Relationships with colleagues

Our interviews with staff across the four trusts were dominated by discussions about relationships. These relationships between groups of midwives, or between midwives and obstetricians, were at the heart of stories about the everyday function of the AMUs and their capacity to work within their maternity systems. The evidence we collected suggests that the relationships between staff working on the AMU and the OU were characterised by a lack of understanding of the nature of each other’s work. Furthermore, sometimes staff found it difficult to empathise with the experiences of the other midwives:

I would say it’s actually improving. The relation didn’t used to be, you know, good. There, I would say there was quite a bit of mis- . . . I wouldn’t say misunderstanding but, um, maybe . . . um . . . what’s the word I’m looking for? Um . . . maybe territorial, you know . . . each sort of unit or area functioned as if they were completely, you know, independent of the other. So you know, relations were a little bit difficult, I must say.

Southcity OU, midwife 5

By interviewing staff from all areas, we found that in some cases staff in single units had different interpretations of the same events. For example, in Northdale, the AMU midwives told us about longstanding problems with the transfer of women to the labour ward:

One of the midwives the other day was saying, ‘Oh, I transferred a woman up because I saw meconium-stained liquor there, and when I got up, I took the woman up and then they phoned back down and said, “Oh we didn’t see any meconium”.’ So she said now they’ve started to do things like save the pads so they can say, ‘Look, this woman did have meconium, look, this is what she had,’ instead of believing them. And all sorts of things happen like, um, you’ll examine a woman internally and say, ‘Oh she’s four centimetres,’ and . . . or five centimetres say, and then the labour ward will phone back and say, ‘Oh she was only two, she wasn’t even in labour.’ Very undermining, very undermining, you can never prove that, you can never prove that.

Northdale, manager 4

However, a senior OU midwife did not recognise that there was a problem:

I don’t know what you’re getting at but I don’t . . . we don’t have a trans- . . . we don’t have a problem with the midwives transferring patients. We don’t honestly perceive a problem, we don’t . . . we don’t think of it as, ‘they’re the birth centre midwives’. They just happen to be the midwife that’s looked after that lady. (. . .) We don’t see a difference between one of our midwives transferring, or from triage to us than from birth centre to us.

Northdale OU, manager 10

This scenario suggests a lack of communication between staff at Northdale that was mirrored by many interviewees in other sites. Although some midwives on the OU admitted that their view of the AMU was distorted by lack of experience of it, their language suggested that they were not so reflective during their everyday dealings with colleagues on the AMU:

You see on here, we only see the bad side of [the AMU], we only see the transfers, and I’ve said this before, they have hundreds and hundreds of babies born over the year what are all normal, but because we’re a labour ward we only see the transfers here, and we always look at the negative: oh they’ve done this, they’ve done that, they ain’t done this, why didn’t they do that? Because that’s how we are – that’s how we work.

Midburn OU, midwife 5

The difficulties groups of midwives had in respecting and empathising with each other meant that silos developed, and an ‘us and them’ culture persisted across all four trusts between midwives on the midwife-led and those on the OU. This ‘us and them’ culture was fertile ground for the circulation of myths about the ‘other’s’ work that were difficult to counteract:

I’m one of the integrated midwives that’s worked all over. Some midwives haven’t, or if they have it was a long, long time ago. So some of the midwives that work on delivery suite haven’t left there for 5 years. They don’t know what happens down here, so they think that the midwives down here are lazy because they look after one person, or they think the midwives down here don’t do anything, you know, because the birth numbers per month here versus upstairs are different. So there was a little bit of kind of . . . not . . . not nastiness per se, but ignorance. Like so if I heard colleagues of mine upstairs being like, ‘What do they even do down there? Like they just sit down there all the time don’t they, like what, looking after one lady all the time, what’s that?’ you know, like . . . I’d sort of say to them, ‘But have you ever worked down there?’

