Background
Interprofessional collaboration is widely promoted across health services, including maternal and child health services, both in the UK [
1,
2] and internationally [
3]. According to the World Health Organization, interprofessional collaboration occurs when different healthcare professionals work together to improve care [
4]. The mounting evidence concerning the importance of one’s early childhood to the rest of the lifespan puts interprofessional collaboration high on government agendas as a strategy for addressing women’s and their families’ unmet needs and improving outcomes [
3,
5‐
7].
In the UK, midwives and health visitors (specialist community public health nurses) are key maternity care providers. These groups share overlapping professional remits both antenatally and postnatally and are encouraged to work together [
8]. Specifically, Public Health England and Department of Health (UK) partnership pathway outlines this working relationship such that midwives and health visitors should be communicating with each other during and after pregnancy regarding the health and wellbeing of mother and baby [
8]. Our recent systematic review of the international evidence on interprofessional collaboration between midwives and health visitors showed that collaboration in practice varied, and is influenced by interlinked structural (e.g. geographical distance, limited resources) and individual factors (e.g. communication, support for colleagues) [
9].
Previous research suggests that collaborative maternity care models can have a positive impact on health outcomes [
10], including breastfeeding [
7], mental health and smoking cessation [
11]. Conversely, poor interprofessional collaboration is associated with negative maternity care experiences, and can result in failures in care [
12]. It is therefore important to identify women’s experiences of midwife-health visitor collaboration, and explore how they envisage maternity services to be developed.
Women’s involvement in the exploration of interprofessional collaboration care models in maternity is limited (e.g. [
13,
14]), despite being service users [
15]. Sandall and colleagues [
12] have suggested that further research on women’s experiences of continuity of care models, which include various health professionals working together, is needed. A recent systematic review of continuity of care with doctors demonstrated that greater continuity of care (defined as repeated contact between a patient and a doctor) was associated with lower mortality [
16]. Continuity of care is also encouraged in maternity care guidance set out by the National Health Service (NHS) in England [
17].
Critical realism [
18‐
20] is a philosophical approach that allows for the understanding of the layers shaping individuals’ experience and reality, and the links between these [
21]. This asserts that reality is comprised of three levels: the empirical, the actual, and the real [
19,
20]. In the context of midwife-health visitor collaboration, the
empirical level concerns the directly observable, perceived and experienced. For example, a woman observes a midwife and a health visitor communicating about her care. Midwives’ and health visitors’ professional competencies as applied to care provision represent the
actual level; these influence the empirical, and are not always observable [
20]. At the deepest level – the
real – are the generative mechanisms causing the observable events. For example, relational factors such as mutual trust for each other [
22] and healthcare professionals’ limited control of financial or structural constraints imposed by the healthcare system [
14]. Therefore, women’s experiences of collaborative care as provided by midwives and health visitors are key to better understanding their care needs and service provision more generally. This study aimed to explore women’s (i) experiences of maternity care as collaboratively provided by midwives and health visitors, and (ii) their perspectives of how their maternity care can best be provided by these healthcare professionals together.
Discussion
This study explored women’s experiences of midwife-health visitor collaboration, as well as their ideal maternity care pathway. The main findings are: 1) women’s experiences of maternity care as delivered by midwives and health visitors are varied, 2) women perceived the communication between midwives and health visitors as limited, fragmented, and associated with conflicting advice, and 3) collaboration throughout the maternity pathway could be beneficial particularly in relation to information-giving and care co-ordination. Each of these will be discussed sequentially.
First, concerning midwife-health visitor collaboration, the findings showed that women’s experiences were a mixture of positive and negative ones, supporting previous research [
30,
31]. For example, a national survey of women’s maternity care in the UK (N= > 4500) found that over 75% of the respondents had positive care experiences [
32]. Women in this study reported valuing their relationships with midwives and health visitors who are supportive (e.g. showing interest in mother and baby) and active listeners. Interestingly, despite the women living in the same geographical area with similar service providers, women still reported varied experiences of care particularly in relation to contacts with health visitors in pregnancy. One possible explanation is the decline of the health visiting workforce in England by 10% (9491 vs. 8588 Full-Time Equivalent) in the 12-month period between June 2016–2017 [
33]. In addition, there has been a 16.88% reduction of antenatal contacts carried out nationally in Quarter 2 of 2017 (60,853 contacts) compared to Quarter 2 of 2016 (73,213 contacts) [
34]. A critical realist approach would also suggest that factors at the real level (e.g. healthcare workforce structure) are influencing the
empirical level given the diversity in women’s reported experiences [
18‐
21].
Second, women reported observing service fragmentation, evidenced by scant communication between midwives and health visitors. This reflects findings from the National Maternity Review, where women emphasised that good communication and information sharing amongst health professionals is essential [
35]. However, participants also acknowledged that women’s needs differ, which could partially explain why they reported limited midwife-health visitor communication. Research has shown that shared goals (e.g. smoking cessation targets) enhanced relationships between healthcare professionals including midwives and health visitors, which could be directly observed by women who are in contact with such services [
36]. Women reported continuity of care, and of carer as important. This has been shown to be linked with lower mortality in terms of continuity with doctors [
16] and needs to be explored in the context midwifery and health visiting. Whilst NHS England [
17] also highlights the value of continuity of care, and of carer, this is focussed on midwifery care.
Finally, women contributed strategies for improving current maternity care provisions, aligned with the National Maternity Review [
35] and Public Health England and Department of Health (UK) midwife-health visitor partnership pathway [
8], specifically focussed on interprofessional collaboration. These included service changes, most notably an increased offering of group-based antenatal care collaboratively delivered by midwives and health visitors within community-based services. Existing maternity care pathways set out in line with policies such as the
Healthy Child Programme [
1] recommend group-based antenatal classes delivered in community or healthcare settings to enhance social support. Accordingly, women in this study considered such classes as a valuable resource, and a channel through for obtaining social support. However, there is evidence to suggest that health visitor involvement in antenatal classes is lacking [
36]. Thus, currently available classes [
36] do not meet these women’s suggestion of classes jointly provided by midwives and health visitors and needs to be considered. Successful collaborative working in maternal health have been characterised by the provision of opportunities for health professionals to interact with each other and have shared activities [
32], which was also reported to be influential by midwives and health visitors. Taken together, the evidence highlights the potential value of group antenatal classes for women, midwives, and health visitors alike.
The participants also made recommendations for improving mental health and breastfeeding support. Both are core requirements of delivering the
Healthy Child Programme [
1]. Redshaw and Henderson’s [
32] research showed that the majority of the women they surveyed (N= > 4500, 82%) reported having been asked about their mental health, mostly by midwives, in pregnancy. Similarly, 90% of those surveyed were asked about their mental health postnatally, with 63% of these women reported having received support [
32]. It was not clear, however, which health professionals were involved in offering postnatal mental health support. It has been shown that group-based breastfeeding support interventions provided jointly by midwives and health visitors can improve breastfeeding, particularly when relationships between these healthcare professionals are strong [
7]. One plausible explanation for the participants’ desire for increased breastfeeding and mental health support is the nature of their personal circumstances. For example, some participants reported having limited proximal familial/social support. However, this finding needs to be interpreted with caution in keeping with a critical realist approach because women will have different constructions and interpretations of reality shaped by the resources and/or support available to them (
actual level), as well as their views on the kind of care that healthcare professionals ought to provide (
real level). Despite these differences which the participants were aware of, they still had shared experiences and needs, suggesting that these layers only provide a partial understanding of the complex nature of reality [
20,
21].
Finally, women suggested that their care pathway could be made clearer to them. This is in line with previous research, where women have stressed the value of being better informed about what they could expect from perinatal care such as the frequency of appointments and the purpose of these [
30]. Generally, it is known that communication is paramount to high-quality maternity care, both from women’s/families’ and health professionals’ perspectives [
35]. Communication was also reported as playing a pivotal role in enabling midwife-health visitor interprofessional collaboration [
9], and identified by women as a key issue in maternal and child health [
36]. Specifically, participants were confident in healthcare professionals’ ability to communicate information in an appropriate manner. They stressed that obtaining their consent for health professionals to share information with each other needs to be done in a respectful way. From a critical realist standpoint, this finding suggests that women lack an awareness of the barriers to communication experienced by midwives and health visitors, which are beyond these individuals’ direct/observed experiences. Specifically, these healthcare professionals do not presently have shared information systems [
35], despite the evidence suggesting that such systems can facilitate collaborative working between these healthcare professionals [
9,
10].
Strengths and limitations of the study
A key strength of this study lies in the manner in which women’s views were elicited – through semi-structured interview questions, and women-led, open group discussion to visualise their ideal maternity care pathway [
24]. This format allowed women to explore their experiences together, and comment on each other’s views and experiences. The diversity of the views obtained from the participants is a further strength of this study. In addition, as is recommended in focus group literature [
23], the groups maintained a level of homogeneity in that they were all based in the same geographical area, with some women attending the same General Practice (GP) surgery. Furthermore, the participants were similar in terms of the number of children they had and gave birth in similar settings.
However, the participants were a self-selected sample, and evidently proactive about their maternity care (e.g. accessing Children’s centres that they advocated for). Additionally, there were pre-existing relationships between a few of the participants (i.e. some were known to each other) which could have influenced how they responded to the questions. However, all the women appeared comfortable in the group setting, and still openly discussed their experiences with the rest of the group.
Clinical practice and research implications
The present study contributes to the body of knowledge by validating past research [
35,
36], and enhances our understanding of maternity care collaboratively provided by midwives and health visitors from the recipients’ perspective. The findings indicate that it is paramount that women are listened to, offered consistent services, and provided unbiased information and advice by midwives
and health visitors. In addition, women’s care pathways need to be made clear to them at the outset, including information about the health professionals who may be involved in their care, and these professionals’ roles. In terms of midwife-health visitor interprofessional collaboration, the participants showed an awareness of the issues previously raised by these healthcare professionals [
10,
37‐
39] such as poor communication and limited access to shared information, thereby supporting the evidence on the identified barriers and enablers to collaborative working [
9]. Whilst the recommendations presented here (e.g. group-based antenatal and postnatal appointments/drop-ins, centralised records) may not necessarily apply to nor be desired by all women, the findings highlight the importance of providing individualised care delivered collaboratively by midwives and health visitors. Thus, it is crucial that women’s voices are heard and considered when providing care [
12,
35], ultimately promoting informed choice.
Considerations for future research include exploring specific service changes for improving maternity care pathways such as the feasibility of group-based antenatal classes jointly provided by midwives and health visitors, and evaluating the impact of midwife-health visitor communication on health (e.g. rates of postnatal depression, mortality) and service outcomes (e.g. referral management). Maternity care models and guidance developed should include health visitor input if services are to achieve midwife-health visitor collaboration throughout the care pathway. In addition, future research should include other stakeholders such as policymakers and service commissioners to obtain a better understanding of how midwifery and health visiting services could be redesigned to support collaborative working.