Chapter 4 Woman-centred, midwife-friendly care
principles, patterns and culture of practice
Midwives hold an important key to positive care around the time of childbirth that will contribute to a good start for the baby and parents during this critical period of human life. The key to unlocking the potential of midwifery is the appropriate organization and culture of care. Where the organization of care is right, allowing for continuity of care, the exercise of autonomy in practice, good support and a strong community base, midwives may provide more effective, sensitive and appropriate care. Highly centralized, fragmented care in which professional autonomy is not possible, severely restricts the potential of midwives to make their full contribution to the care of childbearing women. This chapter examines the principles of midwifery and the way that the organization of practice and the culture or ethos of care may be developed. This reformed midwifery will be referred to as ‘The New Midwifery’ (Page & McCandlish 2006).
The roots of midwifery lie in the care of childbearing women by other women from their own community or family. Even after the professionalization of midwifery, with the registration of midwives, the majority were community-based. The majority of births were home births, with the balance of home versus hospital births being altered over the last half century in the UK. This brought about a division between hospital and community midwifery; where midwives were hospital-based they were organized on a model of acute care nursing. Thus, care became highly fragmented. In addition, as maternity care became more and more technical and medical in its nature, it became more difficult for midwives to practise autonomously. Thus, the potential for an ongoing relationship between the woman and her midwife was eroded, and the ability for midwives to use all their skills and knowledge and to manage care was diminished.
Since the early 1980s, much work has been undertaken to redevelop continuity in the relationship between women and their midwives, and to enable midwives to practise more autonomously. This work has happened in many parts of the world. It has consisted of changes in midwifery regulation, and in policy at governmental and local level, of developments of innovative practice and of research and evaluation. In some countries, e.g. the Netherlands, New Zealand and Canada, many midwives are not employees of a health service but may work in publicly or insurance-funded independent practices. Ideally, although practising independently, these midwives have access to local health services with mechanisms for consultation, referral and transfer when problems occur. In two of the Provinces of Canada, for example, midwives have admitting privileges to local hospitals where they are part of medical departments (Page 2000, Sandall et al 2001).
What has arisen from these developments in policy and practice is a reformation of midwifery that takes in some of the historical values and functions of midwifery while adapting it to the needs of the modern world and more complex health services. What has been called the ‘new midwifery’ has emerged over recent years.
The internationally accepted definition of a midwife is a basis for understanding the scope of practice of midwifery (Nursing and Midwifery Council [NMC] 2004). However, it is only a starting point. This definition provides no ideas on how midwifery is similar to medical maternity practice, and how it differs. There are two aspects of effective midwifery that make it unique. First, midwives are the specialists in normal labour and birth, and hold the potential to support normal healthy outcomes. Second, midwives have the potential to work through a personal relationship with women (the original meaning of midwife) through the whole of pregnancy, birth and the early weeks of life, including labour; this relationship has been described in a number of ways that include one of friendship, of partnership and of skilled companion. Such a relationship is crucial to developing the new midwifery into practice.
The development of the new midwifery contains essential elements. These are:
The principles of patterns of practice that support development of the new midwifery are as follows:
I will discuss each of these principles in detail, then the patterns of practice that will support them.
The term ‘woman-centred care’ is often used to describe the philosophy of care promoted in the early 1990s in the UK (House of Commons 1992, DH 1993, SOHHD 1993). This term means that women and their families should be at the heart of everything midwives do in practice. They should be given choice in the place of birth, caregiver and care, and be given control over their own care and experience. Two keys to achieving these principles are the provision of continuity of carer – a professional who they could get to know and trust over time who would provide and manage most care – and the restoration of autonomous midwifery.
The policy document Maternity Matters: Choice, access and continuity of care in a safe service (DH 2007) widens the principles of woman-centred care in an important way. While some of the principles of the earlier policy documents remain, Maternity Matters also includes the importance of access to care. Widening access to care is important in the light of inequalities in the experience and outcome of care that are influenced by ethnicity and deprivation. Maternity Matters also sets out plans for a reconfiguration of services that will centralize more medically led and complex care in larger hospitals, and provide midwifery-led care in community-based services. This will provide a guarantee of:
The exercise of choice is a complex process that is harder than it sounds, but is important. Widening access to maternity care is one of the most important issues of modern day services and may be linked to continuity and choice in care. In this chapter, I argue that whichever way the maternity services are reconfigured the basis of effective, safe and positive care is a continuing relationship with one named professional over the period of care. The named professional should provide most but not all care and should coordinate care.
To my mind the word ‘choice’ does not do justice to the way in which midwives work with women to help them retain personal autonomy and a sense of being a strong, powerful mother. A more accurate description would be to help women make informed decisions. The best decisions are informed not only by the evidence but also the health, personal circumstances and preferences, beliefs and values of individual women. The midwife is a mediator working with the health service in the interests of the woman and her family, using her experience and the best evidence and information. In Page & McCandlish (2006) a number of experienced midwives have given examples of how they have worked with individual women using the five steps of evidence-based care to help women in making the number of decisions that they face in modern and highly complex maternity services.