Southcity AMU, midwife 1

I’ve heard a couple of midwives say that we don’t, we just don’t examine women round here. Which obviously isn’t true, you know, we do vaginally examine women, you know, when we need to, but what we, because . . . when things are going very normally for a woman who’s had a baby before, for example, we tend to use a lot more signs of natural labour as our showing that she’s making progress.

Westhaven AMU, midwife 3

The relationships between staff on all four sites were not universally poor and they tended to be better between midwives and obstetricians than between different groups of midwives:

The doctors here are really good at accepting and trusting our judgement and asking our opinion, and bouncing ideas back, and we ask them to check our examinations, they’ll ask us to check theirs as well, and they’ll say if we transfer women round they’ll say, ‘Are you just asking us to sign to say she needs something or do you want us to make a plan that . . .?’ They really seem to involve us. I think we’ve got a really nice working relationship.

Westhaven AMU, midwife 6

Good relationships were founded on mutual respect for the others’ roles and their skill, and this was most likely when midwives and obstetricians knew each other and had worked together:

There’s always a difference when one of our midwives, one of our labour ward midwives, goes to work there [on the AMU]. Say for example, you know, there’s times when I say ‘who’s there? [on the AMU]’ she says, ‘Oh, it’s [so and so].’ ‘Oh, that’s all right then.’ You know (. . .) because she knows, obviously, she knows what she’s talking about. Or when, it’s the same as here, when a midwife comes and says, ‘Oh, will you come and see my CTG?’ you know, ‘Just come and have a look at it,’ oh, OK, I’ll come here, something must be wrong.

Midburn, obstetrician 5

The relationships between obstetricians and midwives were less harmonious at Southcity than at other sites. The few alongside unit midwives who had previously worked on the OU attributed this to the high vacancy rate, fast turnover of staff and slow rotation:

I had a great working relationship with doctors. I wasn’t, you know, um . . . sort of rude to them or dismissive of them or anything like that, and them me, because once you actually get to know one another and they trust you and you can have a great working relationship. (. . .) So on a ward round if I’ve written on the board ‘low-risk woman,’ they won’t come and interfere, and then they know if I’ve asked them for help it’s because it’s needed. Because they know you, they trust you, whereas sadly at the moment with staffing levels there’s a lot of agency and bank midwives, so there’s no working relationship there.

Southcity AMU, midwife 1

Although the trust between staff groups varied across the sites, with Southcity having particular problems, there were notable similarities between the experiences of staff at all four sites. No site had found a way to entirely resolve the tensions, in particular between different groups of midwives. Northdale and Midburn benefited from the advocacy of senior midwifery leaders who had achieved widespread support within the trust. These leaders helped to promote the AMU within the maternity services. These leaders, both consultant midwives for normal birth, were tasked with integrating practices to support normal birth within the rest of the service. They gave credibility to the philosophy of practice that was embodied by their midwifery units. The lower-ranking leaders at Westhaven and Southcity felt they were less able to assert themselves amongst the senior maternity professionals and managers.

The autonomy of the alongside midwifery unit

The AMU midwives at all four sites trod a fine line between pressing for autonomy from the OU and remaining close enough to feel supported during obstetric emergencies. The midwives on all sites brought up this tension by talking about the costs and benefits of a physical distance between their two units. AMU staff, when asked about the costs and benefits of their kind of unit, tended to contrast their experiences with those of FMUs, rather than of other AMUs that were located closer to or further from the OU than they were:

I think because we’re quite close in, um, you know, distance, it’s quite easy if something did happen, if the baby was in distress, then it’s quite quick to get them round to say theatre if we needed to, to help baby get, you know, delivered a bit sooner. Um, rather than if you were in a stand-alone birth unit, obviously then you’d have to ring up, get them sent in, it’s a lot more sort of hassle.

Westhaven AMU, midwife 2

If the emergency situation is one that we need people to come to us all we have to do is put out what we call a 2222 call, um, obstetric emergency, shoulder dystocia, Birth Centre Room 6, whatever, and they come flying down to us. Um, whereas if you’re, you know, in that scenario in a stand-alone unit you’ve got longer transfer times haven’t you before help arrives or you go to help.

