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:

Midwife:

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 . . .

Registrar:

No active pushing.

Midwife:

Yeah, not . . .

Registrar:

They let the body . . .

Midwife:

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:

Midwife:

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.

Interviewer:

That’s if she’s on a CTG?

Midwife:

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:

Midwife 5:

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.

Midwife 6:

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:

Postnatal woman:

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:

Midwife:

. . . 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.

Interviewer:

And what was the thinking behind that?

Midwife:

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.