Ackerman B, Cooke P, Hutcherson ALondon: RCM; 2009

Allen D Ethnomethodological insights into insider–outsider relationships in nursing ethnographies of healthcare settings. Nurs Inq. 2004; 11:(1)14-24

Baker SR, Choi PYL, Henshaw CA, Tree J ‘I felt as though I'd been in jail’: Women's experiences of maternity care during labour, delivery, and the immediate postpartum. Feminism and Psychology. 2005; 15:(3)315-42

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011; 343

Improving care for refugees and asylum seekers—Training for midwives pilot delivery report. 2011. (accessed 11 June 2015)

Burns E, Fenwick J, Schmied V, Sheehan A Reflexivity in midwifery research: the insider/outsider debate. Midwifery. 2012; 28:52-60

Care Quality Commission. Homerton University Hospital NHS Foundation Trust, Homerton Hospital Quality Report. 2014. (accessed 11 June 2015)

Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011; 118:1-203

Christian MS, Edwards BD, Bradley JC Situational judgment tests: Constructs assessed and a meta-analysis of their criterion-related validities. Personnel Psychology. 2010; 63:83-117

Corbin J, Strauss A, 2nd edn. Thousand Oaks, CA: SAGE; 1998

Creswell JWThousand Oaks, CA: SAGE; 2007

Darzi ALondon: DH; 2008

Deery R, Hughes D, Kirkham MOxford: Radcliffe Publishing Ltd; 2010

Maternity Matters: choice, access and continuity of care in a safe service.London: DH; 2007

Liberating the NHS: greater choice and control. A consultation on proposals.London: DH; 2010a

Delivering expectations. Midwifery 2020.London: DH; 2010b

2013. (accessed 11 June 2015)

Esposito NW Marginalized women's comparisons of their hospital and freestanding birth center experiences: a contrast of inner-city birthing systems. Health Care Women Int. 1999; 20:(2)111-26

Fannin M Domesticating birth in the hospital: ‘Family-Centered’ birth and the emergence of ‘Homelike’ birthing rooms. Antipode. 2003; 35:(3)513-35

Foureur M Creating birth space to enable undisturbed birth. In: Fahy K, Foureur M, Hastie C Edinburgh: Books for Midwives; 2008

Gaskin INew York: Bantam Books; 2003

Towards better births: A review of maternity services in England.London: Commission for Healthcare Audit and Inspection; 2008

Hodnett ED, Downe S, Walsh D, Weston J Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev. 2010; 8

The birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth. Birthplace in England research programme. Final report part 4. 2011. (accessed 11 June 2015)

Hyde A, Roche-Reid Midwifery practice and the crisis of modernity: implications for the role of the midwife. Soc Sci Med. 2004; 58:(12)2613-23

Keating A, Fleming VE Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective. Midwifery. 2009; 25:(5)518-27

Kirkham MLondon: Books for Midwives; 2003

Koch T Implementation of a hermeneutic inquiry in nursing: philosophy, rigour and representation. J Adv Nurs. 1996; 24:(1)174-84

Lavender T, Chapple J An exploration of midwives' views of the current system of maternity care in England. Midwifery. 2004; 20:324-34

Martin KA Giving birth like a girl. Gender and Society. 2003; 17:(1)54-72

Munro J, Jokinen MLondon: RCM; 2008

Newburn M The best of both worlds - Parents' motivations for using an alongside birth centre from an ethnographic study. Midwifery. 2010; 28:(1)61-6

London: ONS; 2013

Overgaard C, Fenger-Grøn M, Sandall J The impact of birthplace on women's birth experiences and perceptions of care. Soc Sci Med. 2012; 74:(7)973-81

Pollard KC Does being ‘with women’ mean being ‘with midwives’? How relationships between midwives affect their support for women's choices in childbirth in the UK. In: Balin RE New York: Nova Science Publishers Inc; 2005

Raleigh VS, Hussey D, Seccombe I, Hallt K Ethnic and social inequalities in women's experience of maternity care in England: results of a national survey. J R Soc Med. 2010; 103:(5)188-98

Redshaw M, Heikkila KOxford: National Perinatal Epidemiology Unit; 2010

Passive smoking and children.London: RCP; 2010

Rubin HJ, Rubin I, 2nd edn. Thousand Oaks, CA: SAGE; 2005

Ryan P, Revill P, Devane D, Normand C An assessment of the cost-effectiveness of midwife-led care in the United Kingdom. Midwifery. 2013; 29:(4)368-76

