Background
Methods
Inclusion | Exclusion | |
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Participants | All stakeholders involved in implementing midwifery units: maternity teams, health institutions, professionals, service users | Models of care not specific to midwifery, birth settings managed or led by obstetricians or other healthcare professionals other than midwives, home births |
Phenomenon of interest | The process of implementation of a new MU which could be successful or not. For successful implementation we mean the establishment of a new MU after a process of change in the maternity care setting. | Focus on improvements of existing MUs Focus just on clinical outcomes or technical quality of care. Focus on specific issue (e.g. smoking cessation, vaginal birth after caesarean - VBAC). |
Outcomes | Implementation outcomes like acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration and sustainability. | No focus or substantial data on questions relating to implementation, sustaining and uptake or scaling up. |
Study design | All designs including action research, grounded theory, ethnography, mixed methods studies that include qualitative data collection and analysis. | No restrictions on the types of study design were applied. |
Study focus | Studies will need to cover aspects related to implementation outcomes in the data collection and analysis with particular attention to any relevant aspect or strategy related to the establishment of a new MU. | Clinical or technical quality of care. Focus on specific health issue (e.g. smoking cessation, VBAC). |
Setting | Both alongside (AMU) and freestanding (FMU) midwifery units. Birthing rooms physically/organisationally separated from the main OU. Maternity systems willing to/in the process of implementing a new MU. Private and public services All countries | None |
Time period | No time restriction | |
Language | English, Italian, Dutch, Portuguese, Spanish, French | Other languages that the team would not be able to translate adequately. |
Publication type | Peer reviewed articles Dissertation and theses Research reports | Any piece of research which cannot be peer reviewed by the research team (books, opinion pieces, commentaries, diaries etc.) |
Systematic search and screening process
Search terms: | Order | Search strings |
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Implementation | 1 | Mesh terms for implementation |
2 | Keyword search: implementation OR implement* OR “knowledge translation” OR innovation OR utili#ation OR “scale up” OR feasab* OR sustainab* OR “service improvement” OR barrier* OR facilitator* OR enabler* OR adopt* OR diffusion OR establish* OR open* OR transition OR provision OR embed* OR integrat* OR planning OR preparation OR “implement* strategy*” OR promot* | |
3 | 1 OR 2 | |
Midwifery units | 4 | Mesh terms for midwifery units |
5 | Keyword search: “midwifery unit” OR “midwi* led birth* cent*” OR “birth* unit” OR “birth* cent*” OR “birth setting” OR “low risk birth* cent*” or “midwi* unit “OR “midwi* led unit” OR “low-risk birth* room*” or “midwife-led room* “OR “midwi* cent* “OR “low-risk birth* cent*” OR “homely birthplace” OR “homely birth place” OR “homely birth* room*” OR “normal birth* unit” | |
6 | 4 OR 5 | |
Full search | 7 | 3 AND 6 |
Search results
N | Author, Year | Country | Study aims | Design | Participants | Setting and data collected | Findings | Quality |
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1a | Cheung NF et al. 2009 [19] | China | To describe the preparations for setting up a midwife-led normal birth unit which was based on literature and practice review | Action research with a five steps cycle plus a literature review | 8 midwifery team leaders 5 researchers | A highly medicalised maternity department in a Chinese hospital with annual birth rate of over a 3000. The MU was allocated two birthing rooms. The researchers analysed data from meetings, field notes and midwifery training course. | The findings are divided into seven sections: definition, negotiations, accommodation, specific practices, the philosophy of the homely birthplace, policy development, and developing local solutions for local aspirations. | 8 |
1b | Mander R et al. 2009 | China | To explore issues arising during preliminary stages of the action research project to consider the feasibility and the effects of a MU on midwives and women. | Action research using a qualitative descriptive approach | Non-defined number of stakeholders including midwifery staff, managers, university staff and researchers. | (same setting as above) Data were collected at meetings, by non-participant observation and by face-to-face semi-structured interviews. | MU care may be feasible after the analysis of the early stages of implementation. | 8 |
2 | Mackey MC et al.1991 [20] | US | To report on how the idea of birthing room was initiated by nurses and the 8 strategies that led to the implementation of it. | Structured interviews | 4 registered nurses with Master’s degree | Four private hospitals located in the Chicago area. One-hour in-depth interviews. | Eight strategies to be used jointly to open new birthing rooms by nurses’ midwives | 7 |
