Factors influencing the utilisation of free-standing and alongside midwifery units in England: a qualitative research study

Abstract

ObjectiveTo identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.DesignCase studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.Setting and participantsNHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).Main outcome measuresFactors influencing MU use.FindingsThe study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust’s overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.ConclusionsThere are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women’s information needs. If these remain unaddressed, childbearing women’s access to MUs will continue to be restricted.

Relationships and trust: Two key pillars of a well‐functioning freestanding midwifery unit

“…Systematic barriers related to gender, professional, economic, and social disempowerment intersect with “powerful precedents” to constrain midwifery's progress globally (p. 397) 8 . Obstacles persist to establishing the full scope of midwifery practice, including the normalization of MUs 2,8,9 . Ethnographic studies have explored aspects of organizational culture, which support MUs, such as quality of leadership, equitable power dynamics, supportive interprofessional and intraprofessional relationships, and the development of midwifery skills and confidence 10‐12 …”

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

“…This represents a 3% saving on the current budget of £2.6B for maternity care. 7 In addition, our survey showed that MUs were not equally distributed across the country. One-third of local maternity services had no MUs, whereas others achieved 20% of all births in these facilities (designated 'high performing'), and the remainder had MUs but they were frequently underutilised, with < 10% of all births in MUs (designated 'low performing').…”

“…Potentially, this could represent around 45,000 low-risk women per year in England who could birth in a MU but currently have no access to one or are not using existing ones. 7 The mapping exercise also described suboptimal organisational processes within MUs, with the frequent movement of staff out of them to work on OUs and the regular closure of MUs as a consequence. Access to MUs was frustrated by the absence of a streamlined care pathway during pregnancy and inadequate mechanisms for service users to obtain information and exercise choice about and for them.…”

“…Since 1993, maternity care policy in England has promoted women's choice of place of birth. This became the national choice guarantee in Maternity Matters in 2007, 2 with three options: (1) birth in a maternity hospital [obstetric-led unit (OU)]; (2) birth in two types of midwifery-led units (MUs), either alongside midwifery unit (AMU) or free-standing midwifery unit (FMU); or (3) birth at home. Department of Health and Social Care-commissioned research into the outcomes of childbirth in different settings 3 reported that outcomes for low-risk pregnant women and their babies were better and costs reduced if birth occurred in MUs, both AMUs or FMUs, rather than OUs.…”

Innovations for Strengthening Global Midwifery

“…MUs can also encourage innovative ways of providing care and foster fulfilment and empowerment for midwives (Walsh 2007 , 2009 ). However, Walsh et al ( 2020 ) found significant obstacles to MUs reaching their full potential. These included a lack of commitment from healthcare providers to establish MUs as part of essential maternity service provision, an absence of leadership to drive change and lack of capacity and willingness to address women’s information needs.…”