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).
Against the background of an increase in routine birth interventions and an increase in caesarean section rates, interest in midwife-led care has also increased. There is strong evidence to suggest that a ‘social model of care’ with an emphasis on the humanistic approach, is as safe as obstetrician-led care and is associated with increased satisfaction rates among women and their families (Walsh, 2007; Phillips, 2007; Deery et al, 2010; Hodnett et al 2010; Hollowell et al, 2011; Walsh and Devane, 2012; Sandall et al, 2013), including marginalised women (Esposito, 1999). In addition, midwife-led care has been found to be cost-effective for women with low-risk pregnancies (Munro and Jokinen, 2008; Darzi, 2008, Department of Health (DH), 2010a; 2010b; Ryan et al, 2013). Therefore, policy recommendations encourage women to have a choice for the place of birth (DH, 2007; Birthplace in England Collaborative Group, 2011; Sandall et al, 2013).
AMUs have been recommended as an acceptable choice for primiparous women, in particular (Birthplace in England Collaborative Group, 2011; Sandall et al, 2013). They provide women with a low-risk of pregnancy complications individualised and family-centred maternity care (Shallow, 2003; Deery et al, 2010). Such units increase the prospects for spontaneous vaginal birth, while reducing medical interventions and increased maternal satisfaction for women who choose or require little or no medical intervention during labour and birth (Saunders et al, 2000; Hodnett et al, 2010). A Cochrane review comparing AMUs with obstetric care settings found significant decreases in the rates of medical interventions in the alongside units and similar perinatal mortality and morbidity and maternal morbidity (Hodnett et al, 2010). They have also been described as ‘best of both worlds’ with parents suggesting they valued both ‘biopsychosocial’ safety and obstetric safety (Newburn, 2010).
An AMU was the model chosen by a large inner city unit in the north of England, to provide low-risk women with a choice of place of birth and choice of place of postnatal care. The new AMU is situated in a city with one of the highest birth rates in England (about 6200 births in 2010/11) and one of the highest rates of infant mortality—almost double that of England as a whole (Office for National Statistics (ONS), 2013). The catchment for the unit covers an area with a diverse ethnic population including long-established British Asian communities and significant recent immigration from EU countries such as Poland, Slovakia, Latvia, Lithuania and the Czech Republic (ONS, 2013). Most research on midwife-led care has focused on stand-alone birth centres—as such, the opening of a new alongside birth centre, in particular, serving a deprived and ethnically varied population, provides a unique opportunity to research how the culture of care is established for a diverse client population. A major contributory factor in the development of this culture is the attitudes and expectations of the midwives who have been instrumental in setting up the new service; and those who will work in the new birth centre and the alongside OU. Therefore, this study aimed to explore the experiences of midwifery managers and midwives regarding the decision-making and planning of the AMU and their expectations of how the service would be operationalised, before the AMU was open to women and their families.
Methods
A qualitative study of the expectations relating to a new AMU among staff from the existing obstetric service provision was conducted. Semi-structured interviews (face-to-face and by telephone) were conducted with three key midwifery stakeholder groups: prospective birth centre midwives, OU midwives and midwifery managers.
Recruitment of interview participants
For the midwifery managers group, key informants were selected for the particular role they had in the instigation, planning and set-up of the new AMU. The sample comprised a maternity services commissioner, head of midwifery, midwifery manager with a community background and birth centre experiences, matron for midwifery quality and a consultant midwife.
Five prospective AMU midwives were sampled of a population of 21 who had selected to work in the birth centre. They were selected initially on the basis of their response to the midwifery manager's call to be involved with the AMU. In addition, five midwives were sampled to reflect the population of 51 OU midwives on the basis that they had elected to stay on the OU. For these two stakeholder groups, midwives were selected for inclusion into the study with the aim of achieving a maximum variation sample to represent varying levels of midwifery skills and experiences (Creswell, 2007). All potential participants were approached directly by the lead researcher with the study contact details forwarded via Trust emails.
Ethical approval
R&D approval was provided by the NHS Research and Development office at the participating hospital Trust. Ethical approval was sought and granted.
