An ethnographic organisational study of alongside midwifery units: a follow-on study from the Birthplace in England programme

Current policy on place of birth in England

Over the last 10 years, there has been a clear policy direction on the importance of offering women choice in childbearing, and particularly on giving healthy women the choice of where they give birth. The National Service Framework (NSF) emphasised the importance of choice, continuity and control for women in maternity care and advocated more targeted approaches to ensure a safe and high-quality service. 5 The maternity standard of the NSF specified that service providers and trusts should ensure that ‘. . . options for midwife-led care will include midwife-led units in the community or on a hospital site.’ Care is to be provided in a ‘. . . framework which enables easy and early transfer of women and babies who unexpectedly require specialist care’ (© Crown copyright 2004, contains public sector information licensed under the Open Government Licence v2.0). 5 The related guidance Maternity Matters6 identified that all women should have a choice of place of birth by 2009, including birth in a local facility, including a hospital or under the care of a midwife. 6 Current NICE intrapartum care guidelines for healthy women provide information for women, health professionals and managers to inform decision-making on choice of place of birth. 7

Overarching NHS objectives inform the commissioning of maternity services. 8 Maternity services are specifically highlighted within the 2012/13 Operating Framework for the NHS9 with expectations that services will deliver improved continuity of care, choice, access and productivity:

Continuity in all aspects of maternity care is vital, from antenatal care through to support at home. Mothers and their families should feel supported and experience well-coordinated and integrated care.

Para 2.39, © Crown copyright 2011, contains public sector information licensed under the Open Government Licence v2.09

Choice is critical to giving patients more power in our systems. PCT [primary care trust] clusters should drive forward improvements in patient choice so there is a presumption of choice for most services from 2013/14. During 2012/13 this means continuing the implementation of choice about maternity care.

Para 3.22, © Crown copyright 2011, contains public sector information licensed under the Open Government Licence v2.09

In addition, the Outcomes Framework for the NHS 2012/1310 sets the high level nationally required outcome measures that commissioners should use to judge the quality and effectiveness of their services, including maternity services, as reflected in Table 1.

Finally, the Government’s mandate to the NHS Commissioning Board for the period April 2013 to March 201511 advised work with partner organisations to ensure that the NHS:

• offers women the greatest possible choice of providers

• ensures that every woman has a named midwife who is responsible for ensuring she has personalised, one-to-one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a mental health problem.

The Board is legally required to pursue the objectives in the mandate, and the way in which services are organised is an important factor in meeting these policy objectives to improve services. There is considerable variation within and between regions regarding what services are provided and inequalities in provision. Options for place of birth have improved since 2007,12 but almost half of women did not have a full range of choice in 2010. Currently 13% of women give birth outside an OU, in midwife-led units (AMUs or FMUs) or at home. 13

Maternity services offer a range of models of care, aimed at improving continuity14 and organisational configuration reflecting local needs, which include offering services in midwife-led settings of AMUs, FMUs and home. The number of AMUs has increased since 2007 compared with FMUs,4 and they are, therefore, increasingly relevant to the configuration of maternity services currently under consideration in England. They have the potential to deliver responsive and effective high-quality care, but there remains a paucity of evidence to inform these processes, and the ways in which AMUs operate requires greater scrutiny. AMUs are more likely to be developed than FMUs because of the political and financial climate, in which funds for rebuilds are scarce, and also because of concerns about transfer times and distances. 15

Additionally, changes to medical training, the European Working Time Directive,16 maternity staffing standards and neonatal service reconfigurations are all altering the configuration of maternity units, professional practice boundaries, skill mix and relationships. 17

Development of birth centres

Midwife-led birth centres have been developed in an effort to provide a better birth environment for women and their families and to tackle rising intervention rates, but they also aim to address the problem of midwife retention within the NHS. The most comprehensive survey to date on why midwives leave the profession found that, aside from retirement, the most common reason was because they were ‘unwilling to practise the kind of midwifery demanded of them by the NHS, despite their desire to continue working as midwives’. 18 Furthermore, the evidence suggests that this tension between how midwives would like to practise and how they are required to practise is a significant source of emotional difficulty for them. 19 Birth centres were developed in part as an attempt to resolve some of the discrepancy between the ideals of midwifery and the perceived reality of work within the NHS, by creating a separate space within which midwives could practise with a social model of care. 20

Environment and ‘home-like’ spaces

Midwifery scholars and social scientists have both addressed issues of space and place in birth. To date this interest has mainly been incidental to other concerns, such as women’s choice of place of birth21 or the development of midwife-led services outside OUs. 22–26 Other work in this area has focused on midwives rather than women and explored the effects on midwives of working in the community19,27 or in midwife-led units28–30 rather than in consultant-led units. In addition, much of the wider work in health care that has explored problems of space and place has done so while focusing on workplace relationships, for example health-care professionals’ relationships with managers31 and midwives’ relationships with junior doctors32 and support staff. 33,34

Shaw and Kitzinger35 and Davis-Floyd and Davis36 are among scholars who have suggested that women feel more in control of their birth at home or in home-like settings such as free-standing birth centres. One reason given for this feeling of control is that the woman has the higher status of ‘resident’ at home and the midwife is constructed as a ‘visitor’, whereas in hospital these roles are reversed. 37 Following this, Gilmour38 argued that transforming hospital spaces so they are more home-like challenges the dominance of biomedical values, a claim disputed by Fannin,39 who argued that it is presumptive to assume that making a hospital space more like a home will in itself fend off the controlling influence of biomedicine. Others have also been critical of the assumptions that underlie the discourses of pro-home birth academics and activists. The discourse of home equals control assumes that women have agency in their own homes, which is not always the case: ‘home does not signify autonomy and bodily control for all women, nor is domestic space always the safest place for women’. 40

The discipline of geography has put space and place more firmly into the social science agenda. There is little literature by geographers on maternity care, but the literature on geographies of nursing, like that of health and medicine, is growing rapidly. Andrews41–43 and Andrews and Shaw44 have written a number of introductory ‘manifestos’ for the geography of nursing, which explore the role of space in health-care organisations.

Hospital developers, fuelled by the drive to build new hospitals though private finance initiatives,45 have sought to design hospital environments that promote the healing and well-being of patients. Aside from the architecture of the hospital building itself, the introduction of visual art into hospitals (see Lankston et al. 46 for an evaluation of its benefits) is one example of the way in which designers have attempted to make hospitals into therapeutic landscapes. These interior designs have particularly focused on integrating ‘nature’47 and ‘home’38 into the institutional space because they are two arenas strongly imbued with the qualities of a ‘therapeutic landscape’. 48 Contemporary interest in the design of hospitals has applied the principle that a therapeutic landscape is not only one that is outside, but may also be brought into an institution and that ‘the hospital, rather than being a place of scientific inquiry removed from everyday life, is conceptualised as the home place for its inhabitants’. 38

This trend towards designing hospital wards as what are considered to be ‘home-like’ spaces assumes (problematically) that the home is a therapeutic landscape for all women, while also allowing them to birth within a hospital environment that is specifically away from the home, where those tools that are culturally assumed to improve safety, such as medicines, doctors and monitors, are readily available. This ‘hybrid space’38 is a manifestation of a wider cultural conception of childbirth as both a normal life event49 and inherently risky and in need of medical assistance (see Hausman50 for a discussion of the discourse of obstetric risk).

Efficacy and effectiveness

The evidence regarding efficacy and effectiveness with respect to birth settings is also increasing. A Cochrane review of AMUs compared with conventional hospital labour wards (or OUs) found increased likelihood of spontaneous vaginal birth, labour and birth without analgesia or anaesthesia, breastfeeding at 6–8 weeks post partum and satisfaction with care and decreased likelihood of oxytocin augmentation, assisted vaginal birth, caesarean birth and episiotomy. 24 Although no difference occurred in infant outcomes, substantial numbers of women were transferred to standard care, either before or during labour, because of maternal request, such as for epidural pain relief or because they no longer met eligibility criteria for the midwifery unit setting. 51 A similar pattern has been found with planned home birth for ‘low-risk’ healthy women.

The Birthplace in England study assessed outcomes by intended place of birth at the start of care in labour for women at low risk in AMUs, FMUs and home, compared with women planning birth in OUs. 1 For all women, the incidence of major interventions including intrapartum caesarean section was significantly lower and normal birth increased in all settings outside the OU. The overall incidence of adverse perinatal outcomes was low in all birth settings. For multiparae, no significant differences were reported in adverse perinatal outcomes between any settings. For nulliparae, no significant differences were reported in adverse outcomes between AMU or FMU and OU care. However, the risk of a composite adverse perinatal outcome was significantly higher for nulliparae who planned to give birth at home than for those who planned to give birth in an OU.

For all women, planning birth in any of the settings outside the OU significantly lowered the incidence of major interventions, including intrapartum caesarean section, and increased the rate of normal birth, relative to the OU (Table 2).

The study also found that the cost to the NHS of intrapartum and related postnatal care, including costs associated with transfers and clinical complications and admission to higher-level care, was lower for birth planned at home, in a FMU or in an AMU than for planned birth in an OU. 53

Women’s choice, information, access and experience of alongside midwifery units

Unlike women who plan to give birth at home or in FMUs, women who planned to give birth in AMUs were reasonably similar in demographics to women who planned to give birth in OUs in the Birthplace in England study. 1 Research into how women and their families make decisions about where to give birth has tended to focus on home and OUs, with the following factors being consistently important to women: finding a balance between safety and a satisfactory birth experience, the influence of friends, family and doctors, social class and cultural values,54,55 and the model of care on offer. 56 More recent work has found that women value birth centre care, particularly the environment, personal attention, calm ambience and close to obstetric support if needed,51,57–59 in essence what is often perceived as ‘the best of both worlds’. 58

Longworth et al. 60 found that women who chose a home birth valued continuity of care, a homely environment and the ability to make their own decisions regarding interventions. In contrast, hospital birth respondents placed a relatively high value on access to an epidural for pain relief and not needing to be transferred to another location during labour if a problem arose. 60

Transfers from midwifery units

Transfer from midwifery units to OUs both during and after labour is common, especially for first-time mothers and more common from AMUs than free-standing ones. In the Birthplace in England study, the overall intrapartum transfer rate ranged from 21% to 26% for all women, but was higher for nulliparae (36–45%).

The overall intrapartum transfer rate ranged from 21% to 26% for all women but was higher for nulliparae (36–45%), as shown in Table 3.

