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Influences on the implementation of a physiological care approach: A mixed methods study in two obstetric units

Darling, F. (2024). Influences on the implementation of a physiological care approach: A mixed methods study in two obstetric units. (Unpublished Doctoral thesis, City, University of London)


Routine clinical intervention use in labour and birth is evidenced to cause harm. To under-stand continuing increases and wide variations in its use, this thesis presents the findings of original research that explored influences on implementing a physiological care approach. In a physiological care approach, care focuses on meeting the woman’s physical and emotional needs, while clinical intervention is used during labour and birth, only when problems that arise warrant it. The location was two obstetric units where clinical intervention rates are evidenced to be higher than other birth settings.

Aim: To explore and understand influences on the implementation of a physiological care approach in two obstetric units.

Design: An embedded mixed method explanatory study underpinned by Dewey’s Pragmatism.

Sample: This comprised of two consultant midwives and two obstetricians, 12 women and their birth partners who experienced care during labour and birth, and 16 midwives who provided their care.

Methods: Observations and interviews were used. In observations, data was gathered on the midwives’ training; their use of physiological care practices; and decision-making by mid-wives and obstetricians during labour. Interviews explored participants’ experiences of driving; implementing a physiological care approach; and receiving care. Familiarisation with a care guideline was undertaken. Three stages of analysis included (i) a descriptive quantitative analysis of use of physiological care practices; (ii) a thematic analysis of observations of practices, training and interviews; (iii) an integrated analysis of quantitative and qualitative findings.

Findings: Organisational leadership: An important facilitator was the committed leadership of two consultant midwives who collaborated with two consultant obstetricians. However, consultant midwives were of the view that resourcing decisions to prioritise an obstetric framework of care, and resistance to a physiological care approach, acted as a barrier.

Professional Groups: Observation and midwives’ experiences predominantly identified the use of hierarchical decision-making and centralised surveillance to embed an interventionist approach. Midwives’ use of physiological care practices was observed to be variable. The routine use of an interventionist approach was engendered by large workloads, risk preoccupations and lack of skills to facilitate or provide consistent support for implementing a physiological care approach. However, the norm of an interventionist approach was also observed and experienced as a preference amongst most professionals in the OUs including midwives.

Women: Women, with the support of their partners, sought to experience a physiological labour and birth but were not fully supported. Midwives assumed women who used OUs were open to clinical intervention, and routinely offered it to them. There was a lack of advocacy, options for care were not always explored, and informed consent was not always obtained for clinical interventions.

Conclusion: While there were facilitating influences, barriers predominated at all levels, negatively influencing the implementation of a physiological care approach.

Recommendations: A greater understanding of the need to prioritise and resource projects to progress implementation of physiological care approach; increased opportunities to develop skills including provision of clinical support; appraisal work to foster collaborative working between midwives and obstetricians; enhancing women’s understanding of choices to experience a physiological birth; respecting women’s choices, including advocating on women’s behalf during labour can facilitate implementation in OUs.

Publication Type: Thesis (Doctoral)
Subjects: B Philosophy. Psychology. Religion > BF Psychology
R Medicine > RG Gynecology and obstetrics
R Medicine > RT Nursing
Departments: School of Health & Psychological Sciences
School of Health & Psychological Sciences > School of Health & Psychological Sciences Doctoral Theses
Doctoral Theses
[thumbnail of Darling Thesis 2024 Redacted PDF-A.pdf]
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