The interviews
An interview guide was used to aid data collection (Rubin and Rubin, 2005) to ascertain the participants’ views on, and expectations of, the new AMU. Interviews covered the anticipated quality of care and satisfaction with services; competence/confidence of staff, safety of care for women and how they would expect that practice would differ from the current obstetric unit. In addition, prospective AMU midwives were asked to describe their motivations behind volunteering to work in the AMU and those who were remaining in the current obstetric service were asked why they had not expressed an interest in working in the AMU.
Data collection took place over a period of 3–6 months, before the opening of the new AMU. Interviews were conducted in a private location within the participant's workplace and lasted between 30 and 90 minutes (most commonly around 40 minutes). All interviews were audio recorded.
The primary researcher on the study was known to all participants working as she is a senior midwife and supervisor of midwives in the unit where staff were recruited. The researcher maintained a reflexive approach and kept a journal during the study in an attempt to address and make sense of the issue of familiarity with the participants (Koch, 1996).
Analysis
Data analysis techniques described by Corbin and Strauss (1998) were used, including open and axial coding and constant comparative analysis. Coding categories were revised and refined and a comparative conceptual framework was used to explore the expected philosophy of care and practices across OU and AMU. The descriptive coding and categorisation was undertaken by the chief investigator. Further coding refinement and interpretation of data and integration with relevant literature was discussed across the team.
Quotes are provided from the interview transcripts in order to demonstrate the themes presented. The initials provided in brackets at the end of each quote denote the stakeholder group from which the quote came (MM—midwifery manager; M-AMU—prospective AMU midwife; SM-AMU—prospective AMU senior midwife; M-OU—OU midwife; SM-OU—OU senior midwife and JM-OU—Junior OU midwife).
Results
‘Creating a culture’: Selection, design and staffing of AMU
The individuals directly involved with service planning and delivery were attempting to develop a distinct culture of care to that available in the OU, which they felt would be of benefit to low-risk women. Staff wanted to prepare a service that would provide a ‘safe normality’, by which they intended to facilitate normal vaginal births, free from medical intervention that did not include instrumental deliveries and or epidural analgesia. Staff were furthermore aware that achieving this would require the empowerment of women by midwives as well as the positive influence of the birth environment.
Before the service was opened, the foundations that could broadly be termed ‘culture’ were being laid. This was through the choice of an AMU over other midwife-led options; how the environmental characteristics of the new AMU were designed and how they had staffed the AMU in preparation for the first women to use the service.
Strong commitments to a birth centre: Selection of AMU as ‘safe normality’
The catalyst to start the process of delivering a midwifery-led service was the national mandate, Maternity Matters (DH, 2007) that set out the National Choice Guarantee to offer women a choice of place of birth and postnatal care. While it was felt that some choice was provided, in the homebirth form, the portfolio of provision was lacking a midwifery-led alternative, which the team had a strong desire to introduce into their catchment:
‘It was linked to the publication of Maternity Matters and the recommendations about the four choice initiatives and we were very clear that across the area the midwifery-led service was the bit that was missing.’ (MM)
Managers were committed to the idea of delivering a birth-centre option, and while the Maternity Matters remit was a major driver, the strong push from management and the commitment to making a birth centre work reinforced the desire to create a real and different option for their heterogeneous population:
‘One of the other factors was, we started to promote homebirth as more of a normal option, a more realistic option but we still found within particular sectors of our umm … population we weren't getting a huge uptake, our South Asian population certainly weren't … even though they were being offered a positive choice of birth at home they actually are not taking up that option and there were obviously various diverse reasons for that. And also homebirth, as we know is predominantly done by white middle-class women and we don't really have that many of them really so this was seen as a … this was seen as a real kind of opportunity to offer a lot of women a better birth experience rather than a few women a better birth experience really to improve the, um, the options and choices for women across the board all sectors of society.’ (MM)
While the decision to incorporate a midwifery-led service was regarded as crucial in order to offer real choice, the location of the birth centre was a point of debate. Several factors influenced the decision to create an AMU as opposed to a stand-alone birth centre. These included: financial implications; intelligence from reported experiences of stand-alone birth centres; the managers’ understanding of current research evidence; and the location they felt their staff and service users would feel most comfortable with based on both their practice experience and from women who were consulted via the Maternity services Liaison Committee (MSLC) within the catchment area:
‘I think there were 7 or 8 options laid out. Yes, um, and I think really we made quite a pragmatic decision because the other thing about stand-alone is that it's going to be much more expensive … and because we've been such a medicalised consultant-led unit for quite a number of years I think we assumed, and I hope rightly, that probably the staff would go with this much more readily than a stand-alone and as it turned out a lot of stand-alones have closed down and have all become co-located and I think our decisions have also indicated that the Birthplace study, which recommends really that co-located alongside birth centres are really the way forwards.’ (MM)
As noted above, those developing the new service wanted to ensure that they catered for the preferences of their ethnically diverse group, understanding that an AMU would meet these requirements:
‘A lot of our clientele don't speak English and lot of them now, especially the eastern European are very disappointed if a doctor isn't involved. And that's difficult for us to sort of get our head, we're trying to keep them low-risk and they just can't understand why.’ (SM-AMU)
An important aspect is the ‘middle ground’ of providing a distinct choice with its own unique culture, while maintaining the perceived safety (for both staff and service users) associated with birth on the OU:
‘But I think it's just reassuring for the women that they've not got a sort of 20 minute ambulance ride across the city to actually get where they need to be.’ (M-AMU)
Design of AMU
Several options were considered by the Trust maternity work stream of managed clinical network for children and maternity services regarding the design of the AMU, these were:
Option three offered the least building work and as the most cost-effective was considered to be the ‘pragmatic solution’. However, for some managers there was the risk that developing the culture of the AMU may be compromised by the proximity to the OU, in that it would be more difficult to be established as an independent or separate unit:
‘But I think we've got to give this birth centre a real chance to stand on its own and become a proper birth centre not just an extension as I say not just a normal birth bit of the labour ward and I think that really … That's one of the biggest dangers of a co-located birth centre and that your staff kinda keep getting pulled into the melee of the labour ward. But having said that I think we also have to have a bit of a reality check because it sits within an acute Trust and therefore it is part of the Trust and y'know there are things that will apply so it is just getting the balance completely right and that will be a challenge.’ (MM)
The development of the AMU was part of the Trust-wide programme of capital improvements for the corporate strategy from 2008 to 2015. The building work on the AMU was completed and an agreed opening date was set for 26 November 2012. The seven-room unit houses two fast-filling, temperature-regulating birth pools, a communal kitchen with a dining area facility and a new lift linking the birthing facilities with the two postnatal and antenatal wards on the above floors, to enable a private and dignified transfer for those just having given birth. There would also be options for early discharge home postnatally, at 3 hours (infant newborn physical examinations and hearing screening would be provided) for women who chose to do so.
The AMU was designed so as not to resemble a hospital ward, for example, there are no posters or health and safety notices and an absence of medical equipment. The lighting is adjustable, birthing balls, mats, stools and hanging cloths are all available to the women. The AMU rooms contain Bradbury couches and beds which are placed discreetly out of the way to provide maximum space and encourage women to be mobile and change positions during labour. This is distinct from the OU where the hospital bed is the main focus of a room.
The design was intended to achieve a:
‘Warm, friendly and a relaxed birth environment that is a safe maternity service, providing high quality care and offering real choice.’ (MM)
For prospective AMU midwives of all levels, they considered the new environment to be central to the women's satisfaction with the birthing experience. It was perceived by the study participants that being relaxed and comfortable would be beneficial and contribute greatly to a positive birth experience.
‘I can give the women, you know, the calming atmosphere, not sort of like, the consultant-led unit where there seems to be lots of noise and lights are on … I think the whole atmosphere of the place will actually be completely different, that's what the women want and I think that's what the midwives want. Just have a place, where the, sort of, atmosphere, where the environment as well as being safe for the women where they can be.’ (SM-AMU)
It was very important to midwives that, while the environment in the OU was different to that on AMU, at least the standard of appearance and staffing should be equivalent. Therefore, those requiring a transfer between AMU and OU did not have a noticeable shift in standards:
‘We absolutely have to refurbish this labour ward here because Mrs X can't help it if she's high-risk and has to go to the labour ward and why does she have to get a lesser environment and lesser service and so actually as you know we've refurbished the labour suite and it's got a really high standard and a really good standard of decor and done up all the rooms and also looked at the staffing, we've done staffing reviews in the mix as well so everywhere is staffed appropriately’ (MM).
Essentially, in setting up the AMU the service wished to provide enhanced choice—in particular, for a midwifery-led service primarily for low-risk women with a diverse range of sociodemographic characteristics. While the staff realise the potential impact of the environment in creating their vision for a more social model of care provision, the culture the staff creates is also of central importance:
‘And I think that environment is part of it but I think being part of a good team.’ (SM-AMU)
Staffing of AMU
Crucial in the development of a differing culture of care within the AMU was the process of staff selection.
‘The challenge will be staffing. Whether or not the unit can be adequately staffed to leave the birth centre to function as it's meant to function, and the second thing is whether or not the midwives can provide a culture of normal accident-free birth?’ (MM)
This process was largely based on self-selection (excluding newly qualified midwives), in the expectation that those midwives with the appropriate skills, attitude and expectations would be able to work comfortably and autonomously in the new environment and help to generate the culture of care they were hoping to create:
‘In terms of how we recruited the core team to the birth centre, we asked for expressions of interests, um, it's always been a no pressure thing—you either express an interest and we'll take that forwards with you or you're happy to stay where you are. So we had, um, a couple of sessions with people who expressed interest and we involved service users in that as well. They weren't interviews, they weren't formal; they were really informal but we felt that service users had to be involved so we had a couple who came along and they gave us feedback on their impressions during discussions and actions and people talking about their aspirations and where they saw themselves working and everything and so that kinda gave us a core team of staff.’ (MM)
Having the appropriate skill-mix was achieved through taking a whole team approach—community midwives were selected to work flexible shifts, in a team model within the AMU, on the basis they would come with existing homebirth skills.
The confidence of the workforce in AMU
In order to deliver the supportive, nurturing and individually-based care midwives see as crucial with AMU, midwives stressed the importance of having confidence in their midwifery skills in the more ‘exposed’ environment of AMU:
‘Yeah, I find now—6 years since I've been here. I do feel now that I have a little bit more confidence in being able to say I'm absolutely fine I don't need this lady reviewing.’ (SM-OU)
The OU-experienced staff were recruited for their readily available intrapartum skills and familiarity with the hospital system, in addition to having self-selected themselves as having sufficient confidence to work autonomously. Both the community midwives and those who had been working within the OU are skilled in keeping births normal and intervention-free and are able to provide emotional support and encouragement to their colleagues. Assumptions were made about the staff proficiencies; OU and community intrapartum skills were seen to be the same as those for midwifery-led units.
Blurring of boundaries: Challenges of a high-risk population and pre-existing ‘safe normality’ within OU
High-risk population and associated staffing issues
Both midwives and midwifery managers recognised that they practise within a deprived area and, as a result, the population of women they see is skewed towards higher-risk deliveries.
‘I think the feeling is it [AMU] won't be very busy because the majority of our women are high-risk y'know and we look, we often look at our board and think none of the women will be on the birth centre, because of their risk factors. We have a very high-risk, diverse population and there are some low-risk women but y'know majority of them come with some risk factors.’ (M-AMU)
It is a possibility that the AMU will not just be occupied by traditionally defined low-risk women and that transfers in either direction will dilute the distinct culture of intervention-free and supportive care in the AMU. For example, initially women who smoke during pregnancy did not meet the inclusion criteria for birthing in the AMU, given the association between smoking in pregnancy and perinatal mortalities (Royal College of Physicians, 2010; Cantwell et al, 2011). However, management and staff reconsidered their initial reservations aimed at safeguarding AMU practice due to the high rates of smokers found in a deprived inner-city context. While operational policies and interdisciplinary team working will avoid inappropriate high-risk transfers of women to the AMU, at busy times staff will decide those women who are the lowest risk from the high-risk cohort to be transferred to the AMU.
A senior birth centre midwife states that midwives on both units should be facilitating a positive teamwork ethos for the provision for good care for women on the obstetric unit as well as the birth centre:
‘We might be a separate birth centre but at the end of the day we are still a team. The wards, maternity assessment centre and transitional care unit are the same. We're about caring for women and giving them the most safe appropriate thing that they require and y'know I suppose I couldn't be over here [on the birth centre] and have them [on the labour ward] absolutely heaving but to me it'll be the women that will be transferring. I would say to them [on the labour ward] which women are the most appropriate that you could transfer to me (on to the AMU) who we could look after here.’ (SM-AMU)
However, if a possible consequence of this is that staff also end up moving between the OU and AMU to meet the clinical demand, one of the aspects fundamental to creating the distinct culture of the AMU—how the staff were selected—will potentially be compromised and may have the unintended consequence of diluting this culture:
‘So as a band 6 midwife that worked on here [OU], having to then work with midwives who don't quite have that confidence and then having to put them in that position of further undermining their confidence by giving them high-risk cases in a low-risk area, is that gonna happen?’ (M-OU)
Staffing constraints do not allow for options of ring-fencing AMU staff to prevent this threat. In staffing the AMU from the existing intrapartum service there were risks associated with conflicted loyalties between supporting long-standing colleagues in the OU in times of high demand/sickness absence and loyalties to protecting the AMU (and women's choice).
In addition, the additional safeguards in place to deal with higher risk women, if they are being cared for in the new AMU, may also act to compromise the distinct culture they are aiming to achieve:
‘We still have to follow the guidelines because we are still part of the Trust and hospital whereas sort of consultant … of the high risk side there are still guidelines that we have to follow, they are monitored.’ (M-AMU)
Satisfaction with the birth experience: Normality and woman-led care
Of great importance to all midwives was that women and their families were satisfied with the birth experience. This, in part, was related to achieving a normal delivery—intervention-free midwifery care, which in turn is likely to bring about good outcomes. However, a focus on normality was not exclusive to the prospective AMU midwives; OU staff were also keen to promote normality. It was important for OU midwives to emphasise that OU practice does not mean that everything has to be medicalised, since women are still able to have a normal birth without interventions:
‘It's very important, I think it is absolutely essential that you have to have that mindset of the lady that is coming in is low-risk, let's try and keep it low-risk. Sometimes problems arise and that can't be helped but your mindset has to be that, yes, this is an obstetric-led unit and it is medicalised, but yes we do have the low-risk women that come to have their babies and are offered a 3 or 6 hour discharge and some of the women don't have any interaction with medical staff at all.’ (SM-OU)
Yet, the birth experience on the OU can often be confounded by risk, but that satisfaction can be achieved outside of traditional ‘normality’:
‘Because I have quite a bit of a passion about keeping women that are high-risk getting them a decent birth experience and I think that we erm lose sight of, erm, in the middle of this ‘pre-eclamptic’ or in the middle of this ‘high BMI’ sitting on the bed, this is a lady that does actually have the same wishes about her birth experiences as the low-risk women.’ (M-OU)
A potential danger was identified that in the process of creating a specific culture of intervention-free care in the AMU, these core midwifery skills, and accompanying culture of normal care might decline within the OU.
‘I'm not gonna see obviously as many low-risk labours, that's gonna be the thing. So then there's that “will I lose my skills in normal birth?” I don't know but as I say we do try to instil normal birth into the most ‘abnormalist’ [sic] situations anyway so hopefully that will continue, erm, and you will still have women that you can still possibly say, “No you don't need to come in just yet”. Or go outside a room and talk to the doctors about it, they don't need to always come into the room.’ (M-OU).
Among prospective AMU midwives, it was felt that satisfaction with the birth experience within the alongside birth centre would be related to care being led by what the women and family want, rather than by what the midwives want:
‘I look at it from both sides, from a midwives’ view, I want the women to go home sort of knowing that they've had a satisfactory birth, a safe birth, they've got what they wanted, it's sort of not midwife-led birth centre, it's sort of women and partners and family-led birth centre so y’ know it's just trying to get the ethos across to the women.’ (M-AMU)
This view was strongly echoed by the OU staff, seeing the women at the centre of care:
‘Trust, it's a partnership. No woman should walk through the door and be told what to do. It's about working with them and not for them. You are working together.’ (M-OU)
Discussion
The perceptions and understanding of the three sets of practitioners on the development of an AMU have been examined in this study.
While there had been a national mandate regarding the implementation of choice for place of birth (DH, 2007), the Trust in this study showed dedication to providing genuine choice through the development of an AMU. However, the development of an AMU was almost the only option available to the management team given the perceived shift of focus away from stand-alone birth centres, the financial and logistical constraints the Trust was under and the need to develop something that would be acceptable to their diverse population.
The midwives in this study drew on the body of evidence relating to the closure of many FMUs that had been set up to replace OU services since 2001. In some cases, these FMUs became AMU services at sites where OU had been centralised (Dodwell, 2013). For example, a major ongoing investigation into the deaths of several women at Homerton University Hospital NHS Foundation Trust AMU revealed concerns relating to a delayed recognition of deterioration in patients, lack of communication between staff and under-involvement from consultants. ‘Unhappy midwives’ referenced several unspecified serious incidents; however, the investigation did not identify any failings in the standard of care (Bragg et al, 2011; Care Quality Commission, 2014; Stephenson, 2014).
The AMU option was thought to provide a ‘safe normality’ within which the midwifery management and midwives were committed to creating a distinct culture of care. This solution to providing choice, through deploying midwife-led models of care across the service for low- and (potentially medium-) risk women, is generally acknowledged as being important in order to release obstetricians to focus on women with much more complex needs, and has associated cost-saving measures while maintaining levels of safety (Sandall et al, 2010; Ryan et al, 2013). Women have been found to value ‘the best of both worlds’—being close to the OU for medical assistance or an epidural, yet being in a separate ‘nurturing environment that promoted normality’ (Newburn, 2010: 9).
The AMU option was considered particularly attractive to the local population, given the proximity to the OU and subsequent transfer times (Stewart et al, 2005; Newburn, 2010). It is also acknowledged that AMUs can encompass a diverse range of birthing beliefs (Gaskin, 2003; Walsh, 2006a) and foster a greater sense of control and respect for marginalised women than conventional OU care (Esposito, 1999).
The managers drew on their knowledge of the mixed clientele in the population being service to influence the selection of an AMU. Survey evidence has indicated that women from minority ethnic groups worry more about labour and birth than White women, and have been found to have less confidence and trust in staff and are more likely to be left alone and worried (Raleigh et al, 2010; Redshaw and Heikkila, 2010).
Those involved in the development of the AMU felt the design aspects of the AMU were an important component of the distinct culture. The importance of the environment has been observed as being central to the perceptions held by both midwives and women (Foureur, 2008). Walsh (2006b) noted that women frequently had instinctive responses to the environment. Prospective AMU midwives felt that despite refurbishment of the OU, which makes it a ‘nice place’, there were still distinct differences between that and the new AMU—particularly in terms of creating a calming environment with a lack of bright lights, high noise levels and frequent potentially disruptive ward rounds. OU birth settings, with the professional domination, have been accused of stripping women of dignity and independence (Martin, 2003; Baker et al, 2005; Keating and Fleming, 2009).
Staffing was seen as key to creating the desired culture in the new AMU—by recruiting those with the competence and ‘confidence’ to provide midwife-led care. As practitioners within both settings (prospective AMU and OU) were pursuing an ideal of ‘normality’, midwifery managers adopted an informal selection process to recruit midwives with an appropriate skill-mix to work in the new AMU. The value of ‘getting the right people at the right time’ regarding staffing in maternity units is well documented (Sandall et al, 2011). Evidence suggests when such units provide a supportive environment, midwives gain confidence in their practice, yet there is also a risk of this confidence being restricted to practices that will only reflect the dominant unit model (Hyde and Roche-Reid, 2004; Lavender and Chapple, 2004; Pollard, 2005). This concern was echoed in this study; however, those who volunteered (self-screened) to work in the new AMU felt excited about practising and promoting normal midwifery care and, in particular, were looking forward to being autonomous and having control of intrapartum care outside of the medical profession. The increased professional autonomy, clinical freedom and accountability of practice available through working in a midwife-led setting is important for the job satisfaction of those who select to work in this model of care provision. Through this there is the potential for reducing the risk of burnout and low satisfaction stemming from the over-technocratic practices that can be dominant in OU care (Sandall, 1997; Yoder, 2010).
