, obstetric issues, domestic abuse and so on) they can be asked to co-create an individualised action plan with the midwife and health visitor. It’s recommended that a joint meeting with the family is considered. A joint handover in the woman’s home could be beneficial and enable efficient information sharing and care continuity. As this is associated with additional resource, it should be planned with care and provided only when appropriate.

If women require midwifery input after day 14, the midwife and health visitor should aim to have a verbal handover in addition to a written handover. This could be via an online meeting or phone call.

Antenatal contact by health visitors

From 28 weeks of pregnancy a face-to-face contact is to be made with every pregnant woman by the health visiting service. Many women welcome the opportunity to have contact with their health visitor antenatally (9). This is a mandated contact and often done in the woman’s home. To facilitate this contact, midwifery services need to provide information about women to the health visiting service. Many midwifery services share information after the 20-week scan when the pregnancy is seen as viable. This reduces the risk of health visitors contacting women who have suffered a miscarriage. After the contact, health visitors can share any relevant information about the woman and her pregnancy with the midwifery services.

Sharing of information with GPs

Sharing of information may also need to be done with the woman’s GP. As of 2020 to 2021, there is a new requirement for GPs to offer a 6 to 8 week postnatal check for new mothers, as an additional appointment to that for the baby. This makes communication between health visitors and GPs of greater significance than ever before. For example, for maternal mental health, a health visitor needs to refer to local service pathways or specialist services and inform the woman’s GP. It is also important to communicate with the GP if women have declined health visiting services (10).

Using evidence to support care continuity between midwifery and health visiting services

In this section, evidence and practice examples are presented to provide suggestions of how care continuity and collaboration between midwifery and health visiting services can be provided. These consist of:

• communication and information sharing
• understanding each other’s professional roles and responsibilities
• co-location of services
• resourcing

Communication and information sharing

Information can be shared in a number of ways; face-to-face or online meetings, telephone or email contacts, forms and through sharing of health records. Face-to-face meetings are particularly valued by healthcare professionals when supporting families with complex needs (5). Whatever form the communication takes, it needs to be timely and accurate to facilitate good support for women and their family. Practice example 6 shows how a midwife’s communication with a health visitor at postnatal discharge facilitated prompt action on behalf of the family.

Practice example 6: Postnatal communication (Norfolk and Waveney Local Maternity System)

A midwife discharging a postnatal woman called to inform the allocated health visitor that there was little food in the home and the access to Healthy Start support that had been in place had now ended. There were no other concerns and the family was under a universal care pathway. The health visitor was able to access a food parcel that same day and arrange delivery to the family. She then provided telephone support to the family to re-apply for Healthy Start vouchers to supplement their food budget.

Although the midwife and health visitor had not needed to complete joint contacts for this family under Universal care, prompt communication of an identified need meant that health visiting services were able to respond quickly and put support in place for this family.

Women report that fragmented communication between midwifery and health visiting services sometimes results in receiving inconsistent information from healthcare professionals (7). Women also find themselves having to repeat their clinical information and needs to each healthcare professional, which can be irritating and distressing, especially for women with pregnancy- or birth-related trauma. To avoid women having to repeat themselves and to enable consistent information, a tool was developed in Sheffield to share infant feeding plans between parents, midwives and health visitors (see practice example 7).

Practice example 7: Supporting breastfeeding plans: development of a tool to communicate infant feeding plans between parents, midwives and health visitors (South Yorkshire and Bassetlaw Local Maternity System)

The infant feeding leads for both midwifery and health visiting met regularly to explore how practitioners could be supported to engage in timely and effective communication. Extensive consultation took place with main stakeholders including community and postnatal midwifery matrons, postnatal ward and health visiting team leaders, advanced neonatal nurse practitioners, midwives, nursery nurses and mothers and it was agreed that a parent-centred approach would be most appropriate in line with the current personalisation agenda.

A booklet was developed where parents document feeding and expressing, read when and how the plan will be reviewed, how they will be supported back to breast feeding and access further information. It also assists health professionals to review feeding progress and to update the plan, in collaboration with the parents. In addition, a new feeding plan sticker is completed by the midwife and placed in the Child Health Record to alert the health visitor to consult the plan.

This tool is part of a process to promote seamless care between the midwifery and health visiting services in Sheffield, to support mothers whose baby is on a feeding plan. Previously, communication between the midwife, health visitor and mother lacked consistency regarding ongoing support when a feeding plan was in place.

