Tensions and Barriers in Improving Maternity Care

The Story of a Birth Centre

Ruth Deery, Deborah Hughes, Mavis Kirkham

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781315346465
• Topic: Medicine
• Subtopic: Health Care Delivery

We have written this book because the story it tells warrants a wide audience. We see the purpose of this book as informing discussion and decision-making around reconfigurations of maternity care, so that planning, communication, management and recruitment can be improved and shared vision articulated and understood.A" Throughout the world, women-centred care is gaining prominence in providing maternity care. Many birth centres open each year to meet this need - but at the same time, many close or are shelved. So why should the turnover in organisations that deliver such a vital service to women be so high, thwarting many midwives from practising as they would wish? This carefully researched and passionate book tells the story of a birth centre that did fail, and the painful but valuable lessons it presents for others. Many of the issues and behaviours illustrated - lack of leadership, support, vision and plain-dealing, and tensions between bureaucracy and women-centred care - will find resonance in maternity services and midwifery experiences in the UK and throughout the world. Tensions and Barriers in Improving Maternity Care is a vital and challenging resource for all midwives, managers and policy makers and shapers with an interest in maternity and women-centred care. "A remarkably detailed analysis of the politics of a birth centre trapped in a medicalised system that threatened and rapidly destroyed it. It is a vivid example of how autonomous midwifery is undermined by an organisational structure in which management focuses exclusively on one model of care." - From the Foreword by Sheila Kitzinger 'I would recommend this powerful book to all supervisors of midwives as it provides profound insights into the impact of loss and grief upon the midwives who are often left feeling isolated and vulnerable when dealing with difficult circumstances.' - Nessa McHugh, lecturer in midwifery at Edinburgh Napier University, and leader of the Preparation and Practice of Supervisors of Midwives programme.

CHAPTER 1

Birth centres

BACKGROUND TO THE STUDY

Birth centres are defined and organised differently in different places, and some bear other names. Indeed the birth centre studied here has been organised in several different ways during its relatively short history. Hall (2003) describes ‘free-standing low-risk maternity units’ which are defined by their separation from a consultant maternity unit; other birth centres are sited alongside or within the same building as a consultant maternity unit. More importantly, the term ‘birth centre’ represents ‘a set of values and beliefs about birth, without which it has little meaning’ (Shallow, 2003, p. 12). This philosophy is ‘centred on the concept of midwifery being at the heart of a social [rather than a medical] model of care’ (Shallow, 2003, p. 13), in which midwives give skilled support and ‘within which women can achieve normal, physiological birth’ (Shallow, 2003, p. 13).

Such units, although described as a choice which should be available to women at low obstetric risk (Department of Health, 1993, 2004, 2005, 2007), are markedly different from the centralised, medicalised large maternity units, which operate on an industrial model and provide the setting in which the vast majority of babies are born. In 2007, the Department of Health restated its support of birth centres as a means of improving maternity care and offering choice to women (Shribman, 2007), and as a means of improving access to care for women from disadvantaged and vulnerable groups (Department of Health, 2004, 2007).

A number of studies have demonstrated that, when evaluated against obstetric outcomes of safety, births for low-risk women are at least as safe in birth centres as in hospitals (Kirkham, 2003; Walsh, 2007; Hatem et al., 2008; Sandall et al., 2009). There are two possible reasons for the good clinical outcomes associated with birth centres. First, birth may be safe for low-risk women because the gains of ‘high-tech’ settings are offset by the iatrogenic risks that they pose. Secondly, the very different philosophy and skills used by all involved in birth centres may make a positive difference. These factors, which result in safety, are probably impossible to separate.

As well as safe clinical outcomes, care in birth centres is linked with high levels of satisfaction. This is evident with regard to maternal satisfaction in a number of studies (Kirkham, 2003; Walsh, 2007; Hatem et al., 2008). It is noteworthy that satisfaction is also reported by socially marginalised women from several cultures (Esposito, 1999). Fathers expressed satisfaction with the support and respect that they received in the birth centre in Stockholm (Waldenström, 1999), reflecting the focus of birth centre care upon the family rather than solely on the birth. It is interesting that the feeling of being ‘treated with respect’ is reported in these evaluations, particularly with regard to groups which often do not report such treatment (Esposito, 1999; Waldenström, 1999). Such perceptions of respect echo the emphasis that birth centre midwives place upon facilitating supportive relationships around birth. In enhancing the satisfaction of families, birth centre mid-wives are clearly doing something positive and empowering, and not just avoiding iatrogenesis. More work is needed to identify and describe what happens during birth centre care to give such positive outcomes, and such research will help the development of midwifery (Hughes and Deery, 2002).