In AMUs, the primary reason for transfer was failure to progress in labour, followed by request for an epidural. In FMUs or home birth cases, the primary reason was also failure to progress in labour, followed in this case by meconium staining. In both types of midwifery unit, compared with multiparous women aged 25–29 years, nulliparous women aged < 20 years had higher odds of transfer [FMU-adjusted odds ratio (OR) 4.5, 95% confidence interval (CI) 3.10 to 6.57; AMU-adjusted OR 2.6, 95% CI 2.18 to 2.06] and the odds of transfer increased with increasing age. Nulliparous women aged ≥ 35 years in FMUs had 7.4 times the odds of transfer (95% CI 5.43 to 10.10) and, in AMUs, six times the odds of transfer (95% CI 4.81 to 7.41). Starting labour care after 40 weeks of gestation and the presence of complicating conditions at the start of labour care were also independently associated with a higher risk of transfer. 61

A qualitative study drawn from the same cohort found that most women hoped for, or expected, a natural birth and so did not expect to be transferred. Transfer was disappointing for many, but sensitive and supportive care and preparation for the need for transfer helped women to adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from FMUs, the ambulance journey could be described as a limbo period. Women who were worried or fearful felt as though they were being transported rather than cared for. For many, this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but they did not necessarily seek this out if it was not offered. 62 Sensitive care and preparation can help women adjust to changing circumstances, as some apparently straightforward changes to practice have the potential to make an important difference to women’s experience of ambulance transfer and transfer or escalation of care. 2

Organisation of care

Previous research that has focused on AMUs has uncovered a number of questions about their function, particularly in the long term. The Health Care Commission review63 and the Birthplace Mapping Study4 highlighted the ad-hoc nature of the development of AMUs, challenges in developing usable data systems and lack of agreed definitions, eligibility, staffing or operational criteria.

Following on from its previous inquiry into the safety of maternity services, The King’s Fund commissioned further research to answer a fundamental question: can the safety of maternity services be improved by more effectively deploying existing staffing resources? The report Staffing in Maternity Units: Getting the Right People in the Right Place at the Right Time concluded that the key to improving maternity care is using midwives and other maternity staff more effectively. 17 The report considered the available evidence about the relationship between staffing levels and deployment practices and safety of care for mothers and babies, focusing specifically on labour and birth. It reviewed evidence particularly on the relationship between staffing levels and outcomes, the potential for shifting tasks between various health professionals and making use of new and extended roles, the effectiveness of different models of care and the impact of these on use of resources. 17

There is very little published evidence on how midwife units should be organised and staffed. While midwives are present at all births and are the main providers of antenatal and postnatal care, it has been difficult in the past to prescribe appropriate staffing levels because patterns of care vary between maternity services. Staffing needs in both hospital and community settings depend on service design, buildings and facilities, local geography and demographic factors, as well as models of care and the capacity and skills of individual midwives. Other significant variables with an impact on staffing levels include women’s choice and risk status. As maternity services develop different models of service delivery, such as home birth, caseload midwifery practices and FMUs, their staffing requirements may alter, particularly in the service development phase. The ratios of midwives to births recommended by the Royal College of Midwives (RCM)64 are designed to deliver a safe, high-quality maternity service, as described in the Maternity Matters report. 6

The Royal College of Obstetricians and Gynaecologists’ review entitled Safer Childbirth recommended staffing levels in recovery, theatre and high-dependency units. 65 The NHS Litigation Authority66 has published risk management standards for NHS organisations providing labour ward services. 67 The standards require staffing levels for all obstetric midwifery, nursing and support staff for each care setting, which should be calculated using the figures identified in Safer Childbirth. 65 The ratio recommended by Safer Childbirth, based on the expected national birth rate, is 28 births to one whole-time equivalent (WTE) midwife for hospital births and 35 : 1 for home births. Further specific recommendations are as follows:

• Birth centres/midwifery-led units: the normal recommended ratio is 35 : 1 to reflect the generally low dependency of women accessing these services. However, separate assessment is needed when providing intrapartum care for women requiring transfer to hospital care, or providing ante- or postnatal care on an inpatient basis.

• Obstetric units: the number of midwives allocated to each shift must enable a minimum of 1–1.4 midwives for each woman in established labour, depending on case mix.

Research on the development, implementation and sustainability of AMUs has found that wider institutional support and senior leadership are crucial. 68 There has been little research carried out to date on the organisation of midwifery units in the UK, both free-standing69 and alongside. 70,71 The Birthplace in England Organisational Case Studies2 also included three sites with AMUs and two with FMUs. There is evidence that such settings provide a space for the development of specialist midwifery skill and expertise in physiological birth and improved midwife job satisfaction and retention. 72 However, while midwifery units have provided midwives with a space that allows them some congruence between ideals and practice, an unintended consequence is that the philosophy and practice of the midwifery unit and their local OU, labour ward or delivery suite can become polarised. This can have a negative effect on the relationships between the midwives in the two clinical areas. 70

While few studies have been conducted of AMUs, enquiries into safety problems in FMUs and in OUs have indicated that even when formal systems, such as staffing levels and mix, appear well functioning, problems in the informal operation of those systems may arise. These may be as a result of factors such as poor inter-professional teamworking, management and training limitations, and failure to consistently implement agreed guidelines or the effect of economic and political concerns on clinical decision-making. These all lead to quality and safety concerns. 73,74 Additionally, little is known about the effect on the OU or on women with higher or intermediate levels of clinical risk factors of developing separate places with different philosophies of care.

There is a need for research that analyses not only the everyday function of midwifery units, but also their role within the rest of the maternity system and their effects, both intended and unintended, on the function of the OU. Although substantive literature on AMUs is very limited to date, the wider sources and the theoretical literature points to the importance of structural and systemic features of health-care systems, and organisational culture as well as formal organisation. They suggest that power play and local cultures may strongly affect risk and safety within health-care institutions and that interpersonal or professional issues may influence behaviour and decision-making amongst health-care professionals. 70,75,76 Vaughan’s study of health-care organisation, for example, posited ‘structural secrecy’77 – inherent barriers or resistance to communication – as an important source of danger in complex systems. Vaughan proposed that social organisation in itself (rather than merely the actions or omissions of individuals, or technical systems in isolation from social systems) forms a source of safety or danger. 77 The theoretical and substantive literature points to the need to examine the environment and processes of care, looking at different areas of activity and different professional groups as part of a complex system, rather than in isolation. 75

The factors that may influence effective transfer are of particular interest since the Birthplace Cohort Study found that 21% (95% CI 19.2% to 23.2%) of women were transferred from AMUs to OUs during or shortly after labour. Overall, local transfer guidelines were of poor quality. 26 Few studies of transfer have focused on the management of transfers within hospital sites, but a study of home birth transfers in two cultures indicated that organisational and attitudinal factors were a primary cause for concern, rather than the more technical transport issues. 78 This was also found in a Scottish audit of outcomes of community maternity units (FMUs). 79

A case study of an AMU, conducted as part of a wider study of implementation of protocol-based care, indicated that while benefits were observed in terms of satisfaction and midwifery teamworking within the birth centre, there were also unintended consequences – specifically, more negative relationships with obstetric and other midwifery colleagues – which could have an impact on overall quality of care. 80 This study also highlighted, but did not investigate, the key role of managers and management approaches in such developments.

However, a small-scale study by Huber and Sandall81 of intrapartum referral and transfer in an AMU identified a number of organisational issues to be addressed in further research. Rather than promoting safe and effective coworking and transfer, the physical proximity of the units appeared to engender competition around physical and human resources, confusion and conflict around responsibility. Clashes of philosophy, rather than shared understandings or protocols, also formed barriers to teamworking and effective communication. This study indicated the need to explore approaches to staff deployment, management and training, clear guidelines and interprofessional communication that can avoid such problems arising. It echoed findings of the few earlier studies of transfer indicating that organisational and staffing as well as cultural issues may be of major importance to quality and safety.

Questions from the Birthplace in England Research Programme

The Birthplace in England Cohort Study raised a number of questions with particular relevance for AMUs. Although AMUs had lower intervention rates for low-risk women than for those planning to give birth in OUs, the rates were higher than for women planning to give birth in FMUs. 1 This raised questions about the possible reasons for these differences. Apart from differences in the nature and background of women planning to give birth in these settings, are any features of organisation or professional practice contributing to this? The Birthplace Organisational Case Studies2 found that more attention is given to the training and support needs of midwives in FMUs than to the needs of community midwives and those working in AMUs. Are the approaches different between types of midwifery unit and what might the reasons for or implications of this be? The case studies also highlighted a major issue of proximity of the AMUs leading to blurring of spatial and professional boundaries, with potential implications for safety. Differences in equity of information and access were also found. 2 Given that the profile of women in England planning birth in AMUs is more like that of women planning birth in OUs than that of those planning home births or birth in FMUs, do the AMUs offer access to midwife-led care in labour to a more diverse range of women and what might this be based on?

The trend towards provision of AMUs raises important questions. What factors may adversely (or positively) affect the safety of care and experience for women and babies in such units? There is a need to explore the specific function of those midwifery units that are situated close to – usually in the same building, or at least on the same campus as – an OU.

Many of the everyday tensions described by NHS midwives stem from the conflicting demands of different metrics and measures. Therefore, there is value in a study such as this that explores the key performance indicators, financial constraints and local commissioning priorities that filter down to the birth centres and the rest of their local maternity service.

These policy initiatives and previous research findings from the Birthplace Organisational Case Studies raised a number of questions about the organisation and function of AMUs in order to inform service planners and managers developing and operating AMUs in the future. Therefore, this study aimed to clarify the experiences of existing AMUs that impact on their functioning through addressing two key research questions: (1) how are AMUs organised, staffed and managed in order to seek to provide safe and high-quality care on a sustainable basis? (2) What are the professional and service user perceptions and experiences of care in AMUs?

Design and conceptual/theoretical framework

The study used an organisational ethnography approach. 82–84 Since there is very little prior research on this topic, small-scale but in-depth qualitative case studies are most appropriate and will also inform future larger scale development and research. The ethnographic approach is particularly suited to more exploratory phases of research. It can provide a rich description and analysis of service models, which can inform service managers, commissioners and practitioners about how to develop and provide care effectively in such settings. This approach includes a range of data collection methods.

Methods of data collection

Data analysis

Qualitative and structural analytical approaches were employed according to data type and in order to facilitate exploration of process and structural as well as experiential aspects of the systems of care. Data were analysed using a framework approach. 89 A coding framework was developed based on the analysis and emerging questions from the Birthplace study and amended in the light of initial readings and discussion of the data collected and potentially emerging themes. This was done in a series of core study team, co-investigator and advisory group meetings, during the continuing data collection phase. This initial analysis was also used to guide further sampling and data collection decisions. In a framework approach, the prior coding frame is applied and tested by informing study questions and by mapping against the data, but a thematic approach is then incorporated using open coding to identify and explore newly developing themes and progressing to both axial and selective coding to identify key themes and categories. NVivo 10 qualitative data analysis software (QSR International, Warrington, UK) was used to facilitate systematic and rigorous analysis. Box 1 provides an illustration of this process, showing the nodes and codes used within the parent node referring to user experience.

Structural approaches were also utilised to help explore the data. Process maps were used to focus particularly on mapping care pathways, transfer processes, staffing configuration and interprofessional teamworking and communication. While individual site descriptions were drawn up (see Case study site descriptions) subsequent analysis was largely on a cross-site basis. Strengths, weaknesses, opportunities and threats (SWOT)-type summaries for which respondents’ perceptions of advantages or drawbacks, opportunities or threats relating to AMUs were mapped onto tables.

In order to ensure that the process was both valid and trustworthy, preliminary coding and data analyses were commenced as early as possible. Feedback was given at regular intervals to co-investigator and advisory group meetings and discussed fully. The members of the advisory group in particular were asked to comment on whether or not the emerging findings rang true for them, whether or not anything particularly surprised them and whether or not any important issues appeared to be missing or overlooked. A participative meeting approach was used to discuss emerging issues in small groups, to identify and prioritise them and to highlight additional questions or queries. Analysis was primarily conducted by the four core team members (CM, JS, JR and SR) but co-investigators also independently read, coded and discussed the data in selected areas in which they had particular knowledge and interest. Although initially planned for sharing findings, further validation also took place during a series of regional practice-based workshops during the report drafting, in which participants discussed the issues in relation to their own service.

Ethical Issues

Ethical permission to conduct the study was obtained from the National Research Ethics Service Proportionate Review Committee (ref 11/LO/1028). Researchers were especially mindful of the need for continually negotiated consent when observing practice areas to ensure that staff and patients could exercise their right not to be included, and of the need to guard confidentiality when conducting research with small samples. Advisory group members were asked to read a draft of the report with particular reference to inclusion of any material that may lead to an inadvertent breach of confidentiality. Pseudonyms have been used for all people and places and some site details that may identify precise locations have been excluded. Professional and stakeholder respondents have been categorised very broadly to avoid identifying individuals with less common positions or work roles.

Model of care

Westhaven AMU is located in city suburbs with varied levels of deprivation and affluence. The unit was opened in 2005 and since that time has continued to host, as planned, 10% of the trust’s births. This proportion has been maintained despite the increase from 5000 to over 6000 deliveries in the trust, with AMU births rising from 500 in 2005 to over 600 in 2011–12. In 2011/12, the AMU had a little over 900 admissions in labour with a total transfer rate of around 32%. The unit is situated on the same corridor as the OU delivery suite. It is run using an opt-in model, meaning that the OU is the default option and women have to make a specific choice and booking to attend the AMU. The AMU has a core staff of 9 (8.36 WTE): one band 7 midwife (0.6 WTE) and eight band 6 midwives. Support workers are not used on the AMU. The unit has four delivery rooms, all with birthing mats rather than beds, and one has a plumbed-in pool. There is a transitional room used by the AMU and delivery suite for women with some complications but who may not need transferred to the delivery suite. The trust has recently opened a midwifery unit a few miles away.

Alongside midwifery unit history and funding

The AMU was opened in 2005 in response to a public campaign and a trend that had seen a number of trusts opening birth centres at the time. It was funded with a bid won from a government competition. The work was delayed for 2 years by the trust’s financial difficulties, but the money was eventually used to undertake small renovations at one end of the delivery suite and to pay for some furnishing, mats and interior decoration.

Staffing model

While the delivery suite manager has overall responsibility for the AMU as well as the labour ward, the AMU has a designated part-time (band 7) manager who was appointed to lead and promote the unit. Individual shifts are co-ordinated across both areas by the on-duty delivery suite co-ordinator, but in practice the AMU and delivery suite remain quite distinct, with separate off-duties and a core group of midwives who work on the AMU. The AMU is staffed by one midwife per shift during the day and two at night, working 12-hour shifts. There has been a move to have two midwives on the AMU at all times, but this has not yet been implemented. The trust has introduced bespoke in-house training for maternity support workers (MSWs) on the delivery suite with protected study time. The trust plans to use these MSWs to support midwives on the delivery suite to release midwifery time.

Funding and future plans

There are plans to increase the number of midwives employed on the AMU and to increase the numbers of women using the service by making it the default birthplace for all low-risk women (i.e. an opt-out model) unless they request a birth at home, in the FMU or on the delivery suite. AMU staff expressed some concern that increasing their numbers would also increase the likelihood of them being ‘pulled’ (Southcity manager 2) to cover the delivery suite. The AMU is considered by the trust to be functioning well and there is no current threat to its future. This is in part because it is in high demand from women and in part because it is helping the trust achieve its Commissioning for QUality and Innovation targets to increase the normal birth rate by 1%. The trust is recruiting a senior midwife to manage the new FMU and to lead on normal birth across the trust.

Model of care

Northdale is a town with moderate levels of deprivation. In 2011/12, the maternity service cared for a population of women consisting of 77% white and 23% BME. The population of women using the AMU was slightly different as 83% who used the AMU were white and 17% were BME. There were around 6000 births in the trust in 2011/12, with the AMU accommodating 14% of these and the local FMU 10%. Managers reported the transfer rate from AMU to OU in labour as approximately 16%, which is comparable to national averages. The AMU was opened in 2008 as part of a reconfiguration that included the merging of two local trusts. The two delivery suites were centralised at Northdale and the other delivery suite was converted into a FMU. The AMU is located two floors below the delivery suite and has seven en-suite delivery rooms. It is run on an opt-out model, meaning that the AMU is the default option for all women in the area who meet low-risk criteria, unless they request otherwise. The AMU has a core staff of 10.2 WTE midwives (1.2 at band 7 and nine at band 6), with two midwives and one MSW covering each shift. Additionally, on-call community midwives are encouraged to come in to attend births on the unit.

Alongside midwifery unit history and funding

The AMU commenced as a GP (general practitioner) unit in the 1970s, run by community midwives, with two labour rooms and around 250 births a year, which made up 10% of the total births in the trust’s maternity service. It remained a GP unit until the mid-1990s, when the service introduced midwife-led care following the Changing Childbirth91 report In 2001, Northdale Trust merged with another local trust and the obstetric services were centralised at Northdale. The old GP unit became a midwife-led unit next door to delivery suite in a newly built hospital. The head of midwifery drove a redevelopment of the AMU, and in 2008 the AMU opened in its current form. The old midwifery unit was moved to another floor in the hospital and increased in size from four to seven birth rooms, to cater for the increased birth rate.

Staffing model

The AMU has a full-time manager, who is responsible for its day-to-day running. The head of midwifery recently instigated some meetings to improve communication and teamwork between midwives on the AMU and the delivery suite. In the last year, the AMU has developed a core midwifery team headed by a new manager. There are two midwives and a midwifery assistant on duty for each shift and an on-call community midwife can be called in if needed. The AMU midwives are frequently also asked to cover shortages on the delivery suite.

There have been proposals to reintroduce the rotation of staff to improve working relationships between clinical areas. The trust has been using the Lean process ‘Visual Hospital’ to rationalise use of beds and staff92 (see Managing staff resources). This system is intended to facilitate placing midwives where they are most needed between the OU wards, the AMU and FMU.

Funding and future plans

Plans for the AMU are centred on the deployment of staff. Using Visual Hospital is seen by managers as helping them to deploy midwives where they are most needed although alternative plans for rotation or further integration of community midwives were also under consideration (see Managing staff resources). As with all the case study sites, Northdale is struggling with restricted spending and cost-saving measures, so managers aim to reduce the costs of bank staff by using their existing personnel more efficiently.

Model of care

Midburn AMU opened in 2010 as part of the merging of two OUs that centralised at Midburn hospital, in an area of severe multiple deprivation. It is within the same building but on a different floor from the delivery suite. It hosts around 700 births a year, approximately 11% of the total births at the trust. Approximately 27.5% (2010–11) of the women are transferred during or shortly after labour, which is slightly below the national average. The AMU is organised on an opt-out model so that all women who meet low-risk criteria are booked for the AMU by default, unless they choose to birth at home, in the local FMU or in the OU.

The AMU received significant capital investment and a lot of attention was put into making it a comfortable, home-like space. There are six en-suite birthing rooms: two have plumbed pools, and inflatable birth pools are available for the other rooms. The unit has a kitchen that is shared between staff and patients, an aromatherapy room, a patient sitting room and staff room as well as the usual clinical stores and sluice.

Alongside midwifery unit history and funding

The AMU was conceived as part of a strategy to increase the capacity of Midburn maternity services following centralisation. It was proposed with the dual aim of improving facilities for women and attracting midwives to work at the trust, where recruitment had diminished in response to service quality problems that had been publicly observed. The AMU was developed quickly, with full support from the trust executives and an assigned budget to cover the development costs. The money was spent on adapting a ward, with a focus on interior design and decoration of the space.

The project was led by the consultant midwife who provided the brief, oversaw the building work and recruited the core staff team of midwives committed to working in a ‘low-tech’ birthing space that would promote normal birth. A FMU has since been opened nearby.

Staffing model

Midburn AMU has a dedicated manager who is responsible for the day-to-day running of the unit. She is supported by the consultant midwife, who continues to take a close interest in the unit and acts as its advocate both within the trust and by promoting it externally. The AMU midwives are core to that area, although they are frequently asked to cover for staffing shortages on the OU delivery suite. All community midwives are required to do one shift a month on the AMU to maintain their intrapartum skills. At each shift, there are three core AMU midwives, one on-call community midwife and a MSW. The three core midwives are on call for the FMU, which is opened on demand. Currently community midwives are not expected to work at the FMU.

Funding and future plans

A FMU was recently opened near the hospital and an effort is being made to increase the numbers of women using this service. A new manager has recently been appointed to oversee the AMU.

Model of care

The AMU at Southcity was opened in 2001 and had approximately 750 births in 2011–12, which is around 13% of the total births at the hospital. There are plans to increase this to 1000 births a year (a level achieved in previous years), although some managers consider this to be unsustainable at current staffing levels. The unit has six delivery rooms that have delivery mats rather than beds. Approximately 20% of women admitted to the AMU are transferred to the OU delivery suite during or shortly after labour, which reflects the national average. Until recently, the AMU also cared for a proportion of postnatal women from the delivery suite, but this postnatal bay has now been closed. The trust has opened a triage centre to improve management of admissions in early labour and to divert more eligible women to the AMU, which is part of an on-going plan to increase the numbers of AMU births by changing from an opt-in to an opt-out model (AMU as default option for low-risk women unless they choose otherwise).

Alongside midwifery unit history and funding

The unit was opened to increase the capacity of the trust’s maternity services. Although there was some opposition from the trust’s obstetricians at the time, the AMU is now well established. Locally, the trust is known particularly for its obstetric care of higher-risk women. The trust recently merged with a neighbouring hospital, and this has brought challenges in finding consistent practices and guidelines across units with different histories and organisational cultures and a number of changes in management arrangements.

Staffing model

The AMU has two band 7 lead midwives who co-ordinate the everyday running of the unit. It is currently staffed by a core team of midwives but there are proposals for 6-monthly rotations for most midwives, which started to be introduced during the fieldwork period. The plans include keeping a core team on the AMU to ensure that midwives continue to practise according to its ethos of promoting normal birth. With a view to sustainability, the maternity service recently recruited a number of midwives at senior management level and the consultant midwife’s remit has been expanded to include the Southcity AMU.

Funding and future plans

The recent merger presented a number of difficulties for managers striving to create consistent working practices across both sites. The consultant midwife has implemented a number of changes to the AMU including closing the postnatal bay and adjusting AMU eligibility criteria to ensure that they are consistent with the trust’s AMU on its other site.

Pragmatic drivers

Key drivers for managers in respect of midwife units were economic and pragmatic, but also included a quality and safety aspect. Examining the history of these services revealed that the origins of their AMUs were predominantly pragmatic rather than ideological or philosophical, although practical considerations were embraced as opportunities to bring about desired service improvements, with anticipated benefits for service users and providers. In two services, Southcity and Northdale, creating the AMU had been part of a reconfiguration strategy to close a neighbouring OU and centralise services on one hospital site; in another, Midburn, it was a key element of a strategy to turn around what a senior manager described as a ‘failing’ service (Midburn manager 3). Westhaven was created by refurbishing rooms on an existing delivery suite, achieved opportunistically through a government fund for improving hospital environments. In Northdale, a GP unit that was run by community midwives had already been in existence on this hospital site, so that the reconfiguration enabled both continuity and renewal, in terms of offering midwife-led normal birth care.

In the Birthplace Organisational Case Studies, the view commonly expressed by managers, commissioners and many professionals was that midwife units were a luxury and an unaffordable drain on the overall service. 2 Therefore, we were interested to note that in the services included in the current study, finance had formed a key driver for the creation of these units. This was not only linked to reconfiguration of obstetric services towards a more centralised model. In Midburn, managers and senior professionals emphasised that the introduction of the AMU enabled them to provide more appropriate levels of care to women, thus using their resources more effectively to improve quality and safety:

[Before this change] There was no concept of low-risk care, higher-risk care, everybody was just managed poorly in the same way, whatever their risk

Midburn, manager 3

In Southcity, the AMU had been created to resolve an impending bed shortage with the merger of two OUs. When the new build of the maternity hospital proved insufficient, the AMU was designed through refurbishment of a disused ward in the adjoining older hospital building, to provide an additional 1000-birth capacity. Despite its pragmatic origins and support from a number of obstetricians, some saw the unit as a drain on resources in a service hard pressed by financial problems and insufficient midwifery staffing and as taking away from the low-risk birth experience of midwives on the labour ward:

Yeah, it does have an impact and this was a problem to us. It meant that you were sucking out very low risk deliveries from the labour ward and sending them off to a separate unit . . . And I come back to my point: if I were to design a unit I wouldn’t split my shop in two different places on the high street. It just doesn’t make sense to me. If you have everybody all in one place you don’t have those problems. You’ve got greater monitoring of everything that’s going on; you’ve got greater use of your resources, [it’s] more efficient

Southcity, consultant obstetrician 3

In contrast, some professionals – both obstetricians and midwives – talked of the removal of some low-risk women as lightening the workload of the OU:

We’ve got less [laugh] low-risk patients to be fair um [pause] (. . .) It’s made a positive impact that that they have . . . that it has lightened the load on us.

Midburn OU, midwife 8

While some concerns and anxieties were expressed regarding the levels and sensitivity of new tariffs to be shadowed in maternity services in the coming year, the shift from payment by results (measured in terms of interventions) to one based more on risk levels of those booking for care was seen as an opportunity to consolidate recent developments in midwife-led provision. Some obstetricians and managers in Southcity, in particular, commented on normal birth as being a ‘loss-making activity’ (Southcity manager 5) under the current commissioning system, and service managers and obstetric consultants in all services expressed concerns about service funding and midwife staffing levels:

. . . we are looking at, um, the bottom line, service line reporting of all of our services and looking at what makes a loss, what breaks even and what we can do at profit, and maternity, because of CNST [Clinical Negligence Scheme for Trusts], because of the costs of obstetricians and the costs of midwives against the current tariff is unquestionably loss-making. So it’s really difficult. With midwifery-led births, because the tariff is lower, you’ve got more costs to cover within a lower amount of income, so it’s cheaper to do but less profitable. Or rather, more loss-making.

. . . yes you have to make the risk argument, yes you have to make the safety argument, yes all of that has to be there, but you also need to think about how you are going to answer the questions about, well this is going to represent an increased spend on workforce, this, you’re not going to meet the cost reduction targets

Southcity, manager 6

The paradox here was that, although managers recognised that high intervention rates were expensive, leading midwife units to be more cost-effective than OUs,53 payment systems had not been not well matched to this and services in constrained financial situations received greater income for more interventionist approaches to care.

Commissioners explained the degree to which the tariff system had worked through targets and drivers, but despite introduction of specific targets to increase normal birth rates or reduce caesarean section rates, the general tariff system with differential rewards for normal or operative births had not facilitated this:

So you can use the, you know, the contractual levers and use performance as a good starting point really for looking at making the best use of resources. Sometimes it’s about service redesign, there’s not going to be more money so they’ve got to do things differently.

Southcity, commissioners 1 and 2

Midwifery units were seen as a key element in strategies to reduce unnecessary intervention, to contain costs as well as to improve health outcomes, while also enhancing the recruitment and retention of midwives, as reflected in this comment by one Southcity manager:

You know, we’re having to reduce Caesarean section rates, and it’s sad but since, you know, we’re having to save all this money finally even the most sort of, um . . . even the consultants that weren’t so supportive of the birth centre are realising that actually our normal birth rate here is double what it is upstairs [OU], so you know, we are a money-saving, um . . . entity.

Southcity, manager 2

The accounts of managers and obstetricians indicated that the development of a stable AMU service also increased confidence in the abilities of midwives to provide more autonomous care, to ensure escalation and transfer when needed, and in the likely cost-effectiveness of the service. Although each service experienced challenges in inter- and intraprofessional relationships relating to these issues, which will be described in Chapter 4, once embedded and accepted within a maternity service, the AMU appeared to increase confidence in midwifery-led and normal, physiological labour care. Although this was not, in any case, an easy process, it was reflected in decisions to develop FMUs. These had recently been opened in Northdale and Midburn, and one was being developed in Westhaven. These developments were also utilising opportunities created by wider service reconfigurations. A further key consideration was the need to recruit and retain a well-motivated midwifery workforce.

Philosophical drivers

Although the development of AMUs was generally achieved through pragmatic circumstances, managers on all sites had a clear view of the aims and philosophy of the unit to provide a more homely birth environment that would be woman and family centred and facilitate normal birth practices and midwife-led care for low-risk women:

If people are relaxed and in a relaxed environment their hormones and their body can work better than if they’re tense and they feel that they’re being imposed on in here. You know, we say to women as they come in, ‘Make yourself at home, go where you like, move things around, whatever you want to do,’ and it’s their area to do what they want in. And it’s been shown to improve outcomes and . . . I would say, I can’t say shorten labours but not prolong them by that fear aspect of changing, you know, if you’ve been at home and you’ve been relaxed and calm and then you come in and all of a sudden contractions go off, and that’s what we’re trying to avoid really. So they can relax and (pause) get on with their business.

Northdale, manager 2

Managers commented that, although it would be ideal to promote such care in all areas, this had not been achieved in practice previously and lack of progress in creating an environment to support normal birth and to establish midwife-led care on their labour ward had been a key motivator for creating a separate unit:

Part of what was very obvious at that stage, I kind of touched about midwifery performance, um, in the context of midwifery-led care it was virtually non-existent. Um . . . [name] was one of our consultant midwives, had been slaving away here for a few years and had tried to make inroads into providing low-risk/midwifery-led care, and at that point she had succeeded in having a couple of rooms assigned to that within the labour ward on [first hospital]: there was no such, I don’t think there was any such practical arrangement at [the other hospital] at the time. Um, but despite her best intentions it hadn’t really got anywhere because of the culture of the practice both by obstetricians and midwives . . . um . . . aligned to the performance issues that I’ve mentioned.

Midburn, manager 3

Therefore, although managers saw it as desirable to ensure that midwife-led care and supportive care for normal birth was available on OUs, challenges in achieving such aims in practice had formed key motivators for developing a separate space to facilitate such care.

Use of guidelines and protocols

All the services had guidelines for low-risk or midwife-led care rather than guidelines developed specifically for the AMU. In the services that were now developing FMUs, it was interesting to note that focus on guideline development had increased, as staff and managers perceived a need for more specific guidelines when transfer would occur over a distance:

We started off really just focusing on criteria for [the FMU], but obviously in that process we decided we have to review the whole guideline and, and um . . . to be able to look at the sort of whole processes for antenatal risk assessment referral, um, for everywhere. And, er . . . so essentially, you know, it’s important sort of guidance for [the FMU], you know, because . . . because being a midwife-led centre, being a stand-alone centre we want to be able to make sure that women are appropriately selected for there, given that it’s half an hour away. Um . . . on a good day! [Laughs]

Westhaven, manager 4

Nonetheless, such guidelines had apparently not been in place for home births. Guidelines were drawn on in terms of eligibility for admission to an AMU and for decision-making around transfer to the OU in labour.

The key message from managers and professionals was that clear guidelines for admissions and transfers that were supported and adhered to by all were crucial, for the safety and well-being of the service and individual professionals as well for the women:

I think the other thing about success for AMUs is really don’t, really don’t blur those referral criteria.

Westhaven, manager 6

Midwifery units and midwives, as well as the women themselves, were perceived to be vulnerable without such guidelines, which also helped to create and protect a space for supporting physiological birth. In Westhaven, for example, managers emphasised the obstetric support for normal birth and midwife-led care but still saw guidelines as functioning to maintain confidence in this:

In some respects we have the guidelines in place because we want to maintain that confidence and, you know, there are times when things drift and et cetera et cetera, but um, on the whole they don’t want to know about them, but what we do need to know is that . . . that they are being managed in that unit according to what we’d expect, and er, so that you’re not creating any additional risks for the mother. And, um, so I think, I think it will . . . in terms of it being . . . er, you know, the whole idea about having sort of high risk and midwife-led is just to define the women they do need to know about, rather than intervene, interfere in those low-risk women that they don’t want to know about.

Westhaven, manager 4

The majority of managers and midwives stated that guidelines needed to be strictly adhered to for such reasons. However, in practice, there were many grey areas and cases needing consideration regarding low-risk criteria. Individualised assessment was seen as appropriate when maternal age and body mass index were borderline and in the cases of teenage mothers, women who had previously experienced postnatal depression and women around 37 or 42 weeks’ gestation:

They were really, really exclusive with mental illness. I think to begin with it was any mental illness. But that’s daft. If you’ve got somebody who had postnatal depression surely they’re going to be better off like having a nice birth experience. Now, this is the difference between me and some of my colleagues: I might be a bit like, oh . . . like I was, I went there the other day and, um, I accidentally let someone in who was 36 plus six, and they were like, ‘Transfer her!’ and I’m like, oh for God’s sake. You know, 36 plus six, really? One day?

Midburn, midwife 2

Maternal age being one, you know, because it’s ridiculous if you’ve had three children before. (. . .) Of course you’re not suddenly, suddenly high risk. Maybe if you were 42 and you’re having your first baby that’s something that you’d want to look at . . .

Southcity, midwife 4

Some managers also commented on pressures to accept higher-risk women because of service pressures and crowding on the labour ward, both in labour and postnatally:

I find, I think they find it hard to be a birth centre, totally birth centre, because they’re so close to the labour ward that they cannot help being involved with the fact that the labour ward would be full and phone them and say, ‘Well you’re only just downstairs, will you take this woman? Yeah she’s quite high risk but, you know, as you’re only downstairs.’

Northdale, manager 4

Pressures to take women outwith guidelines were strongly resisted because of safety concerns:

There’s a very clear line that we don’t take high-risk women, um, you know, women who are in labour who have got, who are high risk so that they don’t get moved round there because of space – occasionally it does have to happen I think just for the sake of it, so it’s a room, but it’s the excep—, real exception, if you’re desperate for a room you can, you know, you can move a bed, but I think we’ve just tried to keep it as a [pause] you know, the philosophy of the Birth Suite is for low-risk women.