Southcity AMU, midwife 1

The staff on the Westhaven AMU articulated the advantages and disadvantages of being directly next door to the OU in terms of a tension between the quality of their service (because it was separate from the OU) and its safety through being close to obstetric back-up:

I think it’s, it can be seen as good and bad, being alongside as we are. I think the good side to it is there’s always an element of safety obviously in birth, you know, we’re all very proud that we have very low rates of mortality and morbidity and everything (. . .) Therefore being through some double doors, when things do go wrong – and they do sometimes, it’s rare but you know, sometimes you have a bradycardia or whatever – and you’re quite grateful that you’re through a set of double doors! [Laughs] And you can whip round there and, you know, I’ve had a couple of instances like that and I’ve been really glad of that.

Westhaven AMU, midwife 3

I think location is really important, and it’s becoming more obvious to me, just the last couple of weeks of this business of, this suggestion that we should go up there [the delivery suite] for [handover]. If we were in another building, even on the site but in another building, even as close as the antenatal clinic which is just across the car park, that would make a difference (. . .) I would advise anybody setting up an alongside midwife unit not to do it just down the corridor. We’ve kept it going for 6 years but I can feel it being swallowed up, and I know it happens and I’m really worried that it’s going to happen here. So I would advise anyone to just get as far away as reasonably possible, but of course if it was the other side of the hospital it wouldn’t really be alongside, so somewhere in between would be best.

Westhaven AMU, midwife 1

It was not uncommon for maternity staff, like these midwives, to describe quality and safety as mutually exclusive and at odds with each other. This perceived tension was apparently more acute within AMUs than those that were free-standing. Other reported disadvantages to being colocated, as opposed to free-standing, included frequently being asked to care for higher-risk women when the OU was busy, being asked to provide care for women staying postnatally after more complex births on the OU and being asked to work on the OU when it was particularly short staffed. This manager of a FMU explained:

The manager over there [at the AMU] has very different problems than I have, and the alongside issues are very different to the free-standing issues. And the alongside issues are different in as much as . . . 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.’ Or, ‘This woman’s just had a forceps delivery, yes she’s got a drip up, yes she’s on IV [intravenous] antibiotics, but you’re only downstairs’.

Northdale FMU, manager 4

Skills and confidence for midwife-led care

Much of the talk about the ‘other’⁷⁰ midwives revolved around their perceived skill, or lack of it, in caring for either higher-risk or lower-risk women. Midwives tended to contrast the skills needed to care for high-risk women with those of midwifery care or care of normal birth and see each as mutually exclusive of the other. This dichotomisation was not surprising within these services, which partitioned the care of the women according to a binary (high/low) risk status, but the hierarchies associated with such skills are perhaps indicative of wider attitudes towards labour and birth. Much of the debate about skill revolved around who had what skills and which skills were (more) important to have. The findings from all four sites suggest that skills in dealing with abnormal labour were held in higher esteem than the kind of traditional midwifery skills that were used during normal labour. Labour ward midwives were often concerned about birth centre midwives’ skill in detecting abnormality and their capacity to intervene when women developed complications during labour or in an obstetric emergency.

There were reports of alongside unit midwives transferring too soon:

There is animosity I think between the two, the birth centre and the labour ward; sometimes the labour ward will see that they’re transferring things up here too readily.

Northdale, manager 1

And too late:

Um . . . occasionally there have been cases where transfer of the women to labour ward has been slightly delayed. It has never led to an adverse outcome but it led to, it led to the woman being in a prolonged labour ending up on oxytocin for hours on end, because, um, there was this presumption that, oh it’s just the latent phase.

Midburn, obstetrician 1

As a consequence, AMU midwives sometimes felt that, whatever they did, they could not win. When their judgement about transfer was criticised, they felt that this could influence their decision to transfer, with potential implications for patient safety.