There can be inconsistencies about how much information is shared (5). To overcome this, clear liaison forms can help information sharing. For example, Buckinghamshire, Oxfordshire and Berkshire West Local Maternity System has communication guidelines and a liaison form to help information sharing. The form outlines any additional support a woman may need at any time during her care, including physical, emotional, social or educational needs.

In some areas, information is shared via forms sent on email. In other areas, IT systems has been developed for rapid and regular information sharing. Information sharing can be challenging when different services have non-compatible or unaligned systems for women’s care records, rendering information inaccessible to other healthcare professionals. This has been identified as a communication barrier between midwifery and health visiting services, but can also include Family Nurse Partnerships and GP services as well (11). Practice example 8 outlines the information sharing in Bedfordshire, Luton and Milton Keynes Local Maternity System between midwifery and health visiting services.

Practice example 8: Local information sharing agreement for antenatal data exchange within Bedfordshire (Bedfordshire, Luton and Milton Keynes Local Maternity System)

An information sharing agreement was designed to provide the health visiting service in Bedfordshire with the demographic details of every pregnant woman booked for delivery in the Bedfordshire hospitals. This data is used to facilitate antenatal visits by health visitors. Accurate contact and personal details, and date of expected birth are required by the health visiting service after 24 and prior to 32 weeks of pregnancy. Previously, community midwives provided information direct to health visitors, however this was patchy, often inaccurate, provided on paper and has proven difficult to achieve. As a result, a low number of antenatal women received a visit prior to the birth by health visitors.

A joint working group was identified to include commissioners, the maternity service and the health visiting service. The maternity service investigated ways in which their electronic patient records system could be interrogated to obtain the data required and used a software package that could perform this function. A process was drawn up to include the following:

• what information would be required from patient systems and an information-sharing agreement was developed by the group and approved by Caldicott guardians of all services to ensure information governance requirements were met
• women who do not consent to share their information with health visiting services are not included
• secure transfer of data from midwifery to health visiting services
• information is transferred weekly to a secure email via NHS.net and sent to the single point of access at the health visiting service.
• health visiting administrator then access the woman on SystmOne and check pregnancy is still viable and allocate the antenatal visits to the relevant case holding health visitor for contact by 34 weeks

The service is currently achieving 80% of all antenatal visits each month. Of the 20% who have not been seen the majority are booked to deliver in out of area hospitals who do not operate this system. To date, very few women have refused an antenatal contact with the health visitor. Feedback from women is regularly positive, and shows that the service is appreciated.

Before the new process started, midwives were trained in the role of the health visitor, the current offer by health visitors for all pregnant women, how to gain consent from women, how to ensure the maternity system can read that consent has been given, what to do if a woman refuses to share information with the health visiting service, the importance of sharing complex information with the health visiting service and the importance of sharing late or out of area women with the health visiting team locally.

Understanding each other’s professional roles and responsibilities

Providing care continuity may be influenced by how well professionals understand each other’s commissioned service and scope of practice. If midwives and health visitors do not understand each other’s roles, it could lead to uncertainty of the tasks and timeframes the other healthcare professional is responsible for (5). This in turn may cause women to receive conflicting advice, reduced support or incorrect advice about the support available to them from each profession. To increase uptake of the health visiting antenatal contact, Bedfordshire, Luton and Milton Keynes Local Maternity System held training for midwives regarding the health visiting role and service. This, together with an improved electronic information sharing system, increased antenatal contacts (see practice example 8).

Collaborative working and information sharing is enhanced when midwives and health visitors feel part of a team, and have mutual respect and support for each other’s roles (5). When a midwife-health visitor team approach is adopted with women, it becomes easier for women to seek support and connect with services, and discuss their concerns. Practice example 9 provides an example of how a collaborative partnership can be developed.

Practice example 9: Developing collaborative partnerships (Cambridgeshire and Peterborough Local Maternity System)

Work undertaken by Cambridgeshire and Peterborough Healthy Child Programme (HCP) in partnership with North West Anglia Foundation Trust and The Rosie Maternity Unit at Cambridgeshire University Hospitals Foundation Trust led to the identification of the need for a clear, robust pathway for sharing information concerning antenatal booking.

Initially, meetings were arranged with the midwifery leads or matrons from both acute trusts and the Clinical Lead from HCP. The purpose of these initial meetings was to review current practice and identify where improvements could be made, using a PDSA (Planning, Doing, Studying, Acting) approach. These meetings were held face-to-face. Other key individuals who could support progression of this project were identified. The digital midwives were involved very early in the discussions.

Proactive commissioners have been pivotal in supporting the building of relationships and facilitating opportunities for change management. There has also been collaboration with service users.