Westhaven, manager 4

The Birthplace study identified that the proportion of higher-risk women planning birth at the start of labour care in an AMU is low, at 4.4%, although higher than for FMUs, at 2.5%. These figures compare with a higher rate of home births of 7.4%, for which, although professionals can advise women of evidence on safety, criteria for entry cannot be applied. 1

Consultant midwives and AMU managers reported experiencing some pressures to provide AMU care for women who did not fit the clinical criteria, but who may otherwise give birth at home. Most were not comfortable to support this because of perceived risks to the service, as well potential risks to the women, although the greater risk to the woman if she gave birth at home without care was acknowledged. This was also echoed by some consultant obstetricians:

I think it works reasonably well but I do get put under pressure at times as a consultant to be asked to OK it for someone to go to the birth centre when I’m a bit uncomfortable with it. And the truth is by the time they come to me they are already assuming they are going to deliver on the birth centre and it puts me in a difficult stroke impossible position. That does happen. People with gestational diabetes primarily.

Southcity, consultant obstetrician 3

One consultant midwife felt that such risks to the woman placed an onus on the service to provide more individualised care. In either case, written care plans with documentation of advice given and consultation with supervisors of midwives, senior obstetric and midwifery colleagues were recommended. This was in order to protect both the woman and the service and the professionals providing the care, while respecting women’s wishes. In a number of UK maternity services, consultant midwives are providing special clinics for women requesting care that did not fall within the guidelines (consultant midwife, Pauline Cooke, Imperial College Healthcare NHS Trust, 2012, personal communication). Such clinics were not mentioned in this study, but women requesting such care were referred to consultant midwives for individual care planning. Some midwives’ comments indicated a difference of view about accepting such women in AMUs as compared with FMUs, for which transfer distance was a concern:

We don’t get a lot of transfers really, but it’s, it’s because there is a real problem. I think they, you know, they’re selective about who goes there as well. You know, so their criteria . . . their criteria’s supposed to be the same as the [FMU] but they do tend to take a lot, a lot more . . . high-risk stuff on our birth centre [AMU] if a woman’s, may have had a previous section and she’s adamant to have a birth on the birth centre then she’d have had to see a consultant midwife, but then she would have had to, she would be able to go onto the birth centre as long as there’s some plan in place. So whereas at the other birth centre everything’s definitely low risk, . . . there’s got to be no need for a doctor.

Northdale, midwife 6

In one service, Westhaven, managers and professionals described the use of their intermediate room to care for such women. This room was formally part of the OU but lay between both as this AMU was immediately adjacent to the OU, separated only by double doors. This room had been set up to provide a homely environment supporting physiological birth, but with access to obstetric facilities if needed:

I think probably because the birth centre was popular option and women failed to understand why, because of their raised BMI [body mass index] tends to be the problem, the BMI cut-off I think is 30, isn’t it, and, um . . . [laughs] I suppose how many of us do have a BMI of under 30 through pregnancy? Um, and I suppose . . . women don’t necessarily, um . . . see themselves as high risk, so there was a need, particularly I think it was the VBAC [vaginal birth after caesarean] ladies where they’d had a first, they’d had a caesarean section first time, um, who wanted to have . . . encouraged and supported and wanted to have a trial, um, of labour for their next event, but likewise weren’t able to use the birth centre because of their previous caesarean, because of the closer monitoring, and so we try to sort of find a compromise.

Westhaven, manager 2

The use of such a transitional room raises questions around providing care to support physiological birth more routinely on OUs. The challenge of changing OU practices to ensure that such women felt more confident of receiving care to support physiological birth and a positive birth experience was not specifically raised with respect to women who fell outside the guidelines, but respondents referred to a general aim of improving care in OUs, which had not been realised in practice. The majority of managers firmly opposed blurring of boundaries around low- or high-risk care to maintain safety and the philosophy of the unit:

We’ve sometimes had women who want to have a home birth and they’re really not suitable for a home birth. They’ve (. . .) had three previous caesarean sections or . . . and then it’s been, they’ve been to see their consultant and then (. . .) the consultant might say, ‘Oh look, she really doesn’t want to, I don’t want her to deliver at home but could you let her deliver in the birth centre?’ Um, and we’ve been quite . . . we’ve said, ‘No, we can’t, we can’t let her deliver in the birth centre because it’s not . . . it’s not what she needs’ (. . .) The whole ethos there is non-intervention.

Westhaven, manager 6

However, one consultant midwife, when asked about the question of caring for women who had previously had a caesarean section on an AMU, argued that individual documented care plans and senior professional involvement would make this acceptable because the women would be more likely to be monitored closely and less likely to be subjected to potentially risky interventions, and would benefit from the short transfer time if transfer to an OU were required:

I say better place because we’re giving that one-to-one care, you’re not putting someone on a monitor and going out and looking after somebody else for a while, you’re listening and you’re watching and you’re listening in, and you’re there so closely with them, and they’re feeling what they’re feeling, and I think being upstairs on a monitor with an epidural you’re more likely to miss the signs than you are down here.

Northdale, manager 2

This lack of progress in changing care had formed part of the motivation for development of AMUs. Views about the impact of the AMU on practice in the labour ward are discussed in Chapter 6.

Maintaining clear and agreed eligibility guidelines, supported by timely risk assessments, was seen as protective for both the women and the professionals. The importance of good antenatal assessment by community midwives was highlighted, as was the value of effective triage before admission in labour:

What is inappropriate is to have a woman moved from our triage to [AMU] and then there be a discussion there, and say she’s suitable or not. That is not the place, if a woman isn’t suitable for [AMU] and she’s already touched base with our triage midwives, she needs to stay there until that decision’s made. I don’t want her to be in the middle of a discussion between two groups of professionals.

Midburn, manager 1

Management of transfers

While eligibility criteria for planning birth in an AMU were seen as important, guidelines for management of transfer were often cited as being of primary importance:

Transfer guidelines are more important than the guideline for excluding low risk, I feel, um, in terms of the midwives are – it’s very precise as to who can or what should or should not be looked after during or after delivery, um . . . and most of the time it’s followed.

Midburn, consultant obstetrician 1

Good management of transfers across unit boundaries is widely acknowledged to be important for safety and for the quality of women’s care. Managers in Northdale echoed the need for straightforward management in arguing that transfer should simply be about the most appropriate care and who can deliver it. This argument reflected a concern to avoid tensions and also to avoid issues such as territorialism or conflict over workloads that might undermine quality and safety of transfer decisions. We introduce the term ‘permeability’ in this report to capture the concept. This perspective seemed to implicitly emphasise the need to avoid territorial approaches or professional disputes and instead sought to advocate an approach in which different professional roles and areas are viewed as complementary and integrated rather than divided. 94

Given that many professionals and service users see the proximity of AMUs to OUs as a safety feature, what was most striking in our data analysis was the degree to which some AMUs appeared to be under pressure from the OUs to avoid transferring women. In some instances, OU staff perceived transfers to be unnecessary, reflecting AMU midwives’ lack of skills or lack of willingness to use interventions to speed up labour progress:

The main, I think the main reason why they, one of the main reasons they get transferred round is because, um, prolonged second stage, you know, they’re pushing for too long. But once they get transferred round here obviously we actually do get them pushing, because round there they kind of use this, what is it, surge, or . . . they don’t actually use the word . . .

No active pushing.

Yeah, not . . .

They let the body . . .

They just let the body and nature take its course. Well sometimes that’s not enough and you need to really encourage the women and get them to actively push.

Midburn OU, midwives and registrar

Conflict around transfer levels between OU and AMU staff appeared to be complicated by distance and lack of trust between staff groups and tension over resources and burden of care. Such conflict was mainly focused around OU perceptions of excessive transfer, rather than a perception of midwives on AMUs not being willing to transfer women:

When we very first opened you’d phone up and you’d say – and this happens downstairs on the other unit as well – what they’ll say is, ‘Oh, why are you transferring this woman?’ They start questioning why you’re transferring her. Um, you know, ‘Have you done a VE [vaginal examination]?’ ‘Oh, you know, oh leave her another hour,’ or you know, ‘Have you emptied her bladder? Have you done this, have you done that?’ And that’s very demeaning to the midwives. Um, lots and lots of little comments. And then when you do bring the woman over you get cold-shouldered a lot of the time, as though you’ve made a terrible mistake.

Northdale, manager 4

This manager expressed concerns around the impact of such tensions on the safety of transfer decision-making:

When we’re looking after women on here we do the utmost for those women to have a lovely birth on here; that is our aim. The very last thing we want is to transfer a woman from here. But you have to know when to stop. And obviously those transfers then, but we . . . comments are made to . . . within our hearing sometimes . . . you know like you’re doing the walk of shame as you walk up with your woman. And that can have two effects really: one, it makes you, it can make you not want to go upstairs, and perhaps you’ll make a slightly different decision. Hopefully we won’t, and we’ll still make that cut-off where we’re supposed to make it, but it’s got to be there at the back of your mind. And silly things like midwives in the morning have come on and they’ve saved inco-pads because in the past they’ve been questioned on things, their clinical judgement is questioned, it’s as if the midwives up there sometimes think we’re not quite as . . . like a second class of midwife if you like because we don’t do the high risk, we haven’t got those abilities.

Northdale, manager 2

This concern was also echoed by obstetricians:

Because clearly if a woman comes into the birth centre with a breech presentation, particularly as a primip, the appropriate thing is to send her up, the management was completely appropriate. Um, but I think because there can be that ‘them and us’ culture, clearly some of that had been communicated to the couple and they had got the impression that the midwife caring for them was reluctant to have to ring the labour ward to say that they thought she’d got a breech and she needed to come up.

Northdale, obstetrician 1

Such tensions appeared common, but were not universal. One manager defended transfers and argued that OU staff do not understand how vulnerable AMU midwives feel if they have any concern and their need to err on the cautious side regarding transfers. However, some OU staff did express understanding and trust in the skills and judgement of their AMU colleagues:

. . . generally people come up here for that reason [clinical issues mentioned] they don’t normally come up here because they can’t cope any more, which I think is good for the midwives down there because they are obviously doing their jobs properly by you know helping the women aren’t they, to cope.

Southcity OU, midwife

Interviews with a range of staff indicated that such trust and mutuality was more likely in settings where OU and AMU staff had worked together and knew each other well.

Audit, review and governance

As identified in the Birthplace organisational case studies,2 appropriate governance systems were seen as important dimensions of maintaining safe and high-quality care in a distributed system. Managers prioritised open and regular reviews of practice, with routine reviewing of transfers and any untoward incidents and an emphasis on interprofessional participation. However, several commented that this had been an unfamiliar and uncomfortable process for many professionals, needing a strong managerial steer until established as a norm:

[The audit meeting] looks at all the cases from the previous 24 hours where there have been any concerns or emergency sections or things like that, and we’ve made it all right for people to challenge other people’s decisions and practice and so on. . . . it was really difficult at first, you know, people felt really uncomfortable with it, um, but it’s just persistence, and managing those challenges in the right way. You know, this isn’t about being personal, this is about saying, ‘Right, why did you make this decision? Here’s the evidence that suggests x, y and z, so you know . . . would, next time . . .’ kind of almost like a reflective learning environment.