The five steps of evidence based midwifery are:
In many ways, the idea is a simple one. Involving women in making decisions about their own care and that of their baby and having a respectful relationship with them should not be difficult. However, there are a number of things that will make it easier for midwives (and others) to work in this way. First, the choices need to be available. If, for example, the woman wishes to give birth outside of the hospital, this will obviously be difficult if no alternatives are available. Second, decisions are often set against a back drop of a health service in which intervention is the norm, and it is difficult for both midwives and the women they are caring for to make choices that go against this norm. It is particularly difficult to go against this norm if things do not work out as planned. Third, given the amount of information and the number of interventions available, and the diverse nature of many of the communities in which the midwives practise, it is very difficult to have a discussion over time on the basis of a relationship in which the woman and her midwife know and trust each other, unless there is some continuity of care.
The move to give women more personal autonomy and midwives more professional autonomy have paralleled each other over recent decades. Midwives whose scholarly work has been derived from practice have provided rich literature in which this idea of involving women in making decisions about their care and the care of their baby is seen as an important aspect of supporting a positive transition to parenthood in which the woman builds on her own personal strengths and finds confidence in making decisions about her care and the care of her child. This idea, called in shorthand form ‘choice’, represents one of the most fundamental shifts in values in the maternity services. It represents a shift from a situation in which women have things done to them, to a situation in which professionals work with women, planning care around their needs rather than along routine or institutionally driven lines.
Leap and Edwards (2006), in calling for a more nuanced examination of choice, highlight the context of oppression in maternity services and women’s lives, and criticize the idea of informed choice that puts the onus of control on the individual without recognizing that social inequalities are particularly powerful. Genuine choices are often limited by what is available and acceptable to local services and communities. To give women genuine choice requires a change to health services so that choices are actually available. It also requires that all professionals, including medical staff, are encouraged to look their beloved beliefs, practices and rituals in the eye and question them to see if they are genuinely likely to be beneficial to individual women and families. This is not an easy thing for any of us to do.
It is far easier to work with women in helping them make the right decisions for them and their baby and family, if decisions can be talked through, considered over time and in the context of a trusting and respectful relationship. Pairman (2006) describes the relationship as the medium from which midwives practise. Building this relationship requires continuity of care. Freely (1995, p 7) describes the importance of the structure of continuity of care well: ‘Midwives can do a better job if their work is structured in such a way as to enable them to become acquainted with and take responsibility for their patients’. Freeley described the care she received from a team of midwives as ‘care with a face and a memory and an ever open ear. It made me feel like an active participant’ (p 7). In comparison, the care she experienced in the conventional system was from a ‘faceless institution’. It is through the development of relationships between caregivers and childbearing women and their families that we make the change from faceless institution to humanistic supportive care.
The relationship between women and their midwives is seen by women as important in itself, and not only as an instrumental means of leading to other outcomes (Wilkins 2000). However, the development of a relationship is also the basis of the ability to give women choice and control, and helps in the support of physiological birth and in the comforting role of the midwife. Importantly, this relationship is the medium for the support the midwife may give the family in their journey to their new roles and responsibility, the transition to parenthood. As the skilled companion (Campbell 1984), the midwife acts as a guide and supporter, helping the woman through rough and difficult terrain, enjoying the pleasures and excitement of the journey, while allowing the woman and her partner to make their own journey and learn the lessons and gather a sense of their own strength from the journey and its completion.
If midwives know and understand the women they are caring for, and where trust has grown between them, they will find it easier to respond to individual needs, to comfort and to encourage women through some of the difficulties, not only of pregnancy and after the birth but also through labour and birth. Women describe the importance of knowing their midwife, particularly during labour and birth, and of the confidence and trust this brings (McCourt et al 2006).
Women who have received ‘continuity’ of care do not use the term continuity. These women talk about the value of knowing their caregivers and why this is important to them. Women tend to link supportive care with knowing their midwife (McCourt et al 2006).
In the study by McCourt et al (2000, p 282), women who had received one-to-one care described the importance of the availability of the midwife both directly and over time; the words of the women themselves describe the trust that develops and the way that knowing the midwife is reassuring as follows:
I knew exactly what was going to happen, when and how, that was one bit of it. Another thing is you knew the person there, and she was there only herself, no one else.
There is a sense of intimacy, of feeling that the midwife was accessible, on the same level as the woman:
Well I could talk to her about anything and say to her everything, that’s how much confidence I had in her.
Women also described the way midwives become a part of the experience:
Well they do know me, they recognize me, but my midwife, she was part of it, part of the birth, the baby.
Women talked about the midwife as a friend, as being like family. They described midwives they had come to know as ‘my midwife’ in contrast to ‘the midwife’ or ‘they’. There was a sense of closeness to the midwife, of a special relationship.
It is this ‘with woman’ aspect of midwifery that many midwives have tried to reintroduce to midwifery practice over recent years: the relationship that allows a spirit of ‘being with’ rather than ‘doing to’. Midwives have explained the great lengths they go to in order to develop the relationship that puts women at the heart of care, and seeks and supports their active involvement in their pregnancy and birth (Pairman 2006).
Midwives who describe the relationship, like women, describe it in terms of friendship, partnership, professional friendship and professional servant (Kirkham 2000). It is a relationship in which midwife and woman contribute equally, and is one of sharing, involving trust, shared control and respect, and shared meaning through understanding (Pairman 2000). It acts as a foundation for shared decision-making, and facilitates communication. Although called a friendship, it is not exactly a friendship because the midwife enters as an expert, and the relationship is usually terminated at the end of care. It can be seen as a friendship with a purpose.
