Results
Participant characteristics
Thirty-four interviews were conducted with managers (8), midwives (10), pregnant women (8), and physicians (8) in the two hospitals. The partners accompanied three interviewed pregnant women. All interviews took place within the hospital buildings, in line with participants’ preferences. Interviews with pregnant women were sometimes short due to time limitation of child care of other children. Study participant characteristics can be found in Table
3.
Table 3
Participant characteristics
Number of participants | 8 | 10 | 8 | 8 |
Gender |
(men) | 3 | – | – | 1 |
(women) | 5 | 10 | 8 | 7 |
Age |
(average years) | 45 | 42 | 32 | 39 |
(range years) | 31–55 | 25–52 | 26–38 | 30–49 |
Experience |
(average years) | 19 | 19 | – | 11 |
(range years) | 6–27 | 3–30 | – | 4–19 |
Results on sustainability
Results on sustainability characteristics 1.) perceived benefits, 2.) embedded structures and processes to ensure routinization and institutionalization, and 3.) development to sustain ML-AC in the future are described in the following. The authors have translated all quotes from German to English. All quotes are paraphrased.
Characteristic of sustainability: (1) perceived benefits
Benefits include the consistent achievement of goals, lasting improvement in positive outcomes and continued perception of accomplishment [
6,
29]. All participants reported substantial benefits from the ML-AC on a personal (woman, midwife, physician) or unit level (delivery unit). The perceived benefits, such as fewer medical interventions, increase of detailed information about women’s medical history and wishes, and easement of admission processes are presented in the following.
Benefits on a personal level
Midwives and physicians of both hospitals reported
fewer medical interventions in childbirth. This is the major goal of the NES to promote physiological childbirth [
26]. According to one physician in hospital A, they reduced their secondary caesarean section from 40 to 35% and sometimes even 30%. One midwife of hospital A pointed out: “We have fewer interventions, like forceps delivery, caesarean section, or vacuum extraction” (Hospital A-midwife 5). Managers, midwives, and physicians agreed that they have
more and better information about the pregnant women. Midwives and physicians emphasized the general importance of gathering information before the woman arrives in labor pains. Applying the ML-AC allows information to be gathered about the medical history of the pregnant woman allows more time for in-depth questions and consultation. Also, the midwives and physicians pointed out that pregnant women are enabled to make decisions based on this information, e.g., having an episiotomy either performed or not. A midwife of hospital B emphasized: “Often a childbirth looks good in the health care documents, but the woman has anyway a trauma or something. This is a reason [for the pregnant woman] to come to ML-AC. Also acts of violence, death of a person, or relocation [author’s note: are reasons to take advantage of ML-AC].” (Hospital B-midwife 1).
Managers and midwives of both hospitals described how worries and anxieties of pregnant women can be addressed in the ML-AC. Addressing worries and anxieties of pregnant women also enables midwives of both hospitals to empowering pregnant women in their ability to give birth. In consequence, the pregnant women reported a feeling of safety and trust after the ML-AC, as intended by the midwives of both hospitals. One pregnant woman said that the midwives are very experienced, i.e., she trusted the midwife’s assessment during childbirth, and she assumed she endures more than she is expecting from herself. Managers and midwives of both hospitals described how the ML-AC documents enabled them to match preferences addressed by pregnant women with what may happen in the delivery unit. The birth plan, when not interfering with the safety of mother and child, now includes these preferences and serves as a guideline to support the midwives in both hospitals.
It seemed that the pregnant women felt more empowered and reported fewer worries and anxieties. Pregnant women in both hospitals appreciated the opportunity to ask questions, get detailed information, and have the paperwork done before childbirth. Furthermore, the pregnant women’s preferences could be better addressed, including her knowledge about changes that may occur under childbirth and which decisions to make. To explain their preferences and to ask questions in the ML-AC was an important source of relief for the pregnant women. One pregnant woman reported that her first baby was delivered by a secondary caesarean section. And now, after discussing her preferences during the ML-AC, she felt relieved and encouraged to try again to give vaginal birth: “This empowerment, simply empowerment. I had a caesarean section with my first child, an unplanned caesarean section, and now [after ML-AC] I feel encouraged to try anyway with my second child [to give vaginal birth].” (Hospital B-woman 4).
Benefit on a unit level
Managers and physicians of both hospitals and midwives of hospital B underlined an easement in the admission process when the pregnant woman came for childbirth. One manager of hospital A highlighted that time could be saved in both the admission process and in the time spent in the delivery unit. This manager stated that, in the ML-AC, women learn about the latency phase: in other words, women know better what to do and when to come to the hospital. According to this manager, this information saved time, since midwives and nurses had to monitor fewer women in first-stage labor. Another benefit concerning time saving, according to all participants, is that the documents and records for the childbirth are prepared and completed.
The identified benefits are not specific to each group of interviewed study participants. Statements about managers’ and midwives’ intention in offering the ML-AC and how women perceived several of the benefits are compared in Table
4, showing that pregnant women confirm the aims of the intended measures of the managers, midwives, and physicians.
