Evaluating one-to-one care in midwifery: a foundation for standards and evidence based policy
Submitting InstitutionUniversity of West London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Nursing, Public Health and Health Services
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.
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
- Standards of practice;
- nterventions in care and labour outcomes;
- continuity of carer;
- use of economic resources;
- women's responses to their care;
- 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
- 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
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
|Publications: scholarly refereed journals
|Publications: professional peer reviewed journals
|Publications/editorial: other professional and women's groups
|International Conference presentations (ICMTC 1996, 1999)
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
|• James Piercy
||Economist, University of York
|• Andy Vail
||Statistician, University of Leeds
|• Julia Oldham
||Research Computing Manager, University of Leeds
References to the research
Page L, and McCourt C (1996) Report on the evaluation of One-to-One
midwifery. London: Centre for Midwifery Practice, Thames Valley
University, (now University of West London).
Piercy J, Wilson D, Chapman P (1996) Evaluation of One-to-One midwifery
practice. York Health Economic Consortium and Centre for Midwifery
Practice. York: University of York.
Further research outputs
McCourt C, Page L, Hewison J, Vail A (1998) Evaluation of One-to-One
Midwifery: women's responses to care. Birth 25(2): 73-80.
Page L, McCourt C, Beake S (1999) Clinical interventions and outcomes of
One-to-One midwifery practice. Journal of Public Health Medicine 21(3):
McCourt C and Pearce A (2000) Does continuity of carer matter to women
from minority groups? Midwifery 16(2): 145-154.
Beake S, McCourt C, Page L, Vail A (2001) Clinical outcomes of One-to-One
midwifery practice British Journal of Midwifery 9(11): 700 - 706.
||North West Thames Regional Health Authority
||Research Design and protocol
||North Thames Regional Health Authority
|Hammersmith Hospitals Clinical
|Thames Valley University
||Women's responses to care
||Women's responses to care
|Johnson and Johnson
||General Research funds
|Ealing Hammersmith and
Hounslow Health agency
|Smith and Nephew Foundation
||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
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:
- English National Board for Nursing Midwifery and Health Visiting (ENB)
(1995) 'Changing Childbirth': An Educational Resource pack for midwives.
- Royal College of Midwives (RCM) (2008) Woman-centred Care Position
paper. London: RCM
- 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
- 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.