3 | Moudi Z et al. 2013 | Iran | To assess 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran and to examine the reasons why women chose to give birth there. | A mixed-methods research | 19 service users in the postnatal period | The two SDPs in Zahedan, the most populous city in the province. Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran. | Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan. | 9 |
4a | Pereira AL and Moura MA 2009 [21] | Brazil | To identify the determinants of the process of implementing the Birth Center and analyse the influence that hegemonic and counter-hegemonic groups have on that process | Dialectic qualitative research | 4 commissioners 11 technical administrative professionals | Casa de Parto in Rio de Janeiro. Individual semi-structured interviews. | During the establishment process, conservative and transformative forces of the hegemonic childbirth care model clashed in the governmental and civil spheres. Legal and political dispute in the establishment process of the Casa de Parto highlighted the importance of organized social movements, especially the women’s movement. | 7 |
4b | Progianti JM et al. 2013 [22] | Brazil | To discuss how the Brazilian nurse midwives trained in the Japanese birthing centres helped to implement the FMU in Brazil. | Socio-historical study with qualitative approach | 1 Director of nursing 1 Nurse midwife 1 Physician 1 Former nursing director | Casa de Parto in Rio De Janeiro. Written and oral documents. Semi-structured interviews and report of the exchange experience. Data triangulation with policy and background documents. | The exchange programme enabled the Brazilian midwives to implement the first MU in Rio de Janeiro and added a larger volume of capital to their professional habitus. | 9 |
5 | Reszel J et al. 2018 [23] | Canada | To obtain the perspectives of health care providers and managerial staff about the integration of the new FMUs one year after implementation | Qualitative descriptive approach | 24 amongst professionals (18) and managerial staff (6) | Ontario where homebirth and birth in OU were the only two birth settings for women prior the implementation of the two FMUs. Data was collected via 4 focus groups and 1 interview. | The collaborative approach for the planning and implementation of the MUs was a key factor in the successful integration and the positive experience of service users. | 10 |
6 | Walton et al. 2005 [24] | England | To explore organisational factors, midwives role, barriers and facilitators of the change process and training needs for midwives | Action research | Non-defined number of stakeholders including midwives, managers and medical staff. | Inner London teaching hospital that take care of over 4400 women a year. Data from meetings, educational workshops, feedback forms and audit of the 2 birthing rooms | The lack of support from medical staff, the conflicting priorities and the dominance of the medical model of care made the project not feasible and the team abandoned the idea of the MU after this pilot. | 6 |
7 | Walsh et al. 2018 [25] | England | To describe the configuration of midwifery units, both alongside & freestanding, and obstetric units in England | National survey | Heads of Midwifery in English Maternity Services | National Health Service (NHS) in England. Descriptive statistics of AMUs, FMUs and OUs and their annual births/year in English Maternity Services | Number of MUs and births in MUs in England increased after the publication of NICE guidelines (mostly AMUs). Significant difference in terms of utilisation of the MU and this suggest that some are underutilised. | 10 |
8 | Walsh et al. 2020 [14] | England | To identify factors influencing the provision, utilisation and sustainability of MUs in England | Qualitative study | 57 Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners 60 midwives 52 service users | Setting England. Data collected: first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and fourth, by convening a stakeholder workshop. | Most managers and clinicians did not regard their MU provision as being as important as their OU. 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, lack of leadership and institutional norms protecting the status quo. | 10 |
9a | McCourt et al. 2018 [26] | England | To investigate how AMUs are organised, staffed and managed, the experiences of women, and maternity staff including those who work in AMUs and in adjacent obstetric units. Some MUs were already established, other just recently being implemented. | Organisational ethnography approach | 35 managers and key stakeholders 54 professionals 47 service users | Case studies of 4 AMUs in England, selected for maximum variation based on geographical context, length of establishment, size of unit, leadership and physical design. Observations, semi-structured interviews and documentary review were conducted. | Development of AMUs was often opportunistic. Key potential challenges included: boundary work and management; professional issues; developing appropriate staffing models and relationships; midwives’ skills and confidence; and information and access for women. | 10 |