Midburn, manager 2

New managers in one service had worked particularly on its escalation of reporting policy and engendering a culture of participation and staff speaking up following a ‘whistle-blowing incident’ (manager, service X) reported directly to the Care Quality Commission. This simply threw into sharper relief the concerns of all managers to ensure that reporting and review were encouraged in order to learn from and prevent errors. The importance of documentation was also emphasised, although one midwife commented on the tendency to fall back on cardiotocograph (CTG) use in a busy risk-oriented environment:

You know and you’ve got the doctors saying, ‘Can you do this? Can you do that? Can you just go and get that for me? Can you..?’ you know. Too much . . . you know, I know litigation is hovering above us and that’s why but it’s too much really. It is too much. I use my CTG as my little diary because otherwise you literally would be writing going, ‘Hello,’ you know not even looking at the poor woman. So I just tend to ignore my paperwork towards the end and, and write everything quickly on the CTG you know if anything’s happened and use that afterwards as my reference for writing my notes up.

That’s if she’s on a CTG?

Hmm. Which she will be.

Southcity OU, midwife 7

Staff rotation as a safety measure

Managers in all sites were considering introduction of a system of rotation. The idea of midwife rotation as a safety measure encompassed two contrasting issues, which unit managers were constantly working to balance. Rotation of midwives around areas – community and hospital, high and low risk – was seen as a means to ensure and support midwives maintaining their birth skills and knowledge of both high- and low-risk care. It was also seen as a means to preserve good interprofessional relationships and integration across boundaries:

Rotation is the only way I can do it, but then there are service implications, they have a service to deliver, they have pressures, they have caseloads. It is easier said than done. Um, but unless we integrate them, unless they feel part and parcel of the same team, and also subject to the same governance . . .

Midburn, manager 3

However, it was also argued that, without careful management, rotation of midwives could undermine the safety of the AMU as a thriving and sustainable place of care, the development and maintenance of midwifery-specific skills to provide less interventionist care for low-risk women, and midwives’ morale and satisfaction in their work:

. . . we are aware that you can’t just suddenly rotate too many people, so you need to rotate on a slower pace so that you build their skill to be able to function to that area as the culture or environment or, you know, the . . . the guidelines and the principles should be for that place to function. (. . .) And actually major change has happened also, all the practice development midwives will be also doing 50% clinical work with those people, whether it is night shift, weekend shift, all that will happen. So all these works are happening to facilitate that.

Southcity, manager 3

Working to capacity

Although the AMUs were described by managers as mainly working to capacity, in terms of the numbers of women admitted and births per year, relating to unit size and their original targets, managers and professionals identified some issues which reduced the activity and capacity of AMUs, including midwife numbers and booking systems. Finance overall was cited by the majority of managers as a major challenge to maintaining quality and safety, as well as the operation of the AMU, even though they recognised the value of change to meet these challenges, such as introducing new ways of working:

I’ve got to find the, er, savings and, er, it’s quite a challenging time I think across the NHS, because the demand for care is increasing, the birth rate’s increasing significantly in [city], the capacity remains the same, and the establishments remain the same, because the government have said that we have to save 13 to 15 billion by the end of 2013, the NHS as a whole, and every trust has to play its part, and our part is bigger than others because we started with a deficit. And so, um . . . it’s quite challenging trying to deliver a service thinking of the quality and the safety agenda versus the, um . . . versus the fi—, the bottom line on the financial spreadsheet.

Southcity, manager 6

Therefore, although midwifery units were widely seen as a means to improve the clinical effectiveness and efficiency of the service, resource issues including lack of midwifery staff numbers were also cited as a barrier to these units working to capacity or in a fully effective way. These concerns are also discussed in the next section under staff relationships. Shortage of midwives was universally cited, with many accounts of midwives needing to be ‘pulled’ from the AMU to cover shortages on the delivery suite. Competition over midwifery resources was frequently referred to and formed a key source of tension between staff groups, with midwives describing being ‘pulled’ between areas to cover service gaps and conflicts engendered over who was working hardest:

I think the thing that most gets us down is, um . . . lack of support from other areas, and shortage of staff: we are, I feel that, you know, we’re always, or it’s a general feeling that we’re always called upon to help delivery suite out when they’re short-staffed and if, you know . . . I’m completely in agreement we should be helping them out if we’re sort of quiet and they’re busy, but it’s never really reciprocated, and, um . . . mostly because they can’t because they’re always busy, but there are moments. And, um . . . it just sort of . . . recently I’ve found it quite difficult because it’s had a knock-on effect and women actually have had not such good care down here because the second midwife’s been pulled upstairs. So that’s when it really started to upset me recently.

Southcity, manager 2

The worries around midwives being pulled to delivery suite could also have a negative impact on midwives’ willingness to maintain continuity of care by transferring with women:

I would say that when you’re dealing with teenagers they’re afraid of needles so they do tend to avoid the epidural and see how they’ll go, then if you promise that yeah, if they want the epidural you’ll go up, and unlike looking after somebody that comes in on the birth centre if they think they want an epidural, you know what, you don’t want to accept them because if you transfer up they keep you upstairs. That leaves the birth centre closed to other labourers, so you’ve just shut down the birth centre because somebody decides they want an epidural, and they won’t let you hand over care upstairs, because they’re always short-staffed. So you brought her up, you keep her. So there’s like a time clock running.

Southcity, midwife 2

Such conflicts appeared to compound ideological differences or lack of familiarity and trust between groups of midwives:

Sometimes round there, as you say, they get a bit cocky, don’t they? And the band 7s trying to tell them and give them advice, but you can tell by the way that the co-ordinator’s talking, the person on the other end of the phone is not listening and they just want to get them round here.

And then when they do, a lot of the time we say, ‘Yeah, you can bring her round but you’re going to have to stay with her.’ They don’t really like that, you know.

Midburn, OU midwives, group interview

Ruptures and conflicts within a service may have negative effects on quality and safety and also on user experience, as illustrated by this woman’s observations about staff relations during her transfer to Southcity OU:

When she [AMU midwife] was bringing us in and the woman on the [OU] desk said, ‘Oh has she been admitted?’ or ‘Have you admitted her?’ (. . .) . . . there wasn’t like an easy conversation that they had between them (. . .) It felt like oh, they’re bringing another one up and you know, and have they done the paperwork to go with it or something like that.

Southcity, woman 2

Midwives’ and managers’ accounts revealed complex views about the movement of midwives between areas, which reflected at times the perceived fragile nature of the AMU service. Most emphasised the importance and value of supporting each other and working together and acknowledged the benefits of maintaining all-round skills and insight into each others’ experiences:

. . . in an ideal world I’d like to see all the midwives who deliver intrapartum care rotating through different aspects of the care. There are advantages and disadvantages to that, um, but I always feel that unless we rotate midwives through high risk and low risk you end up with kind of a silo mentality, you end up with them and us, um, and that’s not conducive to, to good care, I think, especially when the two overarch, when you’ve got transfer rates that are 20, 25% intrapartum you want people who are comfortable with both. The counter-argument of course is that if you do that neither of them develop the skills that they should be to the right level, but I’d like to think that we would have better training to deal with that, and to me a midwife is a midwife, it’s not a low-risk midwife or a high-risk midwife.

Midburn, manager 3

However, managers and midwives also expressed great concerns about dilution of skills and teamwork in one area by movement of midwives between them in an ad hoc fashion:

. . . you can’t take a skilled member of the birth centre team away and put somebody who doesn’t know how we work down there to start giving advice to people and get involved in labours. (. . .) . . . if you just send somebody who doesn’t want to be there and doesn’t think they have anything to learn, and they practise like they do upstairs, then you’re actually asking for disasters.

And what was the thinking behind that?

To spread our skills. The idea was that we have low risk skills that aren’t recognised, and that people don’t have, and that if we went upstairs and . . . and the other thing is we couldn’t practise our low risk skills like water birth, and having babies off the bed if we didn’t have the equipment up there, and if we had to look after two or three people at once.

Southcity, midwife 2

Some midwives and managers expressed the fear that, without a core of AMU midwives, sufficient skills in normal birth and midwife-led care would not be maintained. Continuity of care or carer issues were less likely to be highlighted by staff and managers as a potential disadvantage of rotation, although continuity of care has been identified as important to women. 2

Managing staff resources

Midwives in AMUs were also concerned about the implications for keeping the unit functional, with typical staffing on any one shift of two midwives. There was a trade-off between size and ability to maintain a sufficient basic number of midwives on each shift: maintaining a limited size was seen as important for the homely and family-centred ethos of the unit, while sufficient numbers were sought to justify a sustainable number of midwives per shift. A dominant staffing model in which midwives staff areas rather than orienting around the women added to the challenges of maintaining the core staffing required to keep the AMU functional. The issue of more women-centred staff models, with community or caseload midwives working with women across boundaries, will be discussed further (see Staffing models).

In Northdale, an IT-based management system based on lean thinking called ‘Visual Hospital’ had been introduced with the aim of ensuring staff were available where most needed. This was welcomed to some extent as supporting efficient use of limited staff resources. However, it contradicted two key quality principles in practice: continuity of care for women and consolidation of working patterns and skills in the AMU. It also failed to overcome the perceived tensions between staff based in different areas:

With Visual Hospital . . . the idea is to be working closely together, working where the women are, and we do go up and work on there [the OU] for hours at a time. And again not always treated the same, they’re not offered drinks or breaks or . . . I don’t know, I can’t explain it. I can’t explain it. They’re just not . . . you know, they want our help but then they’re saying we’re not, you know, quite as good.

Northdale, AMU manager

Therefore, although using Visual Hospital was seen by some managers as helping them to deploy midwives where they are most needed, this had not been popular with staff and this is discussed further in Staff experiences and perspectives.

Two services had different approaches of integrating community midwifery with midwife-unit care, with the aim of enhancing skills as well as deployment of staff resources. In Northdale, community midwives had provided the care in the GP unit, which was the precursor of the current AMU. Community midwives were accustomed to providing such care and had maintained greater levels of experience in attending births as a result. They were motivated to work in the midwife units and the key limitation for this was staffing capacity, which had forced a reduction in their midwifery unit role. In Midburn, community midwives were required to work one shift per month on the AMU to develop and maintain their birth skills. Managers hoped this could be extended in future to the new FMU but considered that community midwives were not yet sufficiently experienced in birth care:

I think that it’s not just here, I think that nationally there is a problem. The model’s fine, but we haven’t found a way of integrating community midwives appropriately by way of development, professional development and training to satisfy ourselves that actually they . . . that they can do a good, that we’ve given them the tools to do a good enough job. I’m not talking about numbers and I’m not talking about how many caseloads and all of that, that, set aside that, I’m talking about having a professional midwife continue to practice safely, continue to be developed, continue to have access to education, to change, to updates, all of that, which I feel just is non-existent in . . . well, is very deficient in community midwifery.

Midburn, manager 3

Managers anticipated that integration with the AMU would facilitate the rebuilding of the community midwives’ birth skills and confidence:

In practice that’s what we’re doing. They are, we are organising some updates for them, some professional updates from a theory perspective. But the main bit of updating is on the ground. Our colocated birth unit is very busy, so actually what I’ve advised is that there are three midwives that actually work in our colocated birth unit and the community midwife is the fourth on each shift; when she comes into the unit she has an induction period, she’s then allocated to a woman to look after that woman with the help of another midwife that’s used to our unit. There has been a recommendation that they never move from [AMU] and they stay there. They don’t go to the ward if we need help, it’s our [AMU] midwives, our colocated midwives go out to the hospital if we need any help. The community midwife stays put.