Table 4
Benefits of ML-AC as reported by study participants
Benefits on a personal level (midwife, physician, woman) |
Fewer medical interventions | | Fewer forceps deliveries, caesarean sections, or vacuum extractions | Reported reduction of caesarean sections | |
Quality of information | Better information on pregnant woman | Better information - taken before labor pain start - better informed women | Better information on and better-informed pregnant women | Possibility to receive information and ask detailed questions without labor pain |
Worries, anxieties of pregnant women are addressed | Worries and anxieties of the pregnant woman can be addressed | Worries and anxieties of the pregnant woman can be addressed | | Worries and anxieties are addressed |
Empowerment of pregnant women | | To empower women to give birth naturally | | Pregnant women feel empowered to give vaginal birth |
Increased feeling of safety for pregnant women | | To support a feeling of safety to the pregnant woman, being trustworthy | | Feeling safe, having confidence in the midwife |
Expanded matching between preferences and services | Service delivery matches the wishes of pregnant women while in the delivery unit | Service delivery matches the wishes of pregnant women while in the delivery unit | | To gain influence on what happens in the delivery unit |
Benefit on a unit level (delivery unit) |
Easement in admission processes | Time can be saved | Quick and easy admission, documents are prepared | Easy admission, documents are prepared | Relieved that medical history and birth plan are done |
Characteristic of sustainability: (2) institutionalization and routinization
Institutionalization and routinization involve the embedding of structures and processes of an intervention such as an NES into the habitual practices of individuals, organizations, and systems. Institutionalization implies the concretization of organizational infrastructure and integration of change in subsystems [
6]. For successful institutionalization of the ML-AC, several structures and processes were crucial: staff budget, time slots for ML-AC appointments, and rooms. Additionally, structural organization and organizational infrastructure needed adaptation and embedding into the everyday practices of midwives and physicians (personal level), as well as on the unit (delivery unit) and organizational levels (hospital). These changes happened according to midwives, mangers and physicians over the last 2–3 years and were accomplished without additional time or resources being set aside for project management. Identified institutionalization and routinization will be described in the following.
Institutionalization
According to the managers of both hospitals, staff budget was increased and institutionalized to offer the ML-AC. In hospital A, the staff budget was initially organized in overtime of midwives. After this initial testing phase in overtime payment, staff budget was increased by hospital management according to the number of midwives needed. In hospital B, staff budget was at first increased from a donation and then by the hospital management. The midwives offering ML-AC in both hospitals emphasized the importance of having separate working schedules to offer the ML-AC. This ensures that, when there are too few midwives, they will not be called on for both, midwifery care in the delivery unit and ML-AC duty simultaneously.
In both hospitals, there was an increase in time slots for the ML-AC appointments. Starting with two mornings, hospital A extended time slots to five mornings a week. In hospital A, there was an increase in consultation time from 30 min in the beginning to 45 min since the original consultation time had not been sufficient. Sometimes even that length was still not enough for some ML-AC sessions. In hospital B, appointments are set for 30 min; if a pregnant woman needs more time, it is possible for her to make a second appointment. Another issue for successful institutionalization was finding and retaining a meeting room for the ML-AC consultation. Both hospitals faced this difficulty. Searching for a room was described by managers and midwives as very challenging, involving multiple discussions with several other units.
Organizational infrastructure includes meetings, interprofessional collaboration, and ongoing training on the ML-AC in both hospitals. According to the managers of hospital B, once per year there is a meeting of physicians and midwives to discuss the ML-AC, among other topics. Additionally, 2–3 times / year the ML-AC is on the agenda at the monthly midwives’ meetings to evaluate the implementation and to discuss new topics which may influence the ML-AC. In both hospitals, the midwives can check back with a physician within a short time: “Well, it means that in some cases we think, well she [the pregnant woman] should have seen a physician. Maybe her gynecologist overlooked something, or the woman did not mention this symptom [to the physician]. We are able to present the case to one of our physicians on short notice” (Hospital B-manager 5).
According to managers, midwives, and physicians, interprofessional collaboration is well-established in both hospitals. The existing good collaboration between midwives and physicians supported the implementation and eased maintaining the ML-AC.
Managers and midwives of both hospitals underlined training and informing all new employees (physicians and midwives) on ML-AC to promote sustainment.
Routinization
Routinization pertains to cycles of repeated action in practice and organizational routines [
6]. The
structural organization to routinize ML-AC shows commonalities and differences in the hospitals. One structure was furnished in both hospitals, namely, all appointments were arranged by outpatient services. Differences are especially apparent in the consultation procedure of each hospital. In hospital A, the managers and midwives reported that pregnant women fill out their medical history and the birth plan themselves. During the ML-AC appointment at hospital A, the midwife and the pregnant woman discuss and complete or adapt the medical history and birth plan. In hospital B, the midwife and pregnant woman fill out the medical history and the birth plan together during the ML-AC consultation. In both hospitals, the consultation is noted in the maternal care record, which stays with the pregnant woman. The midwives in both hospitals highlight important issues for other midwives.
The midwives reported in both hospitals that a copy of the medical history and of the birth plan are stored in the delivery unit. Upon arrival, the woman giving birth and the midwife in the delivery unit discuss the most important details of the documents to ensure a mutual understanding. One midwife emphasized: “And then I know already something about her and I can say: “Yes, you were here“, and I can tie in with her and say ‘you told my colleague’ this and that, and we can talk about it. Or if the documentation shows she is scared of something or she had previous experiences, then I talk to her about it, and I ensure that I have a correct understanding. How I perceived it and how she would like me to deal with it. (...) Or to agree that she can be sure that in this situation I will respect this.” (Hospital B-midwife 7).
Differences and similarities in institutionalization and routinization reported by each participant group and level classification (personal, unit or organizational) can be seen in Table
5.
Table 5
Institutionalization and routinization of ML-AC as reported by study participants
Institutionalization (implies the concretization of organizational infrastructure and integration of a change in subsystems [ 6]) |
Staff budget (Unit level) | Hospital A: Overtime, Hospital B: Donations - After about two years increase in number of midwives positions in both hospitals | Separate timetable for midwives offering ML-AC | |
Time slots for ML-AC appointments (Personal level) | - Hospital A: 30 min. Then 45 min, every day - Hospital B: 30 min. Two days/week - