Presented by Katherine Tadman & Kim Tyler Community Midwives Medway NHS Foundation Trust

 Women presented at their GP for confirmation of their pregnancy.  The GP referred the woman to the midwife who arranged a 1 to 1 booking appointment at 8-10 weeks, usually in the surgery.  At this appointment the booking notes were completed by the midwife.  In addition information regarding diet, lifestyle, screening, benefits, antenatal education, etc were given to the woman to take away and read.  A follow up appointment was made for 16 weeks.

 The one to one appointment could take 1 hour plus  A lot of time was taken up by filling in notes and forms  Each woman had to be given information on screening, diet, lifestyle, timing of appts etc  They were often unsure about their medical/family history

 Having “booking clinics” meant repeating the same information several times in succession. ..... And the question must be raised, was the information given the same standard at the end of the clinic as it was at the beginning?????  In other words were the women all receiving the same quality of care?

 Women should be in contact with a midwife or health professional within 6 weeks into their pregnancy to allow time for information exchange and appropriate screening.  The NICE guidelines for antenatal care also recommends that the first contact should be with a midwife who should give written information with an opportunity for discussion of issues including folic acid supplementation, foods, lifestyle and antenatal screening.

 States that by the end of 2009 every woman should have direct access to a midwife in order to enable earlier access to maternity services.  Information regarding the need to seek care as early as possible including self referral to a midwife should be publically available in easily accessible settings e.g. Pharmacies, community centres, libraries etc.  Effective exchange of information as early as possible in the pregnancy allows women to make choices regarding their care.  This will have a positive effect on pregnancy outcomes.

 By the time the woman saw the midwife they could be 8, 9 or even 10 weeks pregnant.  Often women waited some time for a GP appointment, and then had to wait for a midwife appointment.  Decisions regarding screening had to be made during the initial booking appointment without them having any opportunity to read and discuss their options.  And until their initial midwife appointment, they had no way of directly accessing midwifery services.

Could we do better?????

 We wanted to set up a system that gave women access to our services as soon as their pregnancy was confirmed.  To give them all the information they needed to make informed choices regarding their care.  To make their initial one to one appointment a time for discussing these choices and exchanging information instead of filling in forms and talking at them.

 We tried splitting the appointment in 2 shorter appointments, the first one to give them all the screening, diet and lifestyle information as well as their notes to fill in.  Then bringing them back a week later to complete the booking after they had read all the information.

 Although we were fulfilling the criteria, we still wondered if the quality of the information given was consistent.  There was still too little time for discussion.  Our colleagues argued that it could take longer overall.

Back To The Drawing Board!

 We could get woman to come to us as a group?  Give them all the information as a short presentation, including contact details for their named midwife?  Back this up with written information to take home and read?  Give them their pregnancy notes to fill in?  Invite partners as well?  Give them a one to one appointment at a mutually convenient and appropriate time at the end of the session.

Would it Work?????

 There is not a wealth of literature on the subject of the booking appointment but most research confirms its importance as a health promotion and information giving opportunity (CEMD 2004, CESDI 2001, Rhoads 2005, Baston 2002, Methvern 1989)  Tolofari (2007) wrote about setting up a group booking scheme when faced with booking large numbers of women who needed booking urgently  The NICE guideline for antenatal care (2003) suggests 2 appointments before 12 weeks to accommodate the large amount of information needs in early pregnancy

 So in August 2008 we set a date to change the booking system.  We decided to hold the sessions weekly at lunchtimes, the first session was scheduled for October  The local Health Centre was chosen as it had a large meeting room.  GP’s were sent a letter outlining the proposal and were given a letter to give women when they presented with a positive pregnancy test.  Staff at the Health Centre agreed to take bookings for the sessions.

 Women were given the letter by the GP receptionists  The letter explained that this initial session would be a group session  It also highlighted the fact that it was an information session and that no personal information would be discussed  Women were given the number of the health centre and asked to book themselves onto a session as soon as they could  Posters giving a direct phone no to access the sessions were placed in other public areas e.g. Libraries etc

 We devised a “script” to ensure that we covered all necessary information. This was given in booklet form to the women to take away with them  Notes, screening booklet and information leaflets including our contact details were given out at the start of the session  At the end of the sessions we invited general questions and offered to answer any personal questions on a one to one basis  The women were then given their individual one to one appointment at an appropriate and mutually convenient time

 We soon realised that we had to hold the sessions at least weekly  This gave us managable groups of around 8-10 couples  When we missed a week, we found couples a logistic nightmare when sorting out the one to one appointments  We had to be very organised and have everything ready and to hand for the sessions  We had to be very firm about not discussing any individual problems – this meant being available after the session to answer any individual questions in a private area

 We had to emphasise the importance of women filling in their notes etc before their one to one appointment. We only allowed minutes for this, not long enough if nothing was filled in!  We devised a guide to filling in the notes etc, having it written down seemed to help!  We thought about holding separate sessions for primips to avoid distractions by noisy children but this was not practical so instead we ensured that one of us was available with toys etc as a distraction.

 By January 2009 we had opened the sessions to all the GP surgery’s in our area.  We invited feedback from the women....this was overwhelmingly positive with only 2 out of approximately 43 women attending in February 2009 stating they would have preferred a traditional booking (Both multips).  We found that we could complete the one to one appointment comfortably within 25 minutes.  Waiting times in the clinics went down.

 “You will waste time and resources (i.e. notes) by seeing women as early as 5 weeks, they could miscarry”  “It only takes me 30 minutes to do a booking anyway”  “My GP’s wont like it”  “multips wont want to come, they already have all the information”  “Its impersonal, I like to see my women myself”  “It’s just a timesaving exercise”

 3 of the four community teams in our trust have adopted the earlybird system.  We have introduced sessions on some Saturday mornings held in Childrens centres.  We hope to trial sessions in early evenings in order give more choice.  We hope to address ethnic populations by designing a booklet with all the information given at earlybird to give to these women in their own language. The one to one appointment can then be facilitated with the help of an interpreter.

 We hope that by the end of 2010 all women in our area will have direct access to a midwife without first seeing their GP if that is what they wish.  The information given to the woman will be consistent, research based and up to date.  Women will be able to attend a session that is convenient to their need i.e. Weekends and evenings.  Early engagement will lead to a rise in the uptake of further antenatal and parentcraft sessions.  We end up with happy parents and healthy babies.

That the families in our care are being offered the very best start to parenthood by receiving up to date information early in their pregnancy that will facilitate choice and lay the foundation for their continuing antenatal education. Yes it does save valuable midwifery hours, but if this means that in this time of midwifery shortages we are able to provide a better service and happier new parents surely that’s a good thing?

The proof of the pudding

The start of an exciting journey

Thank You