9b | McCourt et al. 2014 [18] | England | (same as above) | (same as above) | (same as above) | (same as above) | Same as 9A but explored more in detail. | 10 |
Quality appraisal
Data analysis and synthesis
Descriptive findings
Synthesis findings
Readiness
Cultural level - structural issues and perceptions
Structural issues
The information provided to women about choice of place of birth played a key role in the decision-making process that was often found to be rigid. An example of this was asking service users to decide where to give birth at the very first booking appointment [17, 18] with not many occasions to reconsider their choice. This rigidity was also mentioned in the Chinese studies [19, 28].“I have insurance. If I had gone to hospital, it would have been free of charge for me, but I didn't. They annoy us in hospital; they examine too much. It's more comfortable here; it's better.” Service user, [27], page 1078
In this scenario the OU represented the priority of the service and the MU an alternative which could be closed if need be.“A normatively medical outlook persisted, that located midwifery units as marginal rather than as a core maternity service.” Authors, [18] page 18
Norms and perception of safety
Some professionals also mentioned the idea of feeling safer by having all women in the same place and therefore having greater monitoring (and control) than having them in different locations. This preconception was illustrated in this quote by an English consultant obstetrician:“I think majority of women and all my friends will opt for an alongside MU, because most women do want the option of midwifery led but if anything goes wrong they just want to go down that corridor, through that door.” Midwifery Manager, [11], page 5
On the other hand, when professionals were educated and had knowledge on the evidence and the impact that a MU might have, there was better integration and working relationships. This seemed to show the importance of information and education of best available and up to date evidence to make stakeholders aware of the impact of MUs on social and clinical outcomes and cost-effectiveness.“(…) 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” Consultant obstetrician, [17], page 22
The MU constituted the best compromise for that population to gain physical and psychological safety. However, the MU represented also the birthplace option that would allow them to avoid unnecessary medicalisation of childbirth:“I thought, childbirth is just childbirth, no matter which place I go to. Why should I go to hospital, where the costs are very high? I didn't have health insurance, and I had to pay all that money in cash (out of pocket). Therefore, I decided to go to the nearest SDP (MU)” Service user, [27], page 1078
“I love my daughter-in-law very much. Her childbirth was a hard time for me. In hospital, they told me she needed a caesarean, so I took her to the Post (MU). I didn't tell the ladies here (midwives) what I had been told in hospital. And thank God she had a natural delivery.” Service user, [27], page 1079
Professional level - recognition of midwives’ role and scope of practice
The recognition of midwives’ role and scope of practice was needed not just within the organisation and amongst professionals but on a more societal level too. This was not limited to countries where midwives are less autonomous but also to countries like Canada, where professional establishment was relatively autonomous but still recent and small-scale. In this case, the MU became a facilitator for this process of recognition of the midwifery scope of practice and therefore promotion of its role in society:“Although nurses were the initiators of the birthing room (MU) concept and nurses did most of the work towards implementing the concept, there is evidence that physicians are pre-empting the credit. One nurse said, -It’s interesting that now the doctors think it’s their idea-. Another nurse was concerned that nurses never received credit for changes they had made in her hospital and tried to avoid a repeat of that situation.” Authors and nurse midwife quote, [20], page 266
“Many participants perceived that the birth centers (MUs) have increased the respect and legitimacy of midwifery, both to the public and to other health care professionals, allowing these groups to learn more about midwifery and ultimately increase visibility and credibility of their education and practice. One paramedic stated, ‘It elevated the [midwifery] profession for sure . . . I think just having the facility speaks volumes to the interest, the buy-in, the respect, and the credibility of midwifery’.” Authors and paramedic’s quote, [23], page 5462
Organisational level - elements of the local healthcare system
Cost and financing systems