There was an assumption that those who would be working in the AMU would have the appropriate skills. Although the prospective AMU midwives were comfortable facilitating water births, a number lacked some of the wider skills such as hypno-birthing, massage and non-pharmacological approaches for pain-relief such as aromatherapy (Ackerman et al, 2009; Overgaard et al, 2012). This was articulated by some of the prospective AMU midwives who were familiar with the set-up in other midwifery-led units. Other methods of staff selection could have been utilised, such as objective structured clinical examination selection based on a relevant scenario. It has been shown that use of formal employee selection processes that use specific assessment tools, for example ‘situational judgment tests’, can be effective in predicting applicants’ responses to complicated decisions (Christian et al, 2010).
Interviewees also uncovered threats to the possibility of creating the distinct culture of care desired for the AMU. The ‘safe normality’ achieved through co-location was also the greatest potential risk to blurring the boundaries between the AMU and OU, especially given the higher-risk population this unit would serve. It has been noted that dilution of the midwife-led model of care is greater in AMUs compared with stand-alone midwifery units. The Birthplace study (Birthplace in England Collaborative Group, 2011) found a higher percentage of planned transfers from AMUs among first-time mothers (40%) compared with stand-alone midwifery units (36%); this was considerably less common for those having a subsequent pregnancy (planned stand-alone midwifery unit transfers—9%; planned AMU transfers—13%). Transfers for epidural are known to be more common from AMUs than FMUs (Birthplace in England Collaborative Group, 20111). Working with a high-risk population, through the potential movement of less ‘risky’ high-risk women from the OU to AMU, and the associated staffing issues, the distinct culture of the AMU may be also be in jeopardy.
In addition, midwives are aware that they are bound by hospital-wide practice guidelines that dictate the management of intrapartum care (Hodnett et al, 2010; Sandall et al, 2013). It has previously been noted that the potential effects of an alternative environment (such as the new AMU) could be overcome by standard institutional policies and practices (Fannin, 2003). This threat remains a possibility, but it would remain in the hands of midwifery managers and those midwives within both settings to attempt to safeguard against this.
Strengths and limitations
This study provides important qualitative insights into how midwifery managers and midwives attempt to create a distinct culture through the development of a small AMU. The data collected here capture the perceptions and experiences of the key stakeholder groups from midwifery involved in the setting up of a new AMU, importantly before the AMU was opened. The study has the additional strength of focusing on a community with a very diverse population—both ethnically and socioeconomically—and as a consequence the new AMU will be serving a mixed-dependency group. We understand the importance of the ‘cultural characteristics’ created within midwife-led care on the potential for generating many of the positive birthing outcomes (e.g. reduction in interventions) associated with this model of care (Walsh and Devane, 2012).
Through the sampling strategy of recruiting key informant midwifery managers alongside a maximum variation sample of prospective AMU and OU midwives, this study has achieved a range of experiences with differing levels of expertise. As one hospital was used as a case-study, the views gathered do not necessarily represent the views of all midwives practising in the UK; however, this was necessary as we were attempting to gather in-depth data on how the culture in a small unit was created. It is also important to note that not all key stakeholders were included in this study. The study chose to focus on the views and experiences of representatives from the midwifery team involved in the creation and development of the AMU and did not seek the views of other professional groups, including obstetricians. In particular, the accounts of women in receipt of services were not included in this study. While the study did explore how their opinions had been taken into account by the managers designing the service, it would be important to discover how the AMU and OU are experienced by women and their families.
This study acknowledges the presence of an insider perspective, that the researcher is a midwife in the current OU. The advantages and disadvantages of insider research are well documented: while insider research can lead to role confusion and over-identification with participants (Allen, 2004), it also has the potential to take advantage of existing knowledge to achieve richer data (Burns et al, 2012). It is therefore difficult to assess the impact this has had on the research (Taylor, 2011); however, we have attempted to minimise the potential for this to bias the data analysis and interpretation through the collaboration with an ‘outsider’ who does not have a midwifery background and does not have a detailed knowledge of the subject area.
Conclusions
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. 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 of OU midwives that ‘safe normality’ is already available within OU.