Summary of the impact

The thesis of this case study is that a demonstration project, encompassing an organisational change, utilising the principles that underpinned a Department of Health (1993) policy for maternity care, has been influential in corroborating and establishing a philosophy for maternity services in industrialised countries within the 21st century.

The project provided an evidence-based approach to standards and quality of midwifery care. It demonstrates outcomes influencing national and international guidelines and policies for maternity practice. As a result, current midwifery guidelines for the UK and other countries, such as Australia, New Zealand, The Netherlands, Sweden and Canada, include elements of continuity of care/r (including one-to-one care and case loading) informed choice for women and evidence-based practice.

Underpinning research

A collaborative centre for the development of midwifery practice was set up between Queen Charlotte's and Hammersmith Hospitals NHS Trust and Thames Valley University (now University of West London). This implemented a new model of maternity care, as a pilot scheme in 1993, with evaluation integral to its development. The model was based on the ideals of women-centred care embodied in the Department of Health (1993) document `Changing Childbirth'. A comparative evaluative study reviewed and compared two organisational cultures; one was an obstetric model with a birth population of 4,000 deliveries per annum, the other — a group featuring woman-centred care with caseload midwifery practice partnerships (One-to-One care). This group, in a small NHS unit, had a birth population of 1,000 deliveries per annum. The evaluation studied the effects of the differences between the two cultures with the following investigative strands:

1. Standards of practice;
2. nterventions in care and labour outcomes;
3. continuity of carer;
4. use of economic resources;
5. women's responses to their care;
6. attitudes and responses of midwives and other professionals.

Each strand was a study in its own right. Collective evaluation provided in-depth detail and rigour by using qualitative and quantitative research to assess the impact of organisational change. An interim report with analysis in 1995 led to a final report 1996. The scheme continued until the end of the 1990s when changes occurred within the NHS Trust.

The methodological research applied to both organisational cultures included:

• Clinical audit — a study of clinical case notes or medical records (strands 1, 2 and 3);
• economic evaluation undertaken in conjunction with the University of York (strand 4);
• a study of women's views (strand 5) — evaluation comprised a questionnaire survey; additionally, interviews and focus groups were used specifically for different ethnic groups;
• an ethnographic study of professionals' experiences, (strand 6) — collected case study data on 35 caseload midwives over 46 months. The outcomes included job satisfaction due to the relationships formed with women and substantial development of midwives' autonomy, responsibility and skills.

Monitoring was through an advisory committee including medical and midwifery experts. Outcomes indicated: lower rates of key interventions in labour, a high degree of continuity of carer (giving particular benefits for vulnerable ethnic minority women; higher levels of preparedness for labour, satisfaction with birth experience, and cost effectiveness.

The One-to-One project was a `showcase' for continuity of care/r and group practices. The caseload approach has continued within the NHS Trust. In 2013 this offers care for vulnerable women. Research output included:

Main reports of study	2
Publications: scholarly refereed journals	3
Publications: professional peer reviewed journals	7
Publications/editorial: other professional and women's groups publications	10
International Conference presentations (ICMTC 1996, 1999)	2
Book/book chapters	3

Key researchers were:

• Lesley A Page	Professor of Midwifery, 1992-2000
• Christine McCourt	Senior Research Fellow/Principal Lecturer, 1993-1996
• Trudy Stevens	Researcher Practitioner, 1995-1997
• Sara Beake	Research Midwife/ Assistant, 1993-2010
• Alison Pearce	Research Assistant, 1965-1996

External membership:

• James Piercy	Economist, University of York
• Andy Vail	Statistician, University of Leeds
• Julia Oldham	Research Computing Manager, University of Leeds

References to the research

Further research outputs

Research grants/awards:

Process	Body	Amount (£)	Purpose
Seed funding	North West Thames Regional Health Authority	30,000	Research Design and protocol
Evaluation of Project	North Thames Regional Health Authority	20,000	Clinical audit
	Hammersmith Hospitals Clinical Audit Committee	16,100	Clinical Audit
	Thames Valley University	5,596	Women's responses to care
	Kinds Fund	25,000	Women's responses to care
	Johnson and Johnson	75,000	General Research funds
	Ealing Hammersmith and Hounslow Health agency	28,000	Economic study
	Smith and Nephew Foundation	20,000	Case study of change

Details of the impact

Outcomes of the One-to-One midwifery project provided evidence that changing the organisational culture, with principles of care promoting a woman-centred philosophy, would meet the needs of women in the 21st century. This has been germinal in future developments. Women-centred care, with the partnership approach to developing relationships with women, promoted by the One-to-One project, informed the evidence to the House of Commons Select Committee on Health (2003): Provision of Maternity services. The English National Board led adoption of the outcomes from this evaluation, to create change and educate midwives to a new philosophy of care, for Nursing Midwifery and Health Visiting (ENB 1995). The principle of women-centred care is now embedded within professional guidelines throughout the UK, such as the National Service Framework standard 11 (Department of Health 2004). The project is referenced in the RCM position paper on woman-centred care (RCM 2008), and the philosophical approach exemplified by the project underpins the progress towards midwifery-led units in the UK (RCM, 2000).