Studies identified two threads of opinions: one perceived MUs as expensive and unaffordable luxuries, or small and so inefficient [11, 17] and therefore an antithesis to the need of save money of the organisation; the other perceived the cost-saving attribute negatively as if this would necessarily mean a lower quality of care. In Brazil for example, this argument was used by the organisations which were against the promotion of MUs and in favour of a more medicalised approach; they referred to the MU model as “poor care for the poor” [21].“Financial constraints within Trusts were often seen as limiting the development of MUs. While economic evaluations suggest the overall economic outcomes of increasing births in MUs is positive, the start- up costs were seen as a barrier, and the longer term savings from lower morbidity in the target population that accrue across the health system were not recognised. In a climate of scarcity, new ways of structuring care must demonstrably save money, or at least, be perceived to, in the short term.” Authors, [11], page 7
“Although the commissioning environment and payment tariffs had been described as making normal birth a ‘loss-making’ (manager XXX) activity, managers and commissioners hoped that the development of a tariff centred more on assessment of women’s care needs would help to remove such perverse incentives.” Authors [17], page 42
National guidelines
Having a national guideline is a first step and a key facilitator for the implementation of these realities to allow local stakeholders starting a conversation around the adoption of the different model.“In XXX, for example, managers emphasised the need for obstetric support for normal birth and midwife-led care and saw guidelines as helping to sustain obstetricians’ confidence in the alongside unit. It was apparent that obstetricians were more comfortable with midwife-led care away from the obstetric unit if they felt that there was a comprehensive set of guidelines supporting that care that had been agreed across the service. This gave them more confidence that women would be appropriately referred to them for review if medical attention were necessary.” Authors, [18], page 18
Local policies
On the other hand, attempting an implementation without such local guidelines could jeopardise the whole process leaving space to interpretation, no clear distinction in pathways of care and contamination of practices (as will be further discussed in point 4.2 of this review).“Managers and midwives saw the local guidelines for admissions to and transfers from the midwifery unit as protecting a space for physiological birth, as well as a guide and framework for safe practice.” Authors, [18], page 18
When preparing a local protocol for the management and practice in the MU, key topics that needed facing and addressing were the access criteria of the MU and transfer criteria from the MU to the OU.“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.” Authors, [17], page 25
The multidisciplinary exchange in the production of these criteria became an opportunity for collaborative practice and a facilitator to the MU's implementation.“Prior to the opening of the birth center, we managed collaboratively with our key stakeholders, so we managed with the nurse manager but also some of the physicians, the obstetricians, about developing our current [transport] protocol . . . But it [was] something that we, from scratch, met together collectively, collaboratively to get everyone’s approval for the current protocol that we have.” Midwife, [23], page 545
Strategies
Support, training and exposure to the MU model
A good level of knowledge, up to date training and appropriate skills of the midwifery workforce were identified as an important facilitator to develop professionals’ confidence in the MU model and for being able to promote it and spread it.“Because everyone has worked in such a high-risk environment, you become deskilled to an extent, and feel a bit apprehensive about normal birth… you know, trusting that women can have babies low risk.” Focus Group Midwife, [11], page 6
Training
“(…) a number of midwife respondents felt that practicing within them required different skills and a level of confidence, which they were not well prepared for. (…) Midwifery managers and midwives in our study recommended mandatory training in normal birth skills to address this concern.” Authors, [11], page 5 and 6
Several studies described what they termed as “skills hierarchy” when planning training for maternity professionals with more attention given to the so called “high risk skills” and not on the skill for physiological birth. Instead, the kind of skills reported as prerequisite of working in a MU were often the ones more related to physiological birth and autonomy in decision making [11, 17‐19].“Every year at our mandatory training, for three days (…) we have skills drills of obstetric emergencies and haemorrhage and eclamptic fits and stuck babies and breech babies and all of that, and I always, and in the feedback I always write, ‘Where’s our midwifery skills training? You assume everybody is up to speed with physiological third stage and augmenting labour naturally and advice on post-dates pregnancy etcetera … and it’s not given much value by the midwives themselves or by the people who train us or by the obstetricians.” Midwife, [18], page 15
