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Practitioners' views and barriers to implementation of the Keeping Birth Normal tool: A pilot study

02 July 2016
22 min read
Volume 24 · Issue 7



Poor implementation of evidence in practice has been reported as a reason behind the continued rise in unnecessary interventions in labour and birth. A validated tool can enable the systematic measurement of care to target interventions to support implementation of evidence. The Keeping Birth Normal tool has been developed to measure and support implementation of evidence to reduce unnecessary interventions in labour and birth.


This pilot sought the views of midwives about the usefulness and relevance of the Keeping Birth Normal tool in measuring and supporting practice; it also identified barriers to implementation.


Five midwives supported by five preceptors tested the tool on a delivery suite and birth centre in a local NHS Trust. Mixed methods were employed. Participants completed a questionnaire about the relevance and usefulness of the tool. Semi-structured interviews explored participants' experience of using the tool in practice.


The domains and items in the tool were viewed as highly relevant to reducing unnecessary interventions. Not all midwives were open to their practice being observed, but those who were reported benefits from critical reflection and role-modelling to support implementation. An important barrier is a lack of expertise among preceptors to support the implementation of skills to reduce unnecessary interventions. This includes skills in the use of rating scales and critical reflection. Where expertise is available, there is a lack of protected time for such structured supportive activity. Norms in birth environments that do not promote normal birth are another important barrier.


Midwives found the items in the tool relevant to evidence-informed skills to reduce unnecessary interventions and useful for measuring and supporting implementation. To validate and generalise these findings, further evidence about the quality of items needs to be gathered. Successful implementation of the tool requires preceptors skilled in care that reduces unnecessary interventions, using rating scales, role-modelling and critical reflection. Such structured preceptorship requires protected time and can only thrive in a culture that promotes normal birth.

The use of unnecessary interventions in labour and birth continues to rise. A rate of > 19% is seen as medically unnecessary by the World Health Organization (WHO) (Gibbons et al, 2010); in Europe, caesarean section rates vary between 30–58%, except in the Netherlands and Scandinavian countries where the rate is 16–17% (Zeitlin et al, 2013). The caesarean section rate in the UK is currently 26.2%, but wide variations of 18–34% are reported (NHS England, 2013). Morbidities associated with such interventions may have an impact on the long-term physical, mental and sexual health of women and disrupt maternal–infant relationships (Beck and Watson, 2008; Koblinsky et al, 2012; Firoz et al, 2013). Evidence that such interventions increase childhood asthma, obesity, diabetes, cancers and atopic diseases is increasing (Hyde et al, 2012; Dahlen et al, 2013).

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