Table 4 Evidence for cmo configurations

1: Leadership and support

No I think it is down to leadership. Leadership at board level but then also the heads of midwifery giving leadership roles to appropriate people and giving them enough time to lead implementation; I think that’s really key as well … but that the senior leaders have vision and drive and are really wanting it to happen so they are helping motivate that devolved leadership I think (Midwife Interview 1)

The senior managers who are I appreciate following government initiatives that are actually to implement this, but I think there’s a bit of a, I would say there’s a lack of faith. INT: What d’you think drives the lack of faith? RES: People don’t trust what’s going on. […] This feels very invisible, even though there’s lots of communication about it, it’s the nuts and bolts, people want to know how is this going to affect me? (Midwife Interview 3)

I work in a board that’s very, very supportive of each other and any change, this is transformational change, but in any change we have a good I suppose executive nurse director and good lead and work as a team so therefore, and she’s very, very robust in the way that she carries any project through (Midwife Interview 4)

It felt like they issued this report [Best Start] that this change is happening and that’s it and we’ve got to make it happen, and there was just very little information, had to sort of make it up as they went along. (Midwife Interview 5)

Could there have been stages to the strategy, could there be a bit more instruction with the strategy about how this would be implemented? I know there were timelines but there wasn’t even a year to prepare, it was like ‘right, get on with it’. So I feel… so then the strategy has come out without people expecting it and then there wasn’t even time to talk to people about how they felt about it. (Midwife Interview 7)

The team highlighted that having an approachable line manager ‘makes a difference’ to the transitioning to the new model. They highlighted how supported they felt and indicated that without this support and approachability they would have found the process significantly more challenging. (Summary of Facilitated CMC Team Meeting (FCTM) Jan 2019)

There is a strong belief among the midwifery workforce that implementation of CoC will not happen. The resistance and concerns that were identified in the midwives baseline survey have not dissipated. The midwives are anxious and desperate for information about how a future model might work, were it to be implemented. (Summary of FCTM Jan 2019)

2: Trusting relationships

It was great to have continuity of care which made me feel safe and listened to (Women’s Evaluation)

We had such a positive experience of pregnancy and birth, thanks to [the team]. Going into the labour room and being greeted by a familiar face was invaluable, and we felt so well cared for and supported. (Women’s Evaluation)

Having the same midwife for me made the experience better than what it was like having my fist [sic] child. I built a great relationship with [name] and throughout my labour she knew exactly the way I wanted things done. (Women’s Evaluation)

Had excellent midwifery care. There was a sense of investing in a relationship which made a positive difference to my birthing experience. I also felt confident as my midwife is experienced on labour ward (Women’s Evaluation)

Team members are increasingly using each other for moral support. Each member is developing their own support network within the team (and for some outwith), and there is a strong sense of mutual respect and consideration for all members (Summary of FCTM Jan 2019)

The team are really noticing the benefit of getting to know the women, and in their own environment. They report on the satisfaction this gives them in terms of being able to better relate to and understand the women’s preferences and needs, which helps them advocate better for the women, and the ‘nice’ feeling associated with developing a good working therapeutic relationship; the type of relationship they give high value to as part of good professional practice. (Summary of FCTM Feb 2019)

I think what’s really important as well is that midwives need to be treated as respected professionals and adults, they also need to behave in that way but that often, that hasn’t been how services have been run and how midwives have experienced being a midwife, and so I think that means that we don’t get the best from them and how they could practice (Midwife Interview 1)

So the midwife getting to know the woman and how she is and her behaviours and her background and her history so that it’s easier for the midwife to pick up any changes, I think that’s important, I think that would make a difference and I think also for the woman to have built up that relationship and trust already with a midwife and she feels comfortable with her, if there are any changes that she can disclose them, she feels comfortable to act, for example in labour, she feels more comfortable and relaxed because she’s got the midwife that she knows and trusts (Midwife Interview 5)

You’re never going to be, like, one team with the people in the hospital cause they’re based in the hospital and that’s what they do all the time and they don’t, they’re not with you all the time, they don’t know what your work’s like on a day to day basis, you know, it is just being part of a separate team. And then they’re always going to have so many midwives that come in once it’s up and running, you know, I think it’d be quite difficult for them to get to know everyone and for it to feel like all one big happy family sort of thing. So I think it’ll always feel like you’re going into someone else’s workplace rather than… (Midwife Interview 9)

3: Practice change

They’re thinking about their practice and that’s [improving continuity] just an example of one of the things that they’re doing differently (Midwife Interview 4)

So that [sickness in CMC team] provided opportunities for some midwives to go out and just cover for a short couple of weeks and one of the midwives didn’t want to come back, … actually none of the midwives wanted to come back and they’ve continued to work on that model, and because they’re coming into the hospital and working they’re talking to other midwives and we’re now getting quite a surge of midwives who want to work within the continuity models (Midwife Interview 4)

Yeah it’s a different experience. You get to know the woman in her home and how she is in her own environment which I think is important, what her environment is and I think when they let you into their home then that’s again building up another layer of trust. (Midwife Interview 5)

If you know the women better hopefully, I would imagine that means that then you have a much better understanding of that woman’s needs, her life, her home, her everything that then your care is more tailored to her and that presumably then has some impact on the outcomes. (Midwife Interview 7)

And I think it’s [home visit] really important in changing the way that women view their pregnancies, … I think that by having all their checks with a midwife in a very clinical space that they feel the need to be in a clinical space when they need help, …, so I think early labour, … that women who want to see a midwife and they don’t feel comfortable being at home and they feel like they need to go into the hospital because they feel like they need something and they shouldn’t be at home. So …, I feel like our women have definitely been… I don’t think they’ve been going into the hospital as early and being sent home as often as the women I used to have and I feel like… Yeah, like, niggling or contracting regularly but they’re still quite mild, … so I don’t know if the women are feeling just more comfortable being in their own homes in labour and if they’re in labour during the day, like, we’re going out to pop in and be like ‘is everything okay, stay away from triage, don’t go in till you’re ready’ sort of thing. (Midwife Interview 9)

Women seem more relaxed not being in a clinical environment and divulge more (Summary of FCTM Jan 2019)

The significant majority of the team prefer the increased autonomy they have in relation to managing their work life. Being able to work from home, managing own diary and to an extent, working pattern, have been reported as positives and a few feel returning to shifts would now feel very constrained. However, others continue to find it difficult to get the balance (Summary of FCTM April 2019)

The team are beginning to appreciate the enhanced job satisfaction working this model will be able to provide. They are enjoying the relationship the model enables them to build with the women and flexibility in the care they are able to provide (Summary of FCTM Jan 2019)

One of the most significant themes … is the feeling of isolation within the labour ward; being in a room caring for a woman, not entirely sure of care management, equipment, or processes and not feeling able to access peer support if it is not proactively offered, possibly through fear of judgement or reprisal. This does not mean support is not available; rather it suggests a breakdown in communication between the midwives in the room and those they are able to access for advice or assistance (Summary of FCTM Feb 2019)