Improved knowledge of each other’s professional roles and responsibilities can be developed through joint training. Face-to-face workshops can help build rapport and getting to know each other. This can result in an appreciation of each other’s roles, workloads and a greater willingness to work collaboratively, with the potential to improve sharing of information and providing women with consistent messages (12).

Co-location of services

Community hubs or family hubs within settings such as children’s centres can provide one-stop shops for services in convenient locations (13). Co-location of services can improve formal and informal communication, making it faster and more efficient to collaborate. Face to face contact can also help to build professional relationships, facilitate understanding of each other’s roles, as well as enable joint service planning and delivery (13).

To ensure greater collaborative working within a co-located setting, clear pathways and joint policies are needed. Alongside these, facilitative organisational structures and strong managerial support needs to be provided (13). For example, regular meetings between midwifery and health visiting managers allows for practice to be discussed and audited and any changes disseminated quickly.

Resources

A number of resources are needed to implement effective care continuity. Resources include appropriate staffing levels and workloads, adequate time, organisational and managerial support and shared IT systems (5). For example, managerial support is needed to develop standard operating procedures. Barriers to sharing information that can facilitate care continuity includes different service commissioners and therefore funding structures, IT systems, service boundaries and places of work. For example, receiving information about women who give birth in hospitals that are outside the area of the health visiting service can be difficult due to lack of systems and pathways and different ways of working Digital maturity that’s to say how well a maternity service is currently using digital technology and how well prepared the staff, processes and technology are for adopting new digital transformation initiatives, differs across England.

An example of how enhanced resourcing through managerial support and protected staff time led to improved multi-disciplinary working and care planning can be seen in practice example 10 derived from the Lambeth Early Action Partnership (LEAP) Health Team.

Practice example 10: Lambeth Early Action Partnership (LEAP) Health Team (South East London Local Maternity System)

An interprofessional health care team was formed to examine how the primary care professionals who provide care for pregnant women and their families could work better together. The team comprised 4 front-line clinicians (a local GP, a health visitor, and 2 midwives from different local trusts), operating in a flat hierarchy.

Team members were given protected time for this work, which they carried out on the basis of a one day a week secondment from their front-line work. They were given the autonomy to explore any issues that they identified, with a light-touch management steering approach, and were supported to disseminate and implement the solutions they identified.

Together they developed a forensic map of what did and did not work, gathering information through shadowing, meeting stakeholders and service mapping. This led to the development of a wide-range of projects including regular interprofessional meetings to discuss vulnerable families, shared access to local care records held electronically, shared practitioner contact lists, interprofessional training, and improved resources for assessment and referral. Outcomes include improved care planning and multidisciplinary working affecting areas such as safeguarding, medical concerns and family issues.

Measures of success or outcome

High-quality data analysis tools and resources are available for all public health professionals to identify the health (and health needs) of the local population. This contributes to the decision-making process and plans to improve services and reduce inequalities. Commissioners and local services need to demonstrate the impact of their services and this can be achieved by using local measures. Below are examples of outcomes and how they can be measured.

Benefits for women and their families

The following indicators can be used to measure benefits for women and families:

• smoking at time of delivery (available via Maternal and child health profiles)
• maternal mental health (available via Maternal and child health profiles)
• baby’s first feed breast milk (available via maternity services dashboard)
• breastfeeding at 6 to 8 weeks (available via Maternal and child health profiles)
• infant mortality (available via Maternal and child health profiles)
• low birth weight of term babies (available via Maternal and child health profiles)
• emergency hospital admissions (available via Maternal and child health profiles)
• care satisfaction (available via Friends and family questionnaire, CQC maternity services survey, maternity voices partnership)

Benefits for services

The following indicators can be used to measure benefits for services:

• number of mothers who received a first face-to-face antenatal contact with a health visitor (available via Health visitor service delivery metrics)
• new birth visits completed within 14 days (available via Health visitor service delivery metrics)

Benefits for staff

The following indicators can be used to measure benefits for staff:

• informal learning (staff survey and appraisal)
• sharing of resources (staff survey and appraisal)
• job satisfaction (staff survey and appraisal)

A range of background factors for each local area and other indicators relating to women, children and young people can be found in the Child and maternal health section on PHE Fingertips and in the annually updated local authority child health profiles, which can be extracted in PDF format from the Fingertips platform.

