The word midwife originates from Middle English: probably from the obsolete preposition mid meaning ‘with’ and wife in the archaic sense of meaning ‘woman’ (Oxford Dictionaries, 2015). The current International Confederation of Midwives (ICM) (2011) definition concurs, stating that the midwife ‘works in partnership with women’. Therefore, the idea of the midwife working with women is not new; however, the expectation of women being equal partners in the decision-making process about their care has become a priority in recent government policy and professional regulation.
What is a service user?
There is no one definition of a healthcare service user. The Health Professions Council's (HPC) definition is (Chambers and Hickey, 2012: 5):
‘Those who typically use or are affected by the services of registrants once they qualify from programmes and become registered (e.g. patients, clients, carers, organisational clients, colleagues e.t.c.)’
From the service user's perspective, the Shaping our Lives (2015) National User Network views the term as active, positive and meaning more than one thing including the entitlement to receive welfare services and the belief that the shared experience of using services empowers the individual to have a voice and some control over the kind of services they want. Maternity services differ from other healthcare services in that the majority of women and babies receiving care are not ill, but fit and healthy. The definition of a service user in this context, therefore, is more time specific, namely those women who access maternity services from ‘the period from conception to shortly after birth’ (Blunt, 2014: 4), after which point the baby is also a service user.
What is current policy?
The concept of the ‘patient’ no longer being a passive recipient of care is captured in current policy with the phrase ‘no decision about me, without me’ (Department of Health (DH), 2010a: 3). It is embedded within maternity services in response to a succession of policy documents starting with Changing Childbirth (DH, 1993), which identified choice, control and continuity of care as the most important elements of maternity care. This landmark report has been followed by a succession of policy documents outlining how services should be high quality, individualised and woman-centred (DH, 2004; DH and Partnerships for Children, Families and Maternity, 2007). Most recently, the key messages from Midwifery 2020 (DH, 2010b) are that women's needs must be met by ensuring they are supported to have a positive and life enhancing transition to parenthood. From the service user's perspective, the Patient Experience Network for NHS England's report on how to improve maternity service users' experiences (Blunt, 2014) also recommended greater involvement and a louder voice for service users.
What is the Nursing and Midwifery Council's standpoint?
The Nursing and Midwifery Council (NMC) sets standards in relation to the quality of undergraduate education and continuing professional development (CPD); professional behaviour and practice to ensure the public consistently receive high quality, evidence-based healthcare. The newly updated Code (NMC, 2015) clearly states the interests of service users must come first by ensuring their privacy, dignity and confidentiality are preserved and their needs are recognised, assessed and met. Furthermore, the introduction of revalidation (NMC, 2015) to replace the post-registration education and practice (Prep) standards (NMC, 2011) includes the requirement for midwives to demonstrate to the NMC on a regular basis that they continue to remain fit to practise. This will, in part, be evidenced by five written reflective accounts over a 3 year period, based on the requirements of the Code, using feedback from service users, patients, relatives, colleagues and others (NMC, 2015).
What do women want from maternity services?
A literature review into women's definitions of ‘a good midwife’ identified the possession of theoretical knowledge and clinical competency as key attributes; however, good interpersonal skills and moral/ethical values are seen as equally as important for a service where women feel supported, empowered and informed (Borrelli, 2014). Nicholls et al (2011) identified the three most important qualities of a good midwife: provision of individualised care, good communication skills and being life-long learners. In terms of policy, the Health Care Commission's survey in 2007 found that women identify communication, support, being involved in their care and being treated with respect, dignity and kindness as key to a positive childbirth experience.
How is service user satisfaction measured?
The Friends and Family Test (FFT) was launched by NHS England in April 2013 and implemented in maternity services in England from October 2013 with the aim of providing service users with a voice regarding the quality of the care they have received. The test asks service users to answer the question ‘would you recommend this service to friends and family’ with a descriptive six-point response scale from ‘extremely likely’ to ‘extremely unlikely’. This trigger question is then followed by an open-ended question such as, ‘why have you chosen this response?’ to elicit more in-depth, qualitative feedback. By asking people's opinion on the services they have received, it is hoped that the quality of care, both good and poor, will be highlighted in order to improve services to ensure service user expectations are met (NHS England, 2015). In maternity services in England, women are asked about their opinion of the care they have received at three points in the pregnancy contiunuum: in the antenatal period (at 36 week antenatal appointment); at birth or on the postnatal ward (at discharge or following a home birth; in the postnatal period in the community (at discharge from the community midwife). The way service users are surveyed is decided at local level with options including online surveys, telephone interviews, SMS/Text messages, apps or postcards (DH, 2013b). The results are then published on the NHS Choices website thereby providing women with the opportunity to make choices regarding their pregnancy, informed by previous service users' experiences.
‘ The three most important qualities of a good midwife: provision of individualised care, good communication skills and being life-long learners ’
What does this mean for midwives?
Policy and professional regulation dictate that midwives should work in partnership with the women in their care to ensure the service they receive is of the highest quality in the ante-, intra- and postnatal periods. The service user has been given the opportunity to comment on this care through policy in the form of the FFT and through professional regulation with the requirement for midwives to write reflective accounts using service user feedback, to evidence how they are meeting the requirements of the Code (NMC, 2015). The question is can these political and professional measures ensure all women are being cared for by ‘a good midwife’? Can the complex ‘soft skills’ identified as key attributes by women themselves (Health Care Commission, 2007; Nicholls et al, 2011; Borrelli, 2014) be measured by a six-point scale?