The relationship is used intentionally to shift power towards the woman, what Cronk (2000) has described as the professional servant, but midwives cannot empower women unless they themselves are empowered (Kirkham 2000). The trust is not only by the woman from the midwife but requires that the midwife believes in or trusts the woman (Leap 2000). It is recognized that the most powerful help for a woman may come from doing as little as possible, as Leap (2000, p 2) puts it, ‘the less we do the more we give’. Although there are times, particularly in labour, when a midwife may need to take charge or take control, this works better when there is a previously formed relationship (Anderson 2000).
It is difficult to form the kind of relationship described unless the pattern of practice allows the provision of what has become known as ‘continuity of carer’. The term ‘continuity of carer’ is a description of the structure that is set up to enable the relationship between the woman and her midwife to develop over time. This structure should organize care so that individual women may receive most of their care from a named midwife. This named midwife provides and manages most of the midwifery care for a woman, and is likely to be available for critical events in the woman’s pregnancy including labour and birth. This is not the same as solo practice. In the most effective organizations the midwife has a partner or small number of partners who will stand in for the named midwife when she is unavailable, and who will also have formed a relationship with the woman. Essentially, in this system of care, midwives follow women through the service, rather than having women progress through a number of teams of people. The latter is an assembly line or conveyer belt of sorts.
The development of patterns of practice that allow true continuity of caregiver may require radical change. It will also require a system of on call for a large number of midwives. It is the need for these radical changes that has led to the development of tremendous controversy and debate around the need for continuity of carer, particularly among midwives. It has been claimed that what women really want is continuity of care – a shared philosophy. This denies the importance of the relationship in itself to women, and the use of self that a midwife may give in supporting and comforting and encouraging women. It also denies the difficulty of large numbers of people making complex decisions in the same way as others, given their own personal values and knowledge. In addition, the lack of a real knowledge of the medical history and personal values and preferences of the individual woman makes it very difficult to make personally sensitive and appropriate decisions.
It has also been argued that women have other priorities, such as the health of their baby and good information, as though such desires could be ranked in a hierarchy (Page 1995). Some have interpreted evidence in such a way that they argue women do not really want continuity of carer. In reality, evidence to refute or support the idea that it is important for women to have continuity of caregiver, or that particular outcomes are the direct outcomes of continuity of carer, is not easy to develop or interpret from the dominant paradigm of research: the randomized controlled trial. In addition, finding out about what women want from care around birth is difficult. Women tend to expect what is on offer (DeVries et al 2001). Even so, when surveys of women who have experienced ‘continuity of carer’ are undertaken, the majority indicate that it is important to them, and even in surveys of women who have not experienced ‘continuity of carer’, the majority indicate that it would be helpful to them. Moreover, qualitative research is beginning to explain why it is so important to so many women (McCourt et al 2006).
Much of the debate about whether or not women want continuity and about the interpretation of the outcomes of studies of continuity of care have focused on whether or not it is continuity as a shared philosophy of care that is important or whether or not it is knowing one’s midwife that matters. The hierarchy developed by Saulz and adapted for maternity helps clarify the concepts. The following is taken from McCourt et al (2006, p 143–144).
General reviews of continuity of care have tended to conceptualise continuity in a range of ways (Haggerty et al 2003). All have aimed to develop a common understanding of the concept of continuity in order to understand the impact in different settings. Unless we understand the mechanisms through which care delivered over time improves outcomes, continuity interventions may be misdirected or inappropriately evaluated.
From these various definitions, it appears that continuity can most usefully be defined as a hierarchical concept ranging from the basic availability of information about the woman’s past history to a complex interpersonal relationship between provider and woman characterized by trust and a sense of responsibility (Saultz 2003). At the base of this hierarchy is the notion of informational continuity. This concept might be the most important aspect of continuity in preventing medical errors and ensuring safety (Cook et al 2000), but by itself informational continuity might not improve access to, or satisfaction with care. Longitudinal continuity creates a familiar setting in which care can occur and should make it easier for women to access care when needed, but it does not assure a relationship of personal trust between an individual care provider and a recipient of care (Table 4.1).
By arranging these concepts as a hierarchy, it is implied that at least some informational continuity is required for longitudinal continuity to be present and that longitudinal continuity is required for interpersonal continuity to exist in a midwife–woman relationship.
There have been a number of ways of measuring continuity, i.e. who usually provides care, and for how long, normally based on the health record (Saultz 2003). However, these do not take into account the content of the visit and the nature of the interaction. Multiple definitions and measures have also made it difficult to generalize about the effect of continuity (Donaldson 2001). Research on whether continuity of care is effective has measured outcomes such as behaviours of recipients and caregivers, adherence to advice, use of services, clinical sequelae, clinician knowledge of patient’s conditions, costs, and patient and staff satisfaction. Surveys have shown that patients and staff value continuity and that it is positively associated with staff satisfaction, but the causal direction is unknown.