The philosophy of care that the project propounded has assisted with the instigation of movements for organisational change in Australia (Queensland Government, 2012) and New Zealand. The impact of this women-centred approach to care has been demonstrated in the development of midwifery practices in the Canadian provinces (Page 2003).

Whilst organisation of care into caseloading and group practices has not been unique to the project, the findings indicated the value of this form of care. Further research in this area shows that women of ethnic minority prefer integrated community-based midwifery-led care (McAree et al 2010). Dissemination of the One-to-One practice reports within the United Kingdom and internationally has led to the development of varied forms of this type of organisation of care, as shown for example in the Wirral (http://www.onetoonemidwives.org/our-service) and Australia: (http://www.latrobe.edu.au/news/articles/2012/article/one-to-one-midwifery-improves-care).

The Nursing and Midwifery Council now requires student midwives to undertake caseload practice within their training. Adopting caseload or group practice requires adaptation to local circumstances. With current emphasis in policy, for example 'Maternity Matters' (Department of Health 2007) on promotion of an integration of maternity services within the community setting, this evidences encouragement of women to make their own choices for care (a value emergent from the One-to-One report). The term One-to-One is now well-accepted into the language of maternity services for care, antenatally during labour and the post natal period, and is advocated by the National Childbirth Trust in their position statement: (http://www.nct.org.uk/sites/default/files/One- to-one%20midwifery%20care%20in%20labour.pdf).

Continuity of care/r is now considered `best practice' and in particular for disadvantaged and vulnerable women and those in labour (RCM, 2000). The study of vulnerable women in 2013, is being developed further through a PhD thesis at the University of West London researching ethnic minority women's experiences of maternity care.

The importance of continuity in labour and the associated reduction of interventions has led to this becoming a requirement in current policy as well as the women centred care approach to care as indicated in Changing Childbirth. Endorsement is evident in current NICE guidelines (http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf). The advantageous effects of One-to-One care in labour in providing continuity, is recognised as a fundamental requirement within standards of midwifery practice in labour (RCOG 2007), e.g. the minimum standard for normal birth stipulated by the Berkshire West Clinical Commissioning Group Service Specification for the Royal Berkshire Hospital.

Women view continuity of care/r as beneficial (McCourt and Stevens, 2005) and consider this their ideal form of care (NPEU, 2007). An example of 'women voting with their feet' to have One to One care is given on the website of a women's campaign group in maternity care in Yorkshire (http://bornstroppy.wordpress.com/).

Thus the findings from the original One-to-One study have now become accepted within policies and guidelines for maternity care.

Sources to corroborate the impact

• House of Commons Select Committee on Health (2003) Provision of Maternity services. Fourth report of session 2002-3 Volume 1. London: HMSO.
• English National Board for Nursing Midwifery and Health Visiting (ENB) (1995) 'Changing Childbirth': An Educational Resource pack for midwives. London: ENB
• Royal College of Midwives (RCM) (2008) Woman-centred Care Position paper. London: RCM
  http://www.rcm.org.uk/EasysiteWeb/getresource.axd?AssetID=121546.
• Royal College of Midwives (RCM) (2000) Vision 2000. London: RCM.
• Page L (2003) One-to-One midwifery: restoring the "with woman" relationship in midwifery. Journal of Midwifery & Women's Health. 48(2): 119-25.
• Queensland Government (2012) Delivering continuity of midwifery care to Queensland women. A guide to implementation. Brisbane Queensland Government.
• McAree T, McCourt C, Beake, S (2010) Perceptions of group practice midwifery from women living in an ethnically diverse setting. Evidence Based Midwifery 8(3): 91-97.
• Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives, Royal College of Anaesthetists, Royal College of Paediatricians and Child Health (2007) Safer Childbirth. London: RCOG.
• McCourt C and Stevens T (2005) Continuity of carer: what does it mean and does it matter to midwives and birthing women? Canadian Journal of Midwifery Research and Practice 4 (3): 10-20.
• National Perinatal Epidemiology Unit (NPEU) (2007) Recorded Delivery: a national survey of women's experiences of maternity care 2006. Oxford: National Perinatal Epidemiology Unit.