Sandall J Midwives' burnout and continuity of care. British Journal of Midwifery. 1997; 5:(2)106-11

Sandall JD, Devane DH, Soltani H, Hatem M, Gates H S Improving quality and safety in maternity care: The contribution of midwife-led care. J Women Health. 2010; 55:(3)255-61

Sandall J, Homer C, Sadler E Staffing in maternity units, Getting the right people in the right place.London: The King's Fund; 2011

Sandall J, Soltani H, Gates S Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2013; 8

Saunders D, Boulton M, Chapple J, Ratcliffe J, Levitan J Evaluation of Edgware Birthing Centre.London: Barnett Health Authority; 2000

Shallow H The birth centre project. In: Kirkham M London: Books for Midwives; 2003

Homerton safety review after claims from ‘unhappy midwives’. 2014. (accessed 11 June 2015)

Review of evidence about clinical, psychosocial and economic outcomes for women with straightforward pregnancies who plan to give birth in a midwife-led birth centre, and outcomes for their babies. Report of a structured review of birth centre outcomes. 2005. (accessed 11 June 2015)

Taylor J The intimate insider: Negotiating the ethics of friendship when doing insider research. Qual Res. 2011; 11:(1)3-22

Walsh D A birth Centre's encounters with discourses of childbirth: how resistance led to innovation. Sociol Health Illn. 2007; 29:(2)216-32

Walsh D. Subverting the assembly-line: Childbirth in a free-standing birth centre. Social Science & Medicine. 2006a; 62:(6)1330-40

Walsh DJ ‘Nesting’ and ‘Matrescence’ as distinctive features of a free-standing birth centre in the UK. Midwifery. 2006b; 22:(3)228-39

Walsh D, Devane D A metasynthesis of midwife-led care. Qual Health Res. 2012; 22:(7)897-910

Yoder E Compassion fatigue in nurses. Applied Nursing Research. 2010; 23:191-7

Creating a culture of ‘safe normality’: Developing a new inner city alongside midwifery unit

02 July 2015
24 min read
Volume 23 · Issue 7



To investigate how midwives and midwifery managers were attempting to provide choice for women, through the creation of a service with a distinct culture from the obstetric unit (OU) prior to the opening of a new alongside midwifery unit (AMU).


Fifteen purposively sampled midwives and midwifery managers from three practitioner groups: prospective birth centre midwives, obstetric unit midwives and midwifery managers involved in the AMU set-up were interviewed using semi-structured interviews.


Through the development of the AMU, staff perceive that low-risk women will be provided with a choice of ‘safe normality’ for their birthing experience. Staff are attempting to create a culture of care that is distinct from the OU while still benefiting from the perceived safety of close proximity medicalised care. This distinct culture is being created through the choice of an AMU over other alternatives; the design of the AMU and the environment created; and the selection of appropriate staff that have competence and confidence in their ability to deliver women-led care. However, there is a risk that the distinct culture of care may be in jeopardy due to the blurring of boundaries between the AMU and OU. This is partly as a result of the practical issues associated with a case mix skewed towards high-risk women in a deprived inner city context and the strong belief by OU midwives that ‘safe normality’ is already available within the OU.


The AMU appeals strongly to the perceptions of midwives and midwifery managers as providing good quality midwife-led care and a safe place of birth that offers choice that will be accepted by the women they care for.

In the UK, the majority of maternity care is provided through obstetric units (OUs) (accounting for approximately 93% of births). The remainder of births taking place at home (2%); within stand-alone midwifery units—located on a site away from obstetric services in a nearby town or with other community or acute health services (2%); or within alongside midwifery units (AMUs) located in, or on the same site as a hospital to provide quick access to anaesthetic, obstetric and neonatal services where required (3%) (Healthcare Commission, 2008). OU care is provided by both midwives and obstetricians, with the latter taking lead responsibility for women who are at a higher risk in pregnancy and birth. There has been concern for a number of years that OUs continue to over-medicalise birth. This can result in unnecessary intervention and lower satisfaction with the birth experience by women and their partners—commonly termed the ‘medical model of care’ (Newburn, 2010).

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • New content and clinical newsletter updates each month