In maternity care, there has been debate about two important and subtly different concepts to examine here – ‘continuity of care’ and ‘continuity of carer’. Continuity of care means ensuring that there is a shared philosophy and approach to care that women experience. As we will show, this is often discussed but difficult to achieve in large fragmented systems of care, even where there is a ‘team’ approach. Continuity of carer means enabling midwives to organise their practice so that they may form a continuing working relationship with women in their care. It means enabling midwives to work with women through the whole of pregnancy, birth and the early weeks of newborn life, so that they may get to know each other and form a relationship that is based on trust between the two. This relationship, of trust and mutual respect, has been fundamental to the development of midwifery knowledge and wisdom.
Table 4.1 Hierarchical definition of continuity of care
| Level of continuity | Description |
|---|---|
| 1. Informational | An organized collection of medical and social information about each woman is readily available to any healthcare professional caring for her. A systematic process also allows accessing and communicating about this information among those involved in the care. |
| 2. Longitudinal | In addition to informational continuity, each woman has a ‘place’ where she receives most care, which allows the care to occur in an accessible and familiar environment from an organized team of providers. This team assumes responsibility for coordinating the quality of care, including preventive services. |
| 3. Interpersonal | In addition to longitudinal continuity, an ongoing relationship exists between each woman and a midwife. The woman knows the midwife by name and has come to trust the midwife on a personal basis. The woman uses this personal midwife for basic midwifery care and depends on the midwife to assume personal responsibility for her overall care. When the personal midwife is not available, coverage arrangement assures that longitudinal continuity occurs. |
Adapted from (Saultz 2003) in McCourt et al 2006, with permission.
The development of a high level of continuity of carer may be the most difficult change to achieve, but is probably the most fundamental or important change to bring about. It is helped tremendously if community and hospital services can be integrated, and if most of a woman’s care is moved away from centralized institutions and given in the community.
If the midwife can become a part of the woman’s community, getting to know the woman and her family more personally, learning to understand their lives and the nature of the life around them, she will be able to be more responsive to them as individuals, and may be released from the depersonalization of the institution. This is also important in allowing midwives to respond to the needs and characteristics of different neighbourhoods and communities, and to understand the racial and ethnic mix and level of poverty or affluence of ‘her’ patch. Such knowledge helps in deciding whether the development of different community services, for example a shop-front practice or premises within a housing estate, are appropriate (Davies 2000). It takes healthcare to the community rather than expecting women to visit for healthcare. Increasing accessibility and attractiveness are important parts of good healthcare. Community-based care can be provided either in the home (e.g. antenatal visits at home, or a genuine choice of home birth) or in community centres, midwives’ or doctors’ surgeries or offices situated in the community. Small hospitals, and out-of-hospital birth centres, will provide care that is both near the woman’s own home and less acute care for at least a small group of women.
Second, when the care of childbearing women takes place in an acute care setting, in the main by specialists or consultants, there will be a tendency to use more medical and surgical interventions. Care provided by skilled, confident and experienced primary practitioners (midwives and family doctors or GPs) is more likely to support physiological processes and less likely to lead to unnecessary intervention (Page 2007).
Home birth will lead to a more profound change from hospital birth than any other change in the organization of care. The best evidence on the outcomes of home birth and the experience of home birth for women without complications or real risk factors shows persistently that there is a lower rate of interventions, and that women who ask for a home birth generally enjoy the experience (Page 2006). Birth at home means that the woman can relax in her own environment, and that she is in a different power relationship with professionals, who are invited into her home. Although there are exceptions (Edwards 2000), in general, the relationship is of a higher quality. Home birth brings with it its own pattern of practice, and on the whole it is easier to provide the woman with midwives she can get to know and trust.
Community-based care, if organized effectively, may increase access to care. Ensuring wide access is one of the most important factors in reducing inequalities in health and in increasing choice for the majority of women, not only the most informed or affluent. Saving Mothers’ Lives (Lewis 2007) reported that vulnerable women with socially complex lives, those from the most deprived areas of England and asylum seekers and refugees had a higher than average risk of maternal mortality (see Ch. 56).
The factors associated with this higher risk were problems with access, lack of follow-up care, inadequate translation, inadequate referrals, poor interagency working. Continuity of care is a way of combating these gaps in the service. Murray and Bachus (2005) describe a multitude of barriers to accessing timely and optimal care, including the lack of information in appropriate formats, negative and stereotypical attitudes of staff, lack of continuity of care, and poor communication and coordination between maternity and other services.
In England the linking of midwifery group practices with ‘Sure Start’ projects has provided an opportunity to work with other agencies in providing the complex support that more vulnerable and socially excluded and deprived women and their families may need. Sure Start is the government programme to deliver the best start in life for every child. Sure Start brings together, early education, childcare, health and family support in local communities. The One-to-One Midwifery Project at Guy’s and St Thomas’ Maternity Service serving a deprived community in South London had one midwifery practice working with a Sure Start Centre. There was a reduction in the ‘did not attend’ rate between the standard service and the One-to-One Service providing continuity of care (Singh et al, personal communication, 2007). The ‘did not attend rate’ is an important indicator. While the relationship between poor outcomes and failure to attend appointments is unclear, it was found that 17% of the women who died from indirect or direct causes booked for maternity care after 22 weeks’ gestation or had missed over four routine antenatal visits (Lewis 2007).