Midwives and obstetricians favoured the rotation of midwives between clinical areas to help develop midwives’ skills and to break down the silos that had developed between teams:

I feel they . . . the midwives, if they had a compulsory rotation in either places, would make things better on either side. It does become a ‘them and us’. I think anywhere is a core midwifery led it does become them and us. Like they sent the patient to us.

Midburn, obstetrician 1

I think the midwives on the consultant unit complain that the . . . women are transferred up for . . . not . . . reasons that they feel are not appropriate. Um, but . . . I’m not sure that there’s very much that can be done about that, other than again education and if the midwives from the alongside unit participated more in educational meetings they would get, they would get more used to discussing anything with medical staff. Because I think that’s one of the things that these meetings do, they just simply enable people to speak to other people and just get used to speaking to other people.

Northdale OU, manager 8

One midwife at Southcity, who was used to rotating between areas, explained how rotating helped her to understand how the whole maternity system was interconnected. Her description of the benefits that followed suggests that it may bring similar benefits to others:

So I’m actually quite lucky in that I do I will be happy to slot in wherever so even when my home ward isn’t here or hasn’t been there I’ve always been around and it makes me, genuinely makes me laugh the fact that each manager of each department honestly thinks that everyone else has it easier than them. And it’s like really they don’t. You know it’s like postnatal is working their arses off to clear their beds for delivery suite and delivery suite is just harassing postnatal ward, but then postnatal ward will have beds and they won’t ever tell and it’s like my god you know ‘guys can you not just communicate?’ and it is simply communication and I think some of its to do with um . . . a sense of ownership of the ward.

Southcity AMU, midwife 4

Although none of the sites currently had regular rotation for midwives, there were proposals at all sites to introduce it. Most staff that we spoke to supported the idea that midwives would gain better skills from rotating between the OU and the AMU:

I decided, although I loved it on there I asked if I could come out for a little while to consolidate some of the more, the other midwifery, the cannulation, suturing, theatre, everything else that I should be knowing, really, to make me a better midwife, if you like. So I thought I need to do that and then come back. So I did, I went . . . well I wasn’t out for long, I was out for about nine months the way the staffing worked, but it was enough and I did what I wanted.

Northdale AMU, manager 2

Midwives on both the OU and the AMU appreciated that the skill of identifying abnormality was important, but sometimes AMU midwives felt that the focus on training in obstetric skills took attention away from training for midwives in traditional midwifery skills. The proposals for training and the rotation of staff between labour ward and the AMU were concerned with ensuring that AMU midwives maintained their skills in dealing with obstetric emergencies. However, there was no equivalent training for OU midwives to learn skills in caring for women during normal birth. A few OU midwives saw, and explained, the benefits of having some regular exposure to ‘normal birth practices’ such as physiological third stage and water birth:

Midwife:

You know, we don’t tend to utilise that pool because of [the AMU].

Interviewer:

Why not? What’s the connection?

Midwife:

Because we’ve got a water birth room, but because [the AMU]’s got five they, you know . . . And a lot of the issue is like a lot of the midwives [on the OU] aren’t competent really, are they, to . . . You know, I mean it does work both ways, perhaps we should rotate there once every six months or something just to see how they do the water births and things, and I think that is going to happen, you know, people are interested.

Midburn OU, midwife 5

Although the majority of participants at all sites favoured these proposals, some midwives expressed concern to their managers and in interviews that the security of the AMUs relied on them being staffed by midwives who were committed to a birth centre model of care. These concerns were more prevalent at Southcity than elsewhere, perhaps because the AMU at Southcity was the most culturally isolated from its OU and was not supported by all obstetricians. Some Southcity staff explained their concern:

What the birth centre midwives say is that . . . they get any old person coming in to work in the birth centre that doesn’t believe in normality, so the first sign of a bradycardia or a problem, they pull the emergency bell and the woman gets transferred out. And maybe we might be able to tease . . . look at that with regard to the transfer rates for those units that are truly colocated and those units that are on different floors.

