City Research Online

Abstract

Introduction

The Barkantine Birth Centre, opened in 2008, is a well-established urban Freestanding Midwifery Unit (FMU) with a target number of 600 births/year. It is consistently achieving about 82% of spontaneous vaginal births and a similar percentage of normal births, keeping caesarean section rates at 9% and instrumental birth rates at about 8%. High rates of normal birth within FMUs have also been reported nationally by the Birthplace in England Research Programme. However, to date there is a knowledge gap regarding key elements in midwifery practice, environment, and organisation of care, which may potentially affect the care outcomes in FMUs as well as staff job satisfaction and wellbeing. This ethnographic study aimed at contributing to knowledge and theory-generation in the arena of midwifery-led birth settings and particularly midwifery units.

Funding

The study was funded by a National Institute for Health Research Doctoral Clinical Academic Training Fellowship awarded in 2009.

Ethics approval

Final ethics approval was granted in February 2011

Methodology

This is a post-critical ethnographic study carried out by an insider researcher, who carried out fieldwork in a FMU from April 2011 to June 2012. Participants included birth centre service users and staff as well as stakeholders at the referral hospital. A total of 82 participants were recruited. The ABSTRACT 17 participants included all FMU staff as well as service users, who reflected the characteristics of the local multi-ethnic population. The fieldwork included participant observation, semi-structured interviews, analysis of local operational procedures and guidelines. Audio recordings were transcribed and anonymised in order to maintain confidentiality. Analysis was conducted alongside data collection using a modified constructionist Grounded Theory approach, in two intensive waves of analysis in August 2013 and in October 2015. The software package Atlas.ti was used in order to manage the large amount of data but some manual analysis was still included particularly for mapping categories, subcategories and codes. Constant comparative methods were used throughout the analytic process. Participants’ involvement with the study was systematic. Two service users helped writing the protocol, developing the information sheets and both service users and midwives participated with the interpretation of the findings. Two FMU midwives also functioned as ‘key informants’.

Findings

The analysis generated 152 codes, which were organised into categories and subcategories. Eventually the categories were organised into three key categories: key aspects for midwives’, the organisational perspective of the FMU and service users’ expressed needs and views. These were visualised in three models which function as maps, representing the landmarks of well-functioning FMUs: the midwives’ dimension, the organisational dimension and the woman’s dimension.

Conclusion

On the basis of both my ethnographic study and the findings of the meta-synthesis conducted as part of the work, I argue that well-functioning FMUs offer effective care focused on the needs of the woman and her family and facilitate the transition to parenthood by tailoring care around individual needs and wishes rather than being focused on an ‘industrial’ highly regulated model of care. The environment and organisation of work in the FMU not only generated health (salutogenesis) in the women but also created a positive climate among staff who felt that their basic needs of autonomy, competence and relatedness were met. The positive climate at work and the establishment of relationships at work led to the creation of a sort of social capital, which created a positive feedback loop of self-maintenance of the philosophy, culture, knowledge and skills at the FMU.

When the basic needs of the midwives were not met, women could notice a deterioration of the care that they received.

A balanced workload, team values and the wider organisational culture were identified as key aspects to be considered for a well-functioning FMU.

Strengths and Limitations

During the planning phase of my ethnographic study, the conduct of data collection and analysis I have always referred to the quality criteria described by Walsh and Downe (2005) as a framework for guiding my study and ensuring good quality.

There were however some limitations. Being an insider researcher led to both limitations (not having a ‘fresh eye approach’ and challenges in representation) as well as advantages (‘verstehen’ and access to the ‘backstage’ dynamics). Another limitation was not being able to use photographs as a data collection tool as originally planned.

Recommendations

This study highlights the need for the FMU to be considered as an integral part of the maternity services rather than treated as an ‘isolated midwifery unit’. Fostering a culture of interdisciplinary collaboration and positive relations between the FMU and the obstetric unit (OU) also emerged as important aspects.

Mindfulness emerged as a key finding for the midwives and needs to be further explored. Being able to be fully present physically, mentally and emotionally to care for the woman was highlighted as essential both by the midwives and by service users. Mindfulness was also linked to a reduction of stress and increased sense of wellbeing for the midwives.

Evidence-based standards for midwifery units need to be developed in order to define how care should be organised and delivered in MU birth settings. Further research is needed on the relationship between environment, workload, practices and care outcomes.

Publication Type:	Thesis (Doctoral)
Subjects:	R Medicine > RA Public aspects of medicine R Medicine > RG Gynecology and obstetrics R Medicine > RT Nursing
Departments:	School of Health & Medical Sciences > Department of Nursing & Midwifery School of Health & Medical Sciences > School of Health & Medical Sciences Doctoral Theses Doctoral Theses

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