To practise the new midwifery, the midwife needs professional autonomy. This does not mean, however, that the midwife should practise in isolation. She needs to work in an interface with other members of the healthcare team, while knowing that the contribution she makes is unique and cannot be made by any other member of the team. The midwife has specialist approaches and skills that no other member of the healthcare team has, even though some of her role will overlap with that of doctors, both GPs and obstetricians (Page 2001).
Professional autonomy requires that:
The worldview of midwifery is to have confidence in normal or physiological processes, rather than feeling that these could fail at any moment. This worldview requires a different knowledge base, research interest and skill set in midwives. During pregnancy and birth, there should be sufficient focus on the woman’s experience, and help and support for distressing aspects of pregnancy and birth, as well as sharing the enjoyment and joy. Presence, comfort and appropriate touch, reassurance and encouragement are central aspects of midwife-led care. Particularly during labour and birth, midwifery autonomy allows the midwife to take into account the woman as an individual in making decisions about care, and to provide more flexible care. I have never been able to see how midwife-led care or autonomous midwifery can be effective without some basis of continuity. However, there is considerable debate about this matter and midwife-led care rather than continuity has been the aim of a number of innovations.
In most of the Western world, maternity services have been centralized into acute care hospitals. This is despite the fact that pregnancy is a normal part of the life of the majority of women, and that childbearing is in general a healthy life event. Instead it would be more appropriate for care to be given in the primary care sector of the health service, rather than by specialists in an acute care setting.
There are problems with the centralization of birth into acute care, including a tendency, referred to earlier, in all large organizations of people to move towards institutionalization. Kirkham wrote, ‘with the centralization of birth into hierarchically organized and increasingly large hospitals, midwifery increasingly adopted the responses and values of those institutions. All these responses served to protect the status quo which reinforced the values of obstetrics not midwifery’. Kirkham drew on the work of Raphael-Leff who ‘sees the fragmented care given in maternity hospitals as part of a social defence system … constructed to help individual professionals avoid experiencing anxiety, guilt, doubt and uncertainty. Both caring and gratitude are diminished in a system where people are treated in a depersonalized way and any activities which threaten the status quo are intensely resisted’ (Kirkham 2000, p 157).
The majority of midwives in the economically developed world work in large institutions, usually hospitals. Often, such institutions unconsciously attend to the needs of staff before families. Often, they are arranged in such a way that it is very difficult for staff to provide the best care. Any group of people is likely to develop a life of its own. In many health services there is a rigid hierarchy or an informal power structure that may give some groups like midwives little professional autonomy. This is not simply a matter of a hierarchy in which midwives have less power than other professionals because, although it is the case that midwives are often lower in the health service hierarchy than doctors, much of the oppression of midwifery comes from within midwifery itself.
Deery and Kirkham (2006) describe the cultural context of midwifery in the UK. NHS Midwives have talked about their support needs and their lack of support. They believe that because the culture of NHS midwifery is a female culture of ‘service and sacrifice’ (Deery & Kirkham 2006, p 125) it is seen as selfish to address personal needs. Yet, as they point out, while support needs have not moved beyond an acknowledgement of stress and burn out, Sandall’s work (Sandall 1997) has linked support for midwives with both their job satisfaction and the quality of care they give to women.
Midwives manifest a number of ways of coping with the needs of the organization. Deery and Kirkham draw on the work of Menzies Lyth (1979, 1988), Lipsky (1980) Raphael-Leff (1991) to explain and describe the ways midwives cope with the needs of the institution. Task-oriented care, standard practices and rigid routines provide a defence against stress and anxiety. Midwives are like public service workers who work directly with the public within bureaucracies who in practice must deal with clients on a mass basis. ‘At best street level bureaucrats invent benign modes of mass processing that more or less permit them to deal with the public fairly, appropriately and successfully. At worst, they give in to favouritism, stereotyping and routinizing all of which serve private or agency purposes (Lipsky 1980, p xii). Raphael-Leff applies the work of Menzies Lyth to midwifery identifying three defence mechanisms that midwives use to protect themselves against stress and anxiety. These are:
The development of continuity of care, and support for midwives to understand and express some of the anxieties that develop from working with women in a professional relationship (Deery & Kirkham 2006), while enabling autonomous practice, will go a long way to breaking down these defence mechanisms.
Deery and Kirkham (2006) describe the importance of a balance of engagement and detachment in relationships with women. This implies being involved but recognizing limits of what one can and cannot do. The difficulty is that managing the workload often becomes the priority, rather than the needs of women. Social defence systems in the organization that are a dysfunctional form of protecting ourselves from anxiety and distress often involve an evasion of relationship. This evasion inhibits growth. Support for the primary task of midwifery fosters personal and professional growth. It helps to build working structures within which relationships can grow. These need a smaller scale organization of care, and a degree of separation from the obstetrical model, and enhancement of professional autonomy and continuity of care. Positive relationships require higher levels of self awareness and skills in social analysis. Skills of support can be developed and guided reflection and clinical supervision is seen as an important tool (Deery & Kirkham 2006).