Southcity, manager 6

They want to keep the philosophy of care here, about promoting normality. They don’t want midwives coming down here just because they want to see what’s going on; they want midwives down here because they want to be here and they want to promote normality, and they’re good, strong individuals that can make the right decisions.

Southcity AMU, midwife 1

Southcity managers had proposed one potential solution: to have a core of senior midwives working on the AMU, with the rest rotating to the OU or another area.

Philosophy and models of care

Staff at each site described a tension between the ideologies, or ‘philosophies’ as they sometimes described them, on the AMU and the OU. This tension was sometimes presented as a problem and sometimes as something to be celebrated. At most sites, both the benefits and disadvantages were well described. For example, at Westhaven, an AMU midwife described the particular difficulties experienced by the AMU:

I applied to go to the free-standing birth unit which I’m quite excited about if that comes off, if that happens, just because I do find there’s, um . . . I find there’s quite a battle that goes on between the philosophies that I’ve talked about, between the delivery suite and the birth centre, and I find that often you have to sort of fight your corner quite a lot, which I think can be quite exhausting and I think it’s just . . . I’m looking forward to working in a place where that philosophy is shared by everybody and there’s not the answering to people coming at you with a different philosophy, you know, with the medical model philosophy basically, and that sort of lack of understanding. It just does make your job that bit more difficult, I think, that you’re sometimes having to fight to keep things normal.

Westhaven AMU, midwife 3

The AMU manager at Westhaven also explained why keeping the ‘philosophies’ different could benefit the AMU:

At the base of it it’s about trying to keep the birth centre different from delivery suite, because we need to have a different environment and a different ethos, and a different way of practising, otherwise we won’t give the women a different service. And we now know from Birthplace that women get a good service from alongside midwife-led units; they get just as safe a service for themselves and the baby whether they’re primips or multips, and they get less intervention if they’re planning a birth in a midwife, and we know that now. So we have to . . . protect, or . . . what’s the word, keep them going basically.

Westhaven AMU, manager 1

At Westhaven, Northdale and Midburn, the introduction of the AMU had precipitated some diffusion of birth centre practices to the OU. In some cases, these were changes to the environment; for example, at Midburn, the murals that had been commissioned for the AMU were also added to walls in the delivery suite, and at Westhaven birthing balls were introduced to the delivery suite:

I think what’s changed is the . . . bringing more, well I’m hoping a bit more low risk up to the labour ward. So you know, things that we use down there, think oh well I’ll use it up here. So . . . you know, we do use the birthing stool, we do use it a lot more I feel, because, er, the staff see people using it and think, oh well I’ll use that.

Northdale OU/AMU, midwife 6

And also, things like CTGs were done quite routinely on women when they came in. . . . slowly we’ve started, to, move away from that now. Not doing traces on ladies that don’t need it or you know strapping them to the bed um, encouraging mobilisation. Let, giving them a chance, you know, let them try and do it themselves, I think that’s come across as well, you know, giving them a couple of hours let them walk around and if they’re not doing anything, take it from there.

Midburn OU, midwife 8

These were small practical changes, but they had a larger symbolic significance. Some staff, both managers and midwives, aspired to take these changes further:

I think that would be lovely, if we could have the birth centre really coming out more into delivery suite.

Westhaven, manager 5

This kind of influence of the AMU on the OU was often reported at Westhaven, but at Southcity there was less evidence that this was an agenda or an effect of having an AMU. The difference between these two AMUs’ capacity to influence their OUs could have been explained by their relative physical and cultural distance from the OU and how relatively embattled they felt within the service. Southcity had a reputation for being relatively medicalised and obstetric led, in contrast to the wider organisational culture at Westhaven.