Exposure to MU model
The aspect of the exposure to midwifery models was not limited to other midwives but could be promoted to other maternity professionals and students too. In some contexts, where MUs were not established yet, home birth represented another option to experience midwifery led care [23]. This was important not just for witnessing the model of care but also to gain an insight in each other’s role and promote integration amongst the team.“The practical part of the course was held in several institutions. (…) To begin practicing at these Birthing Centers (MUs), the required care for nurse internship at these facilities was addressed. During the internship, it was possible to learn the philosophy and administration of each of the centers. The situations experienced by the nurses reflect the different systems of care in this field that would ultimately influence the professional practice of each one of them upon returning to Brazil.” Authors, [22], page 197
In countries where MUs were already established, AMU represented the middle ground to increase exposure to physiological birth to the maternity team and to consolidate autonomous midwifery care for midwives.“Physician exposure to home birth is associated with more positive attitudes toward home births, highlighting the importance of increased exposure through interprofessional training opportunities in education and practice” Authors, [23], page 547
The concept of “contamination of practice” was also mentioned in three studies in which rotations of staff or an international exchange were applied hoping to bring back into the OU some of the MU philosophy of care [17, 18, 22].“Lack of confidence in working with physiological birth was also reported by some hospital-based midwives, and the alongside midwifery unit was seen as a steppingstone to all midwives developing their skills and confidence in midwife-led care” Authors, [18], page 17
Promote collaborative and well integrated working relationships
Establishing a vision amongst the whole maternity team in which the MU is part of the care pathway for uncomplicated pregnancies and all professionals are on board with that seemed to be a key facilitator. Having opportunities to spend time together during training days was highlighted:“Participants from all 4 hospitals described interprofessional meetings very early in the planning process, ensuring that all voices were considered in the birth center (MU) development.” Authors, [23], page 544
This also helped the strategic planning during meetings held to gain support of the managers and organisational leadership.“Participants gave several examples of interprofessional training opportunities resulting from the opening of the birth centers, including hospital drills, mock EMS (emergency medical service) dispatch calls and transports from the birth centers (MUs), welcoming students from different professions to the centers, and including center tours as part of EMS personnel orientation. These opportunities increased understanding of each other’s knowledge, training, and roles, and improved participants’ ability to communicate with one another.” Authors, [23], page 546
This illuminated an imbalanced power relationship when it comes to planning a change, even towards a model that is midwifery-led.“It appeared that only the nurses gave up some of their plans. Physicians were either for or against a birthing room (MU) in general.” Authors, [20], page 264
Professional relationships
These tensions were noted and voiced not just by midwives but by managers and service users too who perceived these as potentially detrimental to the care provided [18, 20].“Tensions identified among staff were mostly between midwives working in different areas, particularly alongside midwifery units and obstetric units, rather than between obstetricians and midwives.” Authors, [18], page 26
“In fact, unless chief obstetricians positively sanctioned the idea, success would have been impossible. The involvement of the chiefs ranges from strong support for the idea to passivity that allowed nurses to make the idea reality.” Authors, [20], page 263
This seemed to be because midwives often need medical support to be enabled to apply changes and improvements to the service. As mentioned in theme one, gendered dynamics and the hierarchical configuration of the healthcare system play a significant part in this.“In the light of apparent tensions between midwives and doctors voiced in the NBSG (Normal Birth Strategy Group) and because communication with doctors was proving difficult a new attempt was made to gain some insight into the views and opinions of doctors. Initially doctors had not been considered primary stakeholders in midwifery-led care but as the project progressed it became clear that their cooperation in moving the project forward was fundamental.” Authors, [24], page 754
Integration within the service