Deery and Kirkham (2007) also describe the competing organizational and client demands as a health hazard for midwives. They propose that emotions contribute to health if they are mobilized appropriately, but they become ‘toxic’ if they reappear unconsciously in ways that are destructive and unhelpful. There is a higher value placed on technology, competence and efficiency but there is little place for emotional work in midwifery (see also Ch. 2). Humane institutions are people-changing institutions with awareness of the potential for positive and negative change.
The development of a ‘woman-centred’ organization is sometimes seen as being at odds with developing a supportive organization for midwives. Yet this need not be the case. McCourt et al (2006) describe how what provides satisfaction to women can be a mutual source of satisfaction to midwives, in particular the development of a meaningful relationship with women. In the one-to-one service, the midwives’ positive views and their comments on strengths focused on:
Sandall (1997) describes the characteristics of occupational autonomy, developing meaningful relationships with women, and social support as important factors in work satisfaction for midwives.
The development of continuity-of-carer schemes and close relationships with women gives midwives a sense of primary loyalty to women and can release a midwife from feeling that her main allegiance is to the profession or her employer (Brodie 1997, Page 1995). This may be one of the most empowering aspects of working with women. Yet the recognition of the prevailing culture of midwifery shows how difficulties may arise in changing patterns of practice and in creating greater midwifery autonomy.
Woman-centred care need not be at conflict with the needs of midwives or indeed other staff; neither should it be at conflict. Retention of midwives and work satisfaction are crucial to an effective and ‘positive’ organizational culture. A positive culture is, in other words, a place that ‘feels good’ and supports good work.
Organizational culture here means the ethos, atmosphere, aims, values and expectations, and relations between people (professionals and those being cared for) within the structure that is the context for practice. Culture is reflected in the priorities we choose, the way we spend our time, our language and behaviour. In the maternity services, the culture should:
Some of the patterns of care I will review include independent or private practice. Possibly these patterns hold the greatest potential for professional autonomy. However, it is crucial that autonomy is not confused with separation or isolation of practice. In today’s world, women are entitled to more complex and medical care if it is needed. Perhaps one of the highest level skills of any midwife is to be able to differentiate between situations in which she can support physiological birth and those when consultation or referral is needed.
Autonomous midwifery needs a strong interface with colleagues and the health service or hospital. I have seen at first hand the results of a hospital service that treats midwives antagonistically, does not recognize them as professionals and where this antagonism results in delays in care for mother and baby. The worst situations are when a mother or baby has to be transferred to hospital because of acute problems at a home birth, and antagonism to home birth or the midwife are allowed to result in emotional responses that affect care. A connective supportive interface will be helped by multiprofessional guidelines and policies for practice, discussion and active negotiation with colleagues, and help in understanding roles, particularly around a time of change. It is recognized in the discussions about relative safety of home and hospital birth that the safety net of the system is crucial (Olsen 1997). Sometimes guidelines are seen as a hazard to midwifery autonomy, but guidelines such as the ‘Kloosterman list’ in the Netherlands may serve to protect the autonomy of midwives and the right to home birth (Sandall et al 2001).
Balancing the needs to redevelop a distinct identity and a sense of purpose that goes beyond being a doctor’s assistant, yet still working together cooperatively with medical colleagues, may not be easy. It is for this reason that the profession needs strong leaders who can articulate the unique nature of midwifery practice, maintain effective relationships and negotiate a safe environment for midwives who will challenge current boundaries of practice.
There is no such thing as a health service with unlimited resources, nor will it ever be possible, or even right, to develop innovations that take a disproportionate share of the health service budget. Innovations should be cost-effective – this means that resources should be used appropriately and provide value for money; they should add something to the quality of care. In most healthcare systems, there are choices made between priorities. In today’s world it may be that technology or the use of technology will be funded before something like an increase in the number of midwives. This choice reflects the values of the dominant culture. A tool for assessing the number of midwives required is important (Ball & Washbrook 1996).
One problem is that it is often assumed that the current way of organizing things is the most cost-effective, and anything that improves the quality of care of necessity costs more. However, the current system of standard care as it is provided in countries like the UK is actually very wasteful; it is not cost-effective. First, although midwives may not be paid enough for what they do, the numbers are so great, that salaries take up the largest part of the maternity budget. When the role of midwives is restricted, as it is by present culture and structures, this is a huge waste of money and resources. Second, the traditional organization of midwives on shifts is an inflexible system that does not follow the ebb and flow of midwifery workload. Innovations such as one-to-one midwifery have reduced length of stay, have the potential to reduce beds, have reduced the intervention rate and have also increased the number of births per midwife-post (Piercey 1996, Piercey et al 2001). Yet still, even after a thorough evaluation, it is often viewed as being too expensive.
It is important to recognize that the patterns of practice and culture of our midwifery services, whether traditional or innovative, are always a product of the wider social environment and nature of the health service. Thus, for example the nature of midwifery in the Netherlands has arisen because of a number of broad social factors like the nature of the family, the place of women in the family, attitudes to healthcare, and geography. In addition, the structure and culture of the health service, and laws, have established a strong base for the maintenance of midwifery as a profession (Sandall et al 2001). Likewise, the development of midwifery in the UK, its strengths and problems, must be viewed in the light of the nature of the NHS. However, as in all other parts of life, a process of globalization has meant that many of the industrialized countries share similar trends. For example most of these, with the exception of the Netherlands, have centralized maternity services. Many have a very high operative and assisted birth rate. The principles of the new midwifery described earlier require a particular pattern or structure of practice.