Environment

All four of the sites aimed to give their AMUs what one midwifery manager called a ‘low-intervention look’ (Northdale manager 2). A particular ‘look’ was common across all the sites and included elements such as hiding medical equipment away, pushing the bed to one side or closing it into a cupboard, having adjustable low lighting, birth pools, soft furnishings, mats and other props. All four of the birth centres had received significant financial investment and careful interior design, either recently or some time ago. All four were created from former wards, so although their basic footprint could not have been chosen, a lot of thought had gone into how the space was used.

As the term ‘low-intervention look’ suggests, the environment was not only aesthetic, but was constructed to facilitate normal birth. This was geared towards three aims: (1) to promote the physiology of normal birth, (2) to emulate the home and (3) to distinguish the AMU from the delivery suite. Midwives in AMUs explained the connection, as they saw it, between the environment and the physiology of birth:

Midwife:

Everyone who walks into this room is like ‘Oh my gosh, it’s really nice,’ and they’re relaxed and there’s music and it’s calm and there’s no noise and . . . you know, there’s like normal furniture and normal pillows and a rocking chair, just normal stuff (. . .)

Interviewer:

This is going to sound like a really silly question: why is that important?

Midwife:

Your oxytocin is what you need, you know, it’s your labour hormone, brings you on contractions, everything like that, and your oxytocin is hugely inhibited by your fear hormone, your cortisol and your stress hormones and all that.

Westhaven AMU, midwife 1

In addition, the beds were removed or hidden (by folding up to the wall or behind curtains) at some of the sites so that women were encouraged, just by the space they were in, to be more active in labour:

If you’re on delivery suite you’ve got, it is quite clinical, you’ve got your bed, you’ve got your resuscitaire and you’ve got all your equipment and, you know, everything’s there, whereas on the birth centre there’s no bed, you know, there’s a mat on the floor, a ball and a wedge and, you know, it’s all very dimly lit and all very homely looking. Um, so you’re more likely to say, ‘Right, you know, move around more, get on your hands and knees, try standing’.

Westhaven AMU, midwife 2

Not only did the space look different, but those who designed it hoped that it would promote different kinds of practices, both by the women and by the midwives. The distinctive ‘low-intervention look’ of the midwifery units in each trust contrasted with more conventional OU environments, despite the moves to introduce some elements, such as birthing balls or murals, into the OU. This difference demarcated not only the two types of physical space, but also, as the AMU environment was created to mirror and promote a certain kind of birth ‘philosophy’, the ideological differences at work in each space:

Midwife:

It really helps to have the toys to encourage women and make it comfortable. It’s also a sign for the doctors.

Interviewer:

What kind of a sign do you mean?

Midwife:

I think it, I think it’s a . . . well they wouldn’t come down unless it’s an emergency, would they. That it’s not their normal territory.

Southcity AMU, midwife 2

Sometimes midwives described the AMU as a place that helped to soften the sharp contrast between a woman being at home and being in the OU, by bringing elements of the home into the hospital. As the home was a space within which women were assumed to have more control over their environment, a home-like space within the hospital would promote the same feelings of control over their labours. One midwifery manager at Midburn explained:

When I walk in there I see partners walking through the unit and it feels as if I’m walking into their home. It’s quite weird. (. . .) The funny thing about when you go into the midwifery-led unit is you walk in there and the women and the partners have almost, walking around as if, they don’t know you, and they shouldn’t know me. I’m walking into their environment. And it’s lovely. They go into the kitchen and they make their drinks and . . . they don’t, very often the partners aren’t wearing shoes. It’s a very, very relaxed feel about that unit, quite unlike any other unit I’ve been in.

Midburn, manager 1

Although supporting its principles, a few midwives challenged how far this idea could be implemented in practice within an institutional building. However, these analyses were few and far between, particularly at Midburn, which had the clearest commitment to the idea of the home within the hospital:

We call it ‘home-like’, I suppose, because we expect that the woman will feel most comfortable in her home, but of course it isn’t anything like her home. [Laughs] So perhaps it’s a misnomer. Perhaps we should find it something else to call it. Because I don’t think it’s anything like her home (. . .) I don’t know, I think it’s just a name, and what we really mean is a comfortable place. A little nest, really, where she’d feel at home but not in her own home.