Midburn manager 1

In contrast, in Westhaven, such integration with community midwifery had not been established and there was some evidence that community midwifery teams varied in informing women about the option of birth in the AMU. In Southcity, the original integrated model of a small core AMU staff supplemented by community midwives from caseloading group practices coming in to the unit with women on their caseload had not been maintained in a period of service instability and management changes, leaving the AMU midwives feeling relatively isolated within the service.

Northdale managers, in particular, cited the integration of community midwives as a positive strategy for future development, while managers in Midburn also referred to concerns about maintaining the birth skills and confidence of community midwives in a service context with very low home birth rates:

They need some intrapartum experience. And the intrapartum experience that we’re giving them is that we’re expecting all of the community midwives to rotate on a regular basis into our colocated birth unit, for probably a maximum of 3 weeks in a year, to update their skills. So from an intrapartum perspective they need to . . . to develop, and that’s what we’re doing at this present moment in time. That’s probably our biggest challenge.

Midburn, manager 1

Such lack of confidence had also been experienced among hospital-based midwives, and the AMU was seen as a stepping-stone to all midwives developing their skills and confidence in midwife-led care, as well as intrapartum care for community midwives:

There’s been a little bit of resistance from the staff that work in the colocated unit, and that’s probably because they’re really . . . they’re really happy to work in a colocated unit; working in a free-standing is probably a little bit more than they want to take on board. They’re coming on board, so from the staff from within [name of AMU] it’s fine. The midwives, the community midwives to take that on board is quite a challenge for us, because our birth rate in the home and in the community is very low. So we’ve got to do an awful lot of training of our community midwives so that they will be quite comfortable working in the colocated, in the free-standing .

Midburn, manager 1

In three of the four services, support workers were also used on the AMU, augmenting the level of staff cover per shift. Northdale, Midburn and Southcity each had one MSW on duty per shift. MSWs were not used in Westhaven AMU, although the trust had introduced in-house training for them on the delivery suite with protected study time. In Southcity and Midburn managers considered that there was a greater potential role for support workers, especially in postnatal care and breastfeeding support (Southcity manager 6, Midburn manager 3).

Support workers had generally been incorporated in OUs and community services, but they were still seen as a largely ‘untapped’ resource in AMUs (Midburn manager 3). A trainee assistant practitioner on one site said that she received encouragement from the head of midwifery and the local FMU had seemed to accommodate her role quite smoothly. However, in the AMU it was a new function and staff needed to be more informed about the role:

. . . nobody seemed to know anything about it, because it’s new, um, you know, and people say, ‘Well what is it? What is it to do?’ And I just feel that maybe somebody should have got, had a meeting with, especially the staff on here, a meeting with the midwives to tell them what it is really, not left for me to say, ‘Oh this is what they want me to do.’ Because nobody on here knows what I’m supposed to be doing.

Site X, support worker 1 – site pseudonym removed to protect confidentiality owing to small numbers of support workers

A Southcity midwife said that historically MSWs on the labour ward had been doing a lot of cleaning and stocking and were not getting as much patient contact as they had hoped. An associated problem was the lack of clear guidelines to differentiate between band 2 and band 3 support workers. This midwife felt that support workers were underutilised and that they needed guidelines for training and for their role. She saw a need for their role to extend, particularly given increasing pressures on midwives (Southcity midwife 9 – researcher field notes).

A MSW on one site described her function on the labour ward as being ‘sort of a general gopher’. She said that she sometimes felt underutilised and that support workers were undervalued and taken to be ‘glorified cleaners’ but that it had been easier to find a distinct role on the AMU:

. . . whereas here [AMU] I feel that I’m more valued in that I’m able to use my skills that I’ve picked up over the years, er, with breastfeeding, um . . . assisting mums with various things with bathing babies, looking after babies. Um . . . and also I have occasionally, depending on the midwife, been supportive to a labouring mother. If she’s on, if the midwife is on her own and she’s got another labourer that’s a bit more ahead than this one I go and just basically stay there as support if necessary. Um, but that depends on the midwife per se, not all the midwives feel it’s appropriate for us to do that.

Site Y, support worker 1

Inter- and intraprofessional relationships

While it may be assumed that development of AMUs will introduce gaps in working relationships between midwives and obstetricians, we did not find evidence to support this view. With some exceptions among obstetricians who tolerated the role of AMUs, or who lacked confidence in midwife care except in cases for which individual midwives were known and trusted, obstetricians were generally supportive of the role of the AMUs and valued this within the service. Reasons included economy and practicality and a view that midwife-led care and normal birth are more difficult to achieve on the OU and that this is a more appropriate triage of women to levels of care. We experienced greater challenges in recruitment of obstetricians as study respondents as many did not consider the AMUs to be something for them to comment on, except for more senior obstetricians with a strategic role. In Midburn and Northdale, obstetricians saw the AMUs as providing more appropriate care for low-risk women and having contributed to rationalising the service overall. In contrast, obstetric views in Southcity were more divergent with some very supportive, some far less so, and some having quite mixed views set in a challenging context:

I would not . . . absolutely would not stop alongside midwifery unit, I think they are great and they take a lot of . . . not . . . absolutely the wrong word to use rubbish but things that we don’t need to get involved in. It’s busy enough on a high-risk unit, you want your low-risk women to go downstairs so that you can prioritise your attentions on the high-risk women. The problem is we can’t do that as effectively because they can’t take them so we have low-risk women up here diluting the staffing for what we should be doing. So you end up getting, of course you end up getting low-risk women on a monitor because there isn’t a midwife to look after her so it’s not favouring the woman either . . . to my mind, and I am very simple, it boils down to staffing numbers.

Southcity, consultant obstetrician 2

In contrast, another obstetrician in the same service indicated that the unit was tolerated rather than positively welcomed in a service with a reputation for its high-tech medical care:

Um, It was a kind of . . . OK, if we have to, provided we can make sure that things work safely and that the institution’s reputation isn’t harmed in any way by having the birth centre on site.

Southcity, consultant obstetrician 3

The main focus of concern regarding professional relationships was around relationships between groups of midwives. Dividing working spaces for labour and birth risked polarising views of midwifery work and roles. There was a tendency, in busy and hard-pressed services, for each group of midwives to typify the other as working less hard, as less skilled, or as either hanging onto women for ideological reasons, or transferring women too quickly, for practical or resource reasons. Alongside unit midwives were criticised, for example, for failing to use certain interventions, such as augmentation, to avoid transfers of women for slow progress in labour or for greater pain relief. In turn, alongside unit midwives tended to criticise OU midwives for over-medicalising care and for attempting to pass women with some risk factors over to the AMUs for organisational rather than women-centred reasons, such as overspill from postnatal care. This is discussed in more detail in Chapter 4.

Managers highlighted concerns around the impact of tensions among midwives on service quality and safety. Actions planned to address these concerns included shared training approaches, greater rotation of midwives between areas and management-led interventions to improve communication and understanding. In one service, a midwifery meeting to discuss tensions had proved difficult as staff felt either reluctant to give their views openly or misunderstood, while in another service, a meeting organised with external expert facilitation was considered to have been effective.

Experiences of opt-in or opt-out models

Northdale and Midburn had an opt-out policy so that the normal pathway for low-risk women was into the AMU unless they requested another birthplace:

. . . what we was actually told when we phoned in was, was there any complications in the actual pregnancy or with the mother, and as we said no they said they’d advise us to like, for her to give birth, have the baby in this unit.

Midburn, woman 8

This arguably gave women a more limited choice of birthplace, although theoretically they could opt-out to the OU or choose home or FMU birth. At the same time, it could increase their opportunity to birth on the AMU, as a Northdale woman explained:

Now as it happened the birth centre was fine and it was all fine and dandy, but it nearly wasn’t, and that thought that they’re just pushing you into something that you’re not entirely comfortable with . . . is a bit distressing when you’re in your very early stages. (. . .) They just kind of went, ‘We’ll stick you down for birth centre,’ at that point, and it was just accepted throughout until, I think it was maybe 37 weeks when they said, ‘So you’re down for the birth centre, are you happy?‘ Well, I don’t even know if I was asked if I was happy about it, whether I had a choice, to be honest. Um, but because I was happy about it I just didn’t query it.

Northdale, woman 8

More women heard about the AMU from their community midwife at opt-out sites than at opt-in sites in which women had to specifically request the AMU. However, most women in opt-out sites still found out about the AMU first from friends or antenatal classes.

It was particularly important for women at Westhaven and Southcity, where they had to opt in to the service, to get consistent information from community midwives in order to make their choice. However, at these sites, very few of the women we interviewed had first heard of the AMU from their community midwife. Many women instead found out about it through chance encounters or conversations with friends or National Childbirth Trust (NCT) antenatal teachers, or through their own internet research:

At some point where it was explained about the differences between the different units, and I remember somebody explaining, maybe it was in an NCT class, (. . .) that like you go through one door and it’s the Delivery Suite and one, the other door and it’s the [AMU] and they’re just next door to each other. So I think it may have been NCT that explained exactly what the birth centre was. Um, but I always knew that I wanted to be in that if I could, because I wanted a water birth.

Westhaven, woman 4

Even when community midwives mentioned the AMU, some women found the information inadequate:

She just basically said, you know, ‘[Westhaven] has these options: a birth centre, a birthing pool, a delivery unit,’ you know, there were no, she never gave us an opportunity to ask questions as to what they might entail, she didn’t really elaborate. I think she just said like, ‘The birth centre’s a more natural setting,’ um . . . and I think that was pretty much about it.

Westhaven, woman 1

Overall, women’s access to information about their options for place of birth was variable. Although all women saw midwives for their antenatal appointments, not all women had access to antenatal classes or to friends who had knowledge of local maternity services. If community midwives were not giving consistent information, then only some women were able to exercise their choice. Our evidence suggests that midwives at Westhaven and Southcity were less likely to be the first source of information about the AMU and this unequal access to information could make it more difficult for women to have an AMU birth in an opt-in system.

Seeking admission in early labour

The second key potential flashpoint on the women’s pathway, once they were booked for AMU care, was admission to the unit in labour. Two key issues could affect their experiences, diverging from the smooth picture of the theoretical care pathway. First, women may experience prelabour transfer if complications developed or pregnancy became post term and, second, admission to the AMU could be affected by busyness of services or by the assessment of active labour. Figure 3 shows the formal care pathway, and ways in which some women’s pathways diverged from this.

FIGURE 3.

The pathway to admission.

Most women reported knowing that coming into the hospital in early labour had to be carefully timed. They learned this from peers, from midwives at antenatal or NCT classes, or online, and from their previous experiences. Women made efforts to go through labour at home for as long as they could, to avoid coming to the hospital and being asked to go home to wait until their labour was further established:

. . . one of our concerns as well about you know the birth centre or any labour was arriving too early and being sent away then arriving and being sent away . . .

Southcity, woman and partner 2

When they arrived in the AMU, women felt calmed and encouraged if they encountered staff who listened, admitted them to the unit in a timely way and showed the woman from the start that she was expected and there was a room awaiting her. Women were often aware of the pressure on rooms, beds and staff and tolerated this busyness, as long as they felt valued as individuals:

[Midburn AMU] were absolutely fantastic, um, over the phone and in person. Really . . . made you feel like they wanted you to have your baby there rather than just you were a . . . I don’t know . . . a statistic or a number that comes through, which I imagine hospitals do become . . . that’s how they approach things because they do have a huge number of women to see, I suppose.