When planning the implementation of a new MU, there should be awareness that adding a new branch of the service to the current maternity layout may create, especially in the first phase, disjuncture and tensions amongst the professional team [18]. Some initiatives to overcome this barrier were mentioned: planned rotations of staff, mentoring for midwives who are less confident and promotion of case-loading models [17, 18].“Participants described the planning, implementation, and monitoring of the birth centers as a motivating force that improved interprofessional practice between different stakeholders, including nurses, physicians, midwives, paramedics, administrators, and the regional health network.” Authors, [23], page 546
“A problem highlighted during the data collection relates to a perceived shortage of staff. This has particularly serious implications for women likely to give birth at night.” Authors, [28], page 525
“Some initiatives for increasing integration of care were identified which could potentially mitigate the effects of creating new boundaries or discontinuities in the service. These could also support quality and safety of care, and the well-being of professionals as well as service users. They included a planned system of rotation for staff, with mentoring for midwives who are less experienced and skilled in caring for normal physiological birth and more integrated community-hospital models in which midwives based in the community attend the women on their caseload giving birth at home or in the FMU or AMU and transfer with them if required.” Authors, [17] , page 546
Communication
The opportunity of a regular dialogue and exchange of opinions and ideas to review and debrief practice was also mentioned as important factor to improve communication between the different professional parties [17, 18, 23, 24].“We’ve identified gaps in terminology between the people talking on the phone, so we’ve been able to provide education. Yeah, it’s been very, very helpful. Had we not done that, I could see that we could have had conflicts simply because we didn’t understand each other and why we were doing things a certain way and I think we’ve been able to completely avoid that or interrupt it if it was going to start because we’ve been able to go, ‘Oh, why’d they do that?’” Paramedic, [23], page 546
Lack in providing such information and the options to the service users (both during the implementation process and later once the MU was established) was reported to have a significant impact on the implementation outcomes of accessibility and sustainability [11, 18].“Successful implementation was also dependent on a clear clinical pathway from the beginning of pregnancy until the onset of labour.” Authors, [11], page 6
Invest in different components of leadership
N | Country | Year | Who initiated/led the implementation | Drivers to open the MU (WHY?) | Strategy (HOW?) |
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1A | China (A) | 2009 | Researchers | Promote more humanised care to reduce intrapartum interventions and medicalisation | Engagement with leadership and training for midwives. A five-stage action research project was used to: define the plans, assess midwives’ confidence and ability, outline policies, procedures and standards of practice, review and tackle the obstacles found in the previous steps. |
1B | China (B) | 2009 | Researchers | (See 1A) | A follow up from study 1A with the same strategies and adding the involvement of a wider range of stakeholders (including midwifery staff managers and researchers) to assess feasibility of the MU. |
2 | US | 1991 | Nurse-midwives in four different institutions | Negotiating a middle-ground service between homebirths and the medicalised OU | Eight strategies were used, described as: going it alone, compromising, getting others involved, capitalising on consumer pressure, promoting the idea of “it’s not different”, playing the waiting game and overcoming government regulation. |
3 | Iran | 2013 | UNFPA and the Health Centre of Sistan and Balochestan Province | Increasing accessibility to perinatal care in areas with poor access to care | Response to a local situation in which vulnerable women lacked access to appropriate care and a high birth rate to increase accessibility of facilities and reduce perinatal mortality. UNFPA supervised the first three years of operation. |
4A | Brazil | 2009 | Brazilian Ministry of Health | Promoting more humanised care to reduce intrapartum interventions and medicalisation | Normal Childbirth Centers or Childbirth Houses were implemented as consequence of a strategic governmental initiative to reduce medicalization in childbirth in Brazil. |
4B | Brazil | 2013 | Brazilian Ministry of Health (MoH) | (see 4A) | The MoH invested in nurse-midwives’ professional profile by sending them for an international exchange in a country where MUs were established. This was considered to give them greater symbolic power to fight for the implementation of the MU. |
5 | Canada | 2018 | The Ontario Ministry of Health and Long Term Care | Implementing evidence into practice | The availability of evidence was the reason why the MoH decided to invest in this model of care. They used interprofessional approach for planning the change, develop appropriate policies, protocols and to enhance teamwork. They also gave attention to the midwives’ admission privileges at the moment of transfer and to the continuous service evaluation. |