Westhaven AMU, manager 1

So, for me, a home-like space would not for example have Entonox on the wall. But it does in a hospital, it does in a birth centre because it’s an easy way of doing it um . . . and there’s nothing wrong with that you know. A home-like space does not have a birthing pool in the middle um, it probably doesn’t have this kind of floor so you know it’s the it’s the little things but I think you know, it is actually the little things that do make a difference because um, for a woman, wherever, when she walks into that room it is inevitably going to be a medicalised space unless, you can do some sort of magic to it (. . .) I’m always telling people that they need they can bring whatever they want in but realistically you can’t, you know. I couldn’t bring in my big picture of Stonehenge, which is on my wall, you know, or I couldn’t bring in . . . I can’t bring in my cats [laughs] as much as I’d love to.

Southcity AMU, midwife 4

Some obstetricians were dismissive about what they saw as senior midwives’ unnecessary preoccupation with interior design:

I believe, really believe that if a woman is a, for want of a better way of describing it, a midwifery-led labour and delivery, then that midwifery care should be able to be provided anywhere and if that lady happens to be in one of the rooms which is nominally in the [labour ward] at the moment because say the birth centre is full, then why should her care be any different from what it would be if she were ‘round the corner?’ (. . .) Therefore the whole obsession with the curtains – having to have a curtain to put around any bit of machinery, all that sort of thing does seem a bit like nonsense to me.

Westhaven, obstetrician 3

The obstetrician above apparently felt that quality of care did not, and should not, depend on the environment of care per se and dismissed the impact of the environment on labour and birth, whether real or symbolic. This could be understood in terms of differing physiological theories of birth, or potentially in terms of gender concepts, or medical versus social models of birth. The decoration of the midwifery units reflected both the gendered and classed dynamics of the maternity unit. One midwife at Midburn said of her AMU that ‘it’s almost like a really white, middle-class concept, do you know what I mean? Put it in somewhere like [middle class area] or [middle class area] and people would be all over it’ (Midburn AMU, midwife 2). However, this belied its deprived, inner-city location and the fact that a socially and ethnically diverse range of women in this socioeconomically deprived community were giving birth in the AMU. As we discuss in Chapter 5, while it may be argued that concepts of a domestic space are gendered and/or class-based, the AMU environment was important to and valued by a diverse range of service users.

Working in an alongside midwifery unit

Notwithstanding these many challenges, midwives at all sites talked about working at the AMU as a positive experience. This was despite recognising the difficulties they faced, particularly in being an AMU:

I just thank my lucky stars that I came to this trust really, I know that sounds a bit sycophantic, but to have two working birth centres in one trust, and it does work. Yes there are trials and tribulations of the relationships, but it does work. Women come and they enjoy the services, in both places. And . . . we enjoy working in it. [Laughs] You know, it’s for the women but it’s for the midwives as well. That’s who we are, that’s what we want to do, and it’s difficult practising in the way we practise sometimes when you’re in a very medicalised environment.

Northdale, manager 2

It’s just, just completely the sort of midwifery that I love, I love to . . . to do, really, it’s how it should be. Unless it’s too busy that you can’t be with the woman, but you know, it’s such, so nice to strip it back and be in this sort of home environment, it’s really nice.

Westhaven AMU, midwife 5

It was lovely and it was nice to go sort of back to basics and back to normality, because a lot of the time on delivery suite obviously people are round there because there’s complications, so it’s nice to get back to lack of use of monitors and . . . and goodness knows, and trying to pre-empt everything that’s going to go wrong! And just let the women get on and do it themselves, which is really great.