The pattern of practice is defined here as the structure or organization of care around four key characteristics. These characteristics are:
First I will define and describe these key characteristics, and then I will give an example of a different pattern of practice that integrates these characteristics.
In some parts of the world (e.g. the Netherlands, New Zealand and some of the Provinces of Canada), midwives practise as independent practitioners, having their services funded for each course of care either by the health service or health insurance. There is a big difference between publicly funded or privately funded independent midwifery practice because a publicly funded practice, if widely enough available, will give access to the majority of women rather than the small numbers who are able or willing to pay for their midwifery care. In general, publicly funded independent midwives may find it easier than privately funded midwives to form an interface with the maternity services for back-up, consultation, referral and transfer. In the UK, the Independent Midwives Association (IMA) are working to have a community model where midwives who are practising independently (with a contract with individual women and their families) to work under the umbrella of the NHS so that women may use their care as NHS patients (see http://www.independentmidwives.org.uk/s).
Midwives who are an employee of an organization will inevitably find some limitations on practice, as the midwife must follow the policies and guidelines of the institution or employer. However, with enlightened and strong midwifery leadership, this may not be too much of a problem, and there is usually greater security for the midwife in such a position. In services that are not progressive, or where there is not strong and enlightened midwifery leadership, the situation can be very frustrating and will severely limit the ability of any midwife to give of her best.
At one end of the continuum the woman may have all of her care at home, including the birth and care after the birth. Some women will have all of their care in pregnancy and most of the care after the birth in the community – either at home or in the midwife’s or doctor’s surgery or office. Some services will integrate community and hospital so that the emphasis is on having a midwife follow women through the system of care from start to finish. At the other extreme, women receive all their care in an acute care centralized hospital setting. The place of care and birth will have a profound effect on the nature of care, outcomes of care and the ability of the midwife to use her abilities to the full.
The highest level of continuity of caregiver is to have one practitioner who provides all the care, including care during labour and birth. A few women receive this from midwives in solo practice. However, this is impractical for many midwives as it places permanent on-call demands on them. Close to this is a system whereby the woman has most of her care from one named midwife who is responsible for all care and provides most hands-on care. This midwife is supported by another midwife, or small number of midwives, who will get to know the women in their partner’s caseload and provide cover when the named midwife is unavailable. This is often called a personal caseload. Approaches to this pattern of practice are described in detail by McCourt et al (2006).
Some patterns, usually called team midwifery, will offer continuity from a team of midwives. This is often known as a team caseload rather than a personal caseload (Page et al 2000). In general, the level of continuity achieved is not so high. Some teams, if they are too large, or extend only to hospital or community care, may even break down continuity.
For a time, in the UK, there was an emphasis on providing shared care. This was aimed at making the services of a specialist or consultant obstetrician available to all women. Some use the term ‘shared care’ differently. Canadian midwives may use the term to describe sharing care with a partner or colleague, another midwife. In the UK, the principle of shared care led to complete fragmentation, and moved much care into the hospital. There are still a number of women who have not met the doctor who is a name on the medical records, and who see a different person at nearly every visit.
The upper end of midwifery autonomy will be found in independent midwifery, and in home births and out-of-hospital birth centres. It is important to repeat that this term implies professional control over how the practice is organized, values of the practice and the use of interventions. It does not imply practising in isolation or antagonism with others in the health service. Midwifery, as discussed at length earlier in the chapter, has a distinct and unique approach to childbirth care. Midwifery autonomy allows this to be expressed in practice. However, in many parts of the world, midwifery follows the obstetric model.
The maternity services in the economically developed world are configured in a number of different ways. They may consist of small to large hospitals, general practice or family doctor care, birth centres, small community hospitals, community services. Here I will focus on a pattern of care called One-to-One Midwifery as an example of a development that increased continuity of carer in a large medicalized maternity service in London. It has been replicated in a number of other services and in different parts of the world.
This form of practice provides one named midwife who is responsible for the care of individual women. This named midwife works with a midwife partner who gets to know the women in her caseload and provides on-call cover when the named midwife is unavailable. This pattern of practice integrates a high level of continuity with midwifery-led care. Care is organized in group practices of six to eight midwives to provide support, allocation of the caseload and peer review of practice. The pilot (McCourt & Page 1996) was set up to provide for the requirements of the ‘Changing Childbirth’ report (DH 1993), specifically to provide a service that is sensitive to the needs of individual women and their families, and to give women choice, continuity and control.
Midwives meet the woman at the beginning of pregnancy and provide care throughout. Because it is geographically-based, the midwives are situated in a local community and provide much care in the woman’s own home. All women in the local neighbourhood are cared for by the service, including low and high risk women. Where the woman has a low risk pregnancy the midwife is the lead professional and responsible for all care. Where the woman has complications or is high risk the midwife works with the medical team but is still responsible for all midwifery care. Women choose whether to give birth in the home or in the hospital.