Midburn, woman 4

Half of the women we interviewed came to the unit and were admitted. In many cases, AMU midwives had reassured them during telephone assessments and encouraged them to stay home for as long as possible:

I think I phoned about three, and they said, ‘Call us back when they’re about three minutes apart and lasting for about a minute,’ I think they said, I can’t remember. (. . .) They were extremely relaxed, and they said to me, ‘You sound like you’re in control, you sound calm,’ they sort of reassured me in that sense that I didn’t need to rush in. And actually I was quite happy here [at home].

Westhaven, woman 5

The other half of the women we interviewed were sent home from the AMU in early labour, and most of those went willingly, if not happily. Sometimes these women were given the choice to stay or leave and opted to go home, but mostly they were advised to wait for their labour to progress at home and were not given the option to stay. Some women were advised by midwives that home was ‘the best place’ for them in early labour. Some observed that the AMU was short of rooms and women in more advanced labour were given priority. Units appeared to differ in their early labour policies. While women at Northdale and Southcity reported being given the option to stay in early labour, Midburn midwives encouraged all the women we interviewed who arrived in early labour to go home. Some Midburn women were happy to leave but three women were asked to go home when they did not want to:

And I was like, ‘Please, we’ve got to go back in, we’ve got to go back in.’ But again, it wasn’t because I wanted them to do anything, I just felt, I just needed to be there because I thought I’d feel safe.

Westhaven, woman 3

Two of them birthed very quickly on arrival back in the unit and reported feeling unsafe or even traumatised in consequence:

Horrible time for me was when they sent me back home. First pregnancy. According to me – home is not best place for me. Midwife advice, best position, they examine you again and again. Energy drinks. When they sent me home, confusing time for me. Go out, go in – painful time for your body, innit. They should keep the woman in [AMU] for the labour.

Why do you think they don’t keep you in?

I don’t know why. Because pain was stronger. They don’t tell me why.

Midburn, woman 7

She told me, ‘Unfortunately you’re only two centimetres dilated.’ And I was just like, oh, so defeated, I was like, ‘Oh no . . . please don’t send me home, please don’t tell me you have to send me home.’ And they’re like, ‘Unfortunately, because you’re only two centimetres dilated we’re going to have to send you home, because the policy here at [the birth centre],’ which I didn’t really know at the time, was you needed to be four centimetres dilated, that’s what they class as active labour, in order for you to stay at the [the birth centre]. (. . .) I think of the worst case scenario, you know, I could have, um . . . I could have laboured in the car park and then, you know, not knowing what was happening, no one was prepared, you know . . . he could have died.

Midburn, woman 2

Midburn woman 2 associated her postnatal depression with having had negative feelings about her birth during her experience of returning to the hospital in great pain in more advanced labour.

While midwives’ advice to women to stay at home in early labour was often argued in terms of a model of care intended to avoid medically unnecessary interventions, women’s experiences of admission also indicated to the women that busyness and lack of staffing were impacting on their ability to gain admission:

. . . when we got to the hospital (. . .) the first midwife we met was actually really quite rude and she was really abrupt and she was like, I’m really busy I’ve got three women in labour and um, I think she thought maybe I’d just started to have pains. I don’t think she’d obviously realised that I’d been in and come back . . .

Southcity woman 6

As in other situations they described, several women expressed understanding of NHS resource difficulties. Additionally, the ways in which professionals dealt with a difficult resource situation could make a considerable difference to the women’s experience:

. . . someone came and I explained who I was and they said, ‘Oh the birth centre’s full at the moment, but if you come up here we’ve got a room for you.’ (. . .) it was, it was a shame but (. . .) there was nothing I could do, if there was no room available. (. . .) And then about 20 minutes later . . . the midwife who actually ended up being with me the whole way through appeared and said, ‘I understand you want to give birth in the birth centre in a pool. It’s available now, would you like to come down?’ At which point I said, ‘Yes please. Definitely.’ And that was brilliant, at that point she took over my care. And she was fabulous.

Westhaven, woman 5

Traditionally, women have been encouraged to spend their early labour at home to avoid unnecessary medical intervention in hospital. The AMU midwives we spoke to gave this as one reason for encouraging women to go home, along with problems of capacity when caring for women during a potentially long latent phase. Our evidence suggests that the policy that home is the best place for all women in early labour was being continued in AMUs. Even though AMUs were presented as a home-like rather than a medical space, as midwives still had concerns about ‘the clock ticking’,96 they potentially felt pressure to intervene with women who appeared to be progressing slowly in labour. While few women were sent home against their will, some women were encouraged to stay at home for longer than they might have wished and feelings of uncertainty and worry around early labour care were evident across many of the women’s stories. This is something that has been frequently addressed in literature about care of women in an OU, but the issues around translating such a policy to AMUs deserve further attention.

Experiences in labour, delivery and postnatal care

Once women had been admitted to the AMU, their experiences were influenced by a number of factors, including their partner’s experience, the environment they laboured in, their choice of pain management strategies, whether or not they felt in control and, crucially, their previous expectations of what their labour and birth would be like. Figure 4 maps the established pathway from AMU care in labour to postnatal care and ways in which some women’s experiences deviated from this.

FIGURE 4.

Pathway from labour to postnatal care.

Approaches to booking: opt-in or opt-out

The majority of NHS care in the UK is primary care based, yet maternity care has been based in acute services since the 1970s. A key model on which the efficiency and effectiveness of the NHS arguably rests is one in which primary care professionals assess health needs and refer to specialist care when clinically appropriate, continuing to provide a large proportion of care for their populations. 93 This secondary-based model of care is, therefore, unusual within the NHS context and has not changed fundamentally in a period of considerable and continuing policy focus on shifting services to a more primary-care base and orientation.

The AMUs in our study provided intrapartum care for between 11% and 13% of births in their services. The rates of birth in their OUs remained > 80% in all settings, even when home births and FMU births (recently opened in two services) were taken into account. This suggests that potentially a larger number of women could receive labour and birth care in midwifery units.

Two of the AMUs in our study operated a primarily opt-in model, in which women had to actively opt for AMU care, and two operated an opt-out model in which AMU care was the normal pathway of care for low-risk women. Our data suggest that the proportion of births booked for and taking place in AMUs did not appear to be affected by which of these two pathway approaches was used. However, other factors, such as age and capacity of the unit and staffing constraints, could also have an impact on numbers. In practice, there was convergence between models; some women in both types of model did not receive information about birthplace options. Under the opt-out model, some women were not clearly informed that they had been booked into the AMU. As has been documented before, in the opt-in model some women do not hear about the opportunity. In theory, an opt-out model of booking has the potential to increase equity of access to choice of birthplace, since less socially advantaged women may otherwise be less likely to be aware and informed about such options. However, without improvement in the consistency and quality of information-giving, these potential benefits may not be fully realised. There were indications in our data that some professionals were choosing not to inform women about the option of birth in an AMU, while some were said to be too busy to remember to do so. This suggests that AMUs are not always fully integrated into their service and that information-giving is not routine and is subject to professional tensions or lack of familiarity and comfort with the concept of birth in midwife units. As the number of services included in this qualitative study was small, no firm conclusions can be drawn about the potential impact of the opt-out model for increasing equity.

The key concern that may be raised with respect to an opt-out approach is one of informed choice. Current policy states that women should make an informed decision about their place of birth and, in the case of an AMU, they need to be aware that transfer may be needed for personal or clinical reasons. However, in practice we found that lack of, or poor quality, information-giving applied in some cases in either an opt-in or an opt-out model. Additionally, we found no evidence that professionals are informing women of any of the well-established maternal risks associated with OU care, such as that choosing an OU may make it more likely that they have more interventions. 1 Instead, the data from both women and midwives indicated that information is often presented as a simple trade-off between a ‘nice’ environment and access to pharmacological pain relief, or between a ‘nice’ environment and clinical safety. One service provided antenatal visits in late pregnancy on the AMU, and midwives felt this offered a better opportunity for information and preparation for giving birth in the unit, including managing labour pain, as well as an opportunity to meet the midwives working there. Midwives working in the other case study AMUs suggested that more information and preparation opportunities should be available. These professional observations were supported by the data from women and partners, which indicated they had received limited information about physiological labour, managing pain or about the risks and benefits of different options from midwives. In addition, we found that some women received information later in pregnancy and through more informal sources rather than from midwives. Equality of access may be strengthened by the adoption of approaches in which the midwifery unit, rather than the OU, is the default pathway for low-risk care, with women fully informed and offered preparation for physiological birth as well as being given alternative choices of birth setting.

Continuity of care has value from the women’s and partners’ viewpoint, as well as a service quality and safety perspective. Effective integration of the AMU within its service and appropriate arrangements for transfer can support continuity and quality of care. Movement across service boundaries was a potential difficulty for women and being admitted to, or transferred from the units were key points that could influence their experience and sense of well-being. The need for an integrated system from the women’s viewpoint mirrored the needs expressed by midwives for good working relationships across the boundaries.

Both a medical model of care and a social model of care may advocate for women to remain at home during early or latent phase labour. In a medical model, the view is that, until active labour is established, hospital care is not relevant, while a social model may regard the home environment as a more appropriate and relaxing place to be while labour becomes established. In either model, the view of the ‘clock ticking’ following formal admission may impact on professionals’ views of the appropriate place to be. 96 It was notable, therefore, that the policies used in these AMUs were essentially similar to those found nationally for OUs, despite the philosophy and environment designed and considered to be conducive to normal, physiological birth.

Stakeholder interviews

The interview sample will be refined based on each case but is likely to include as a minimum:

• clinical director and chief nurse

• clinical lead obstetrics

• clinical neonatology lead

• head of midwifery

• consultant midwife

• supervisors of midwives

• service commissioners

• Maternity Services Liaison Committee members, including lay members

• local consumer representatives

• key managers or personnel involved with transfer services and risk management.

Questions and topics will include:

• service configuration, including consultations, service reconfigurations or developments and reasons for these

• details of service configuration and organisation, including workforce arrangements, skill mix, models of care and escalation/transfer services and protocols

• any previous or current plans for change or development and reasons for these.

Interviews with professionals

Topics and questions will include discussion on the following:

• experiences of working on, or in, relation to the AMU (using photos taken of the space as prompts for discussion)

• service organisation, including workforce arrangements, skill mix, models of care and escalation/transfer services and protocols

• facilitators and barriers to choice of place of birth in different settings for low-risk women.

• facilitators and barriers for professionals working in different birth settings

• training provision and needs for staff working in different birth settings

• management and staff support and development arrangements

• any local, contextual or organisational factors impacting on quality of care and staff or user satisfaction.

Interviews with women and their partners

Topics and questions will include the discussion of the following:

• Women’s pathways through care, including choices offered and made and any change of plans or referrals.

• (How) did they choose to give birth in the AMU?

• Women’s experience of maternity care, with particular focus on the AMU birth setting.

• Experiences of birth complications and escalation or transfer of care.

• Experiences of any transfers of care or setting for organisational reasons, or personal choice.

• Wishes for future births.