Associated tools and guidance

Policy

Better Births, 2016

Better Births 4 Years On: A review of progress, 2020

Healthy Child Programme: Pregnancy and the first 5 years of life, 2009

National Maternity Transformation Programme

NHS Long-Term Plan, 2019

The Best Start for Life: A Vision for the 1,001 Critical Days, 2021

Research

Aquino MR, Olander EK, Needle JJ, Bryar RM. ‘Midwives’ and health visitors’ collaborative relationships: A systematic review of qualitative and quantitative studies’, 2016, International Journal of Nursing Studies 62, 193-206

Aquino MRJV, Olander, EK, Bryar RM. ‘A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England’, 2018, BMC Pregnancy Childbirth 18, 505

Olander EK, Aquino MRJ, Chhoa C, Harris E, Lee S, Bryar RM. ‘Women’s views of continuity of information provided during and after pregnancy: A qualitative interview study’, 2019, Health and Social Care in the Community 27(5), 1214-1223

Sanders J, Channon S, Gobat N, and others. ‘Implementation of the Family Nurse Partnership programme in England: experiences of key health professionals explored through trial parallel process evaluation’, 2019, BMC Nursing 18, 13

Guidance

Antenatal and postnatal mental health: clinical management and service guidance, NICE, 2020

Health visiting and midwifery partnership – pregnancy and early weeks, 2015

Health Visiting Programme: Pathway to support professional practice and deliver new service offer Maternal mental health pathway 3, 2012

Making Every Contact Count

Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors, NICE, 2010

Postnatal care up to 8 weeks after birth, NICE, 2015

Examples of practice

LEAP health team

The Lambeth Early Action Partnership (LEAP) health team consists of 2 midwives, a health visitor, and a GP, led by a public health specialist. The team works within the South East London Local Maternity System, but was funded by the National Lottery Better Start fund. The team does not see families directly but instead works with local organisations to improve communication pathways between midwives, health visitors, GPs and other services to enhance joined-up working amongst the primary health care team surrounding pregnant women and families with children aged 0 to 3.

The team has set up inter-disciplinary training to share skills and is working with their local area on developing trauma-informed services. The team won the 2018 Royal Society of Medicine and Centre for the Advancement of Professional Education John Horder Award for a multi-disciplinary team. In 2019, they won the Maternity and Midwifery Forum Team Award.

The published case studies and local practice examples can be found in the World Health Organization Collaborating Centre library.

1. Case studies
2. Local practice examples

References

1. Sandall J and others. ‘Midwife‐led continuity models versus other models of care for childbearing women’, Cochrane Database of Systematic Reviews, 2016 (4)

2. Homer CS and others. ‘Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997 to 2009)’, Midwifery, 2017, 48: pages 1-10

3. Edge D. ‘“It’s leaflet, leaflet, leaflet, then, see you later.” Black Caribbean women’s perceptions of perinatal mental health care’, British Journal of General Practice, 2011, 61(585): pages 256-262

4. Knight M and others. ‘Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study’, British Medical Journal, 2020, 369: page m2107

5. Aquino MRJV and others. ‘Midwives’ and health visitors’ collaborative relationships: A systematic review of qualitative and quantitative studies’, International Journal of Nursing Studies, 2016, 62: pages 193-206

6. Bilson A and PWB Bywaters. ‘Born into care: evidence of a failed state’, Children and Youth Services Review, 2020, pages 105-164

7. Olander EK, and others. ‘Women’s views of continuity of information provided during and after pregnancy: A qualitative interview study’, Health and Social Care in the Community, 2019, 27(5): pages 1,214-1,223

8. Aquino MRJV, EK Olander and RM Bryar. ‘A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England’, BMC Pregnancy and Childbirth, 2018, 18(1): page 505

9. Olander EK and others. ‘Women’s views on contact with a health visitor during pregnancy: an interview study’, Primary Health Care Research and Development, 2019, 20: page e105

10. King-Hicks K and J Jessup. ‘A 0 to 19 report on behalf of South East and North West Children, Young People and Families ADPH Networks’, 2020

11. Sanders J and others. ‘Implementation of the Family Nurse Partnership programme in England: experiences of key health professionals explored through trial parallel process evaluation’, BMC nursing, 2019, 18(1): page 13

12. Olander E and others. ‘A multi-method evaluation of interprofessional education for healthcare professionals caring for women during and after pregnancy’, Journal of Interprofessional Care, 2018, 32(4): pages 509-512

13. Olander EK, MRJ Aquino and R Bryar. ‘Three perspectives on the co-location of maternity services: qualitative interviews with mothers, midwives and health visitors’, Journal of Interprofessional Care, 2020, pages 1-9