6 | England | 2005 | Consultant midwife | Opportunistic or pragmatic reasons such as reconfiguration of the service, including centralisation | The refurbishment of the maternity setting became the opportunity to promote the inclusion of a MU. Consultant midwife doing a postgraduate thesis initiated an action research study, which included different stakeholders (including managers midwives and medical staff) and established a group to promote normal birth. |
7 | England | 2018 | Local managers (not specified) | Implementing evidence into practice | After the publication of the Birthplace study in 2011 the NICE Intrapartum guidelines published in 2014 recommended all 4 options of birthplace. This guideline had a significant impact and was used by stakeholders as main facilitator to make the case and open new MUs nationally. |
8 | England | 2020 | Midwifery managers | Implementing evidence into practice | Key factors for successful implementation were: leadership (and continuity of it), active promotion of the MU as part of the local policy, clear clinical pathway from the beginning of pregnancy until the onset of labour and appropriate information for women. |
9A 9B | England | 2014 and 2018 | Midwifery managers | Opportunistic or pragmatic reasons such as reconfiguration of the service, including centralisation | Key drivers for development of AMUs in all the services studied had been a combination of pragmatic, even opportunistic, decisions. Lead midwives had often seized an incidental chance to develop the service responding also to financial constraints or existing plans for service redesign or improvement, including merging of different OUs within a single service organisation. |
“-it's crucial to have an inspirational leader. If you don't have somebody at the very top who is passionate about it (MUs) happening, it won't happen. And they must cascade, get everybody onboard. – (Midwives Focus Group)
The figure of one charismatic and motivated leader was reported to be essential especially at the early stages and later, during the planning process, this leader needed to be combined with a group of stakeholders and interdisciplinary members of which the obstetric component is essential. This layer of leadership was described to be necessary for the integration of the service and for promoting a culture of inclusion of different figures (including service users) in the development of a service change:-a charismatic leader to kind of bring it together… unless you’ve got that then I think it’s quite hard to bring it to fruition.- (Manager)” Midwife and manager, [11], page 6
Overall, the studies in this review identified the key functions of leadership to support the implementation of a new MU:“Management respondents emphasised the importance of senior midwifery, obstetric and general managers working together to support and sustain the development.” Authors, [17], page 24
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Inspire and start a conversation about the change and promote a vision
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Advocate for the team and for the service users
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Promote participation of different figures for planning and developing the change
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Ensure integration within the service
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Negotiate and move strategically with inside knowledge
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Support training and establish a learning culture
Think physical environment
The literature reported that an appropriate use of the physical environment has the potential to be an important strategy for the new MU, especially at the beginning of the negotiations when involving different stakeholders [11, 17, 18, 24].“The accounts of professionals and service users suggest that these different aspects of the care environment cannot simply be unpicked as they are closely inter-related. Although some respondents regarded the design aspects of the environment, such as domestic touches, as superficial in relation to actual care processes, our study findings overall suggest that attempts to alter either processes or environment of care in isolation are less likely to be effective.” Authors, [17], page 26
The clear physical separation from the OUs was also mentioned as facilitator for the implementation of the new MU:“I’m afraid we could end up with a room that’s just decorated differently; that’s about all that would be different” Midwife, [20], page 265
And when it was not, it became an obstacle to the MU model of care:“We thought it would be easier to do it outside the hospital due to institutional resistance.” Manager, [21], page 872
“As there was no physical barrier between these rooms and the rest of the labour ward, it was too easy to use them for other purposes when demand was high.” Authors, [24], page 754