Westhaven OU, midwife 2

The common thread in AMU midwives’ accounts was that the unit was a protected space in which they could do ‘the sort of midwifery that I love’ (Westhaven AMU, midwife 5). The AMU appeared to provide such a space for the midwives working on it and a break from a different kind of midwifery for those OU midwives who worked there occasionally. However, as we can see from the findings of the interviews with staff, this was not without cost in terms of intraprofessional relations.

Summary

A SWOT analysis is often used within organisations to identify the possible consequences of a change or intervention. In the analysis of qualitative research findings, it can be used to draw out the trends across a large number of interviews. We carried out a summary analysis, using similar techniques, focusing on the presence of a thriving birth centre to identify the SWOTs to the four birth centres from our analysis of the perspectives of the staff working there and their OUs. Analysing the data in this way showed how the comments different professionals made in interviews collectively formed a way of talking about the birth centre amongst and between the staff in the different clinical areas.

The perspective of the AMU midwives, unsurprisingly, was that the AMU was beneficial to both women and midwives. Women’s experiences of AMU care will be discussed in Chapter 5. It was a place where midwives had more professional autonomy than they had experienced within the OU setting, where they had a supportive team of colleagues with a shared philosophy and where they could provide care with fewer time constraints, in a quiet and relaxing environment that facilitated normal birth. Obstetricians were generally supportive of the AMU, but often midwives (and sometimes obstetricians themselves) spoke about keeping medical staff from ‘interfering’ with normal labour. The midwives tended to attribute their AMU’s weaknesses to factors outside their control, for example staff shortages, overwork, the OU, community midwives’ unwillingness to work on the unit and the privilege of medical over midwifery skills.

Most OU staff described the benefits of the AMU in terms of its relationship with the OU, rather than as having benefits in its own right. The AMU took pressure off the OU and AMU midwives were willing (at times) to provide cover. However, they attributed weaknesses of the model to the perceived attitude and clinical skill of the midwives working on the AMUs and what was perceived as their preoccupation with normal birth. A few commented on how their own lack of exposure to normal birth encouraged them to see birth as high risk and to view the AMU in this way. They also expressed some concern, therefore, that increasing numbers of women in AMUs might further increase this divergence of perspectives.

Midwives working in both settings gave insightful and helpful examples of opportunities that were open to the AMU. The AMU midwives focused on strategies to improve the numbers of women using the service, for example by becoming opt-out if they were not already, giving women better-quality information and instituting better triage for women who come to the labour ward in early labour. Similarly to the OU midwives, they emphasised the need for rotation to improve midwives’ familiarity and skill in different clinical areas, but also called for a good skill mix on birth centre shifts and the recruitment of staff whose values were congruent with what they considered to be a birth centre ethos.

The differences between groups of staff were more striking than any differences of experience between sites. Each group tended to view the characteristics of the AMUs from firmly within their own shoes. The disagreements focused particularly on midwives’ skills and the value of medical compared with midwifery skill. From the perspective of many OU staff, the skills hierarchy was topped by technical skills such as cannulation and suturing, whereas the alongside unit midwives tended to prioritise the benefits of active birth skills, birth environment, family-centredness and flexibility.

These rather stereotypical attitudes were not ubiquitous, and most professionals understood the issues from the other’s perspective, even if they did not necessarily use the reflexivity they demonstrated during interviews in their everyday work. However, the attitudes summarised here formed an evident collective trend among and between the two groups of staff.

The midwifery units were built to provide a physical space for a particular kind of midwifery practice. The physical wall(s) or doors between the AMUs and their OUs help to ensure that normal birth practice is protected from what is perceived as the influence of medicalised, high-intervention care of the OU. However, when a wall is built, there is an obligation to ensure that it can also be crossed safely by women who need to transfer to the labour ward and by staff who are accompanying them. The challenges faced by the AMU staff were predominately found before, during and immediately after these crossings. In Chapter 5, which focuses on the experiences of women using the service and their partners, we go on to describe how these crossings also form key points of potential disjuncture, which may affect women’s feelings of being safe and the quality of care they experienced.