One-to-one midwifery was first implemented in November 1993. Two cohort studies were undertaken to assess one-to-one midwifery and to compare it with standard care (McCourt et al 2006, Page et al 1999, 2001). The first was undertaken soon after implementation, and the second when the service was well established. As far as we know it is the only study of an innovation once it had been running for some time. The study focused on:
There was a lower rate of clinical intervention associated with one-to-one care, and the differences between the groups were increased in the second cohort. The high level of continuity through all the processes of pregnancy and birth, and after birth, was maintained in the second cohort (Page et al 1999, 2001). Standards of care were also maintained, despite the newness of the service in the first cohort (McCourt & Page 1996).
Women receiving one-to-one care were far more satisfied with their care, and had a closer relationship with those midwives caring for them. In general, the responses to pregnancy and birth were more positive. Many women in both groups felt it was important to have continuity of carer through the whole process including labour and birth; the majority of women who had received one-to-one care felt that it was very important (76%) or quite important (10%) (Beake et al 2001).
Especially if the savings from the reduced interventions are taken into account, one-to-one promises to be a very cost-effective pattern of care. Midwives who chose to practise in this way were highly satisfied with this approach to practice (Beake et al 2001, McCourt & Page 1996, Page et al 2001).
In this pattern of practice you will be called on to provide skilled and knowledgeable care through all the periods of pregnancy and birth. Many midwives will feel the need to refresh skills in a particular area. You should talk to an experienced midwife, and look at your job description or requirements of practice carefully, thinking through areas in which you need development. A good orientation and support for the first weeks, plus an orientation manual, are very important for midwives starting out in this pattern of practice (Stevens & McCourt 2001). Having confidence and competence in these clinical skills will reduce the stress of starting out. But remember that one of the advantages of this form of practice is that you will learn very quickly.
You also need to think about time management. There are a number of patterns of on-call and it is important to find one that suits you and your partners. You will need to work flexibly, but ensure that you keep enough time for personal life, family, friends and rest and relaxation. Good administrative support is invaluable. Some times will be very busy, and some very quiet; it is important to use the quiet time for rest and relaxation. Accessories that will allow organization and enhance security include a palm pilot, a mobile phone, a security alarm and a good map or satellite navigator. You will be required to travel for some of your time. It is important to have a good tour of your patch, and learn about one-way streets and parking; about safe and less safe areas and about weather patterns if in more remote or northerly areas. You need to think about how you might safeguard your personal security on the streets and in homes.
There are a number of policies regarding lone worker security that provide useful policy and advice.
Your skills will be integrated through your relationship with individual women and their families, making them central to the decision-making process and using evidence to inform decisions. This takes considerable experience and good interpersonal skills. You will wish to find out about the groups of people in your area; are there different racial or ethnic groups, and are there pockets of poverty? Although your care will be very important to the women and families in your practice, you will need to recognize that you may not be able to sort out a long or complex background of difficulties, nor may you be able to ameliorate all social situations. Although you should seek to form a supportive relationship that may feel like friendship, it is important to ensure that there are boundaries around your life so you may meet your own needs for a healthy balanced life. Having your own network of support at home and at work is important.
One of the rewards of working in a small practice is the possible camaraderie with your colleagues. These practices can be supportive, stimulating and fun. However, when there are severe tensions between members of the group it can be very difficult. Even if you have chosen your partners, you may find difficulties in working together. It is important to talk through and agree values and practices as far as is possible, and to hold regular meetings (Stevens & McCourt 2001, Sandall et al 2008). Establishing a process of peer review that is both challenging but supportive is important. You will work with a number of other professionals in the health service. As in all relationships, a level of trust is crucial to effective working relationships.
Many maternity services will not offer midwives a choice of patterns of practice and many midwives will not be free to move to find a maternity service of their choice. Some midwifery services will make good care very difficult to achieve; even if you can achieve good care it may take a lot out of you. When practising in less than ideal situations it is important to do the best you can, while recognizing that there are some factors out of your control and accepting that your contribution is limited. It is important, though, not to give up completely. Work out your most important principles and how to put them into practice. For example, giving women choice and control when you meet them for the first time in active labour is not easy. But still you can make sure you spend even a little ‘contracted’ time in establishing a relationship, and in finding out about the woman’s central values and preferences, even if this has to be done between contractions. Watching body language is more important than ever in this situation.
Everyone is a potential leader, not just those in management positions. Sometimes suggesting and helping to make a small change can make a big difference. Perhaps you could suggest, for example, moving the furniture in the birth room around so that it is easier for the woman to move. Or you might get furniture, such as rocking chairs and birth balls, in place. Often there is a manager or managers who will feel empowered knowing that midwives at the grass roots are seeking change. Do not be frightened to make suggestions. Enthusiasm among students and staff is infectious and adds more than can be imagined to the work situation. If you find problems, be ready to describe them to the appropriate people, but be ready to propose a solution and if possible to contribute to it.
Few midwives practise in a perfect environment. Frustrations may arise in any pattern of practice. When they do it is important to be clear on what is the most important value to you, and that you know that you are doing no harm to those in your care. If circumstances lead you to believe that any situation is unsafe, it is a professional responsibility to seek help and to report the situation.
Midwives have the potential to make a big difference to the start of life for the family. This difference may be good or harmful. The pattern and culture of practice will affect the ability of midwives to give of their best. Careful consideration and development of the most effective, efficient and humane pattern of practice may be the most important part of healthcare.
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