Midwives also report satisfaction with working in birth centres (e.g. Saunders et al., 2000; Kirkham, 2003), relishing the challenges offered by the difference from working in hospitals, and the greater responsibility involved.

Birth centres, under various names, have long been part of maternity care in the UK. They induce great loyalty in those who use them and work in them. Nevertheless, despite their clinical effectiveness and the satisfaction of their users and workers, there is considerable tension concerning the availability of this model of care, which deviates greatly from mainstream UK obstetrics.

BACKGROUND AND CONTEXT

Any change in maternity care has to be seen in the context of the wider situation in society, in the National Health Service (NHS), and in public services in general at the time of its introduction. In recent years, technical intervention in childbirth has increased greatly, with little improvement in clinical outcomes (NHS Institute for Innovation and Improvement, 2006). This reflects changing social attitudes to pain, choice and technology.

… many of the social and cultural values, such as convenience, ease and control, that underpin Western society in the 21st century correlate with what intervention has to offer, which results in intervention being increasingly sought after and utilised. This milieu of intervention, which increasingly surrounds childbirth, is shown to be calling into question those things that have traditionally been at the heart of childbirth: the ability of the woman to birth and the clinical skills of the health professional. (McAra-Couper, 2007, p. ix)

The aims of a birth centre relate to values that were prevalent before such recent changes, and therefore create some tensions for all concerned. They may also be seen as a gauge that indicates current social changes in progress which are revaluing human relationships with regard to technology and medicine (Hunter et al., 2008).

The birth centre studied here was set up at a time of frequent and continuing reorganisation of public services, together with policy priorities to run such services efficiently and economically. Although none of these pressures are new (Lipsky, 1980), the year-on-year requirements for economies and reorganisation have created mounting pressure on those providing services.

Within maternity care, service users and providers are aware of a growing tension between the rhetoric of public policy to provide women with choice, control and continuity of care, and the reality of staff shortages and increasing centralisation of services. Many midwives have responded to the mounting pressures upon them by reducing their working hours (Kirkham et al., 2006) or by leaving midwifery (Ball et al., 2002). Although the adjustment of midwifery staffing figures in the face of economic stringencies may cloak the shortage of midwives, a vicious circle has been created in which midwives experience frustration because they cannot practise as they wish. Midwives leaving the profession leads to increased work for those remaining, and the situation becomes ever more acute.

Centralisation of services has been a key feature of the organisation of maternity care in recent years. This economically led movement runs in uneasy counterpoint with the concurrent rhetoric of public policy concerning clients’ choice. Many large cities now have one maternity unit with an annual birth rate far higher than anything in this country in the past or elsewhere in Europe at present. We are unaware of any research that demonstrates the long-term economic benefits of centralisation of services that are claimed when hospital closures are planned. However, centralisation does have various consequences, and can present opportunities for innovative service reconfiguration. Some highly successful birth centres have emerged as a result of the closure of maternity hospitals (e.g. Jones and Walker, 2003). Nevertheless, the pressures and fears generated by frequent, major service changes have led many NHS workers and service users to see the words ‘reconfiguration’, ‘closure’ and ‘centralisation’ as interchangeable. As Macfarlane (2008) has clearly pointed out, there are problems associated with larger units and reconfigurations and the potential for consequent detrimental effects on care. Furthermore, there has been no systematic analysis concerning the size of these units and the quality of the clinical care that they deliver (Macfarlane, 2008).

Another key factor in modern maternity care is the standardisation of services that has resulted from the proliferation of policies, protocols and clinical guidelines. Two major factors have fuelled the standardisation of practice. Initially this developed from efforts to provide clinical care based upon research evidence (Sackett et al., 1996, 1997). Secondly, and more recently, standardisation has accelerated following the growing emphasis upon clinical governance in the NHS, especially in maternity care, where litigation is very costly. The requirements of the Clinical Negligence Scheme for Trusts (NHS Litigation Authority, 2009) link guidelines to costs, and add a further economic imperative to the many pressures to standardise care. In Chapter 9 we shall discuss the conceptualisation by Stronach et al. (2002) of professional identity as caught between such ‘economies of performance’ and ‘ecologies of practice.’

The habits and vocabulary of proceduralisation, originally based upon research evidence, lead to expectations of standardised behaviour and a ‘right way’ for clinicians to act in any situation. This situation usually reflects the culture of the local service, and may pay little heed to individual women’s circumstances, needs and expectations (Kirkham and Stapleton, 2001). Behaving in the ‘right way’ or becoming ‘obedient technicians’ (Deery and Hunter, 2010) gives midwives and obstetricians the security afforded by clinical governance, but can be seen as protecting the organisation rather than its users or clinicians. Such rule following is described by a colleague of ours as ‘teflon-coated management’, to which neither blame nor responsibility can adhere.

In a study of midwives returning to practice, and therefore able to make comparisons across time, it was found that returning midwives saw standardisation as improving the service for clients in some respects, but also as reducing opportunities for midwives to use their clinical judgement to tailor care to the needs of individual women. In a climate of fear of litigation and defensive practice, together with shortage of staff and pressure to get through the work, delivery of the standardised package of care is seen as a professional duty, and individualised care as being lost due to lack of time (Kirkham and Morgan, 2006; Bryson and Deery, 2009).

Hochschild described a ‘professional’ flight attendant as ‘one who has completely accepted the rules of standardisation’ (Hochschild, 1983, p. 103). ‘By linking standardisation to honour and the suggestion of autonomy’, and by identifying the work as ‘professional’, both flight attendants and midwives practise in a highly controlled manner. It is interesting that many aspects of the standardisation of practice originated from the aviation industry. Yet such Taylorist control (Torrington et al., 2002) of the details of work within service organisations creates considerable moral dilemmas and occupational stress for midwives, especially within hospitals. It is also possible to envisage that the comprehensive protocolisation of clinical practice will interfere with professional progression ‘from novice to expert’ (Benner, 1984), because of the discouragement of intuitive caregiving (Drummond and Standish, 2007; Ilott and Cooke, 2007).

Expectation of standardisation makes it difficult for management and staff to envisage different ways of providing care, to innovate on a small scale or to create pilot schemes. Protocolisation of care is seen as superseding old ways. This is one reason why problems are encountered in maintaining home birth services in many areas, while prioritising the resource needs of a modern central delivery suite. Birth centres represent an aspect of maternity care that has a long history (such as the earlier general practitioner (GP) maternity homes), so their introduction may now be seen as a backward step or as a deviation from modern maternity care. Birth centres (and home birth) are difficult to tolerate when the ‘right’ way to give birth has been established as medicalised care in a consultant unit.

Midwives and their managers are increasingly aware of, and even more cynical about, changes in the language of policy that repackage previously negative concepts as positive. ‘Reconfiguration’ is a modern packaging of what were previously termed ‘cuts and closures.’ A shortage of, or reduction in, professional clinical staff is repackaged as ‘skill mix.’ Cuts in the number of antenatal and postnatal visits to women at home have been described as ‘individualised care’, although midwives find it difficult to increase the care of particularly needy women. Similarly, ‘protocol-based care’ (Malone and Fontenia, 2007; Ilott and Munroe, 2008) is positively packaged as evidence based and managing risk, but may not respond to the needs and wishes of individual women. We have heard such terminology referred to as ‘menu midwifery.’ This is not to say that any of these modern initiatives are without merit. However, the language in which they are presented, the intolerance of any alternatives (Jowett, 2009; Kirkham, 2009), and the identification of these initiatives with ongoing efforts to reduce costs all lead to cynicism among clinical midwives.

For midwifery and for low-risk birth, recent changes in the NHS have produced both losses and gains. Constant change and shortages of staff have wearied and demoralised midwives (Deery, 2005; Deery and Fisher, 2010). The gap between the rhetoric of choice and woman-cent...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• About the authors
• Authors’ note
• 1 BIRTH CENTRES
• 2 THE RESEARCH STORY
• 3 THE STORY OF THE BIRTH CENTRE
• 4 THE DREAM JOB: NICHE PRACTICE IN MIDWIFERY
• 5 OPPOSITION TO THE BIRTH CENTRE
• 6 THE EXPERIENCE OF THE BIRTH CENTRE MIDWIVES
• 7 SPIRALLING DOWNWARDS: INTERVENTIONS IN THE BIRTH CENTRE
• 8 THE WRITING ON THE WALL
• 9 THE BIRTH CENTRE: IDEALS, MODELS AND TENSIONS
• 10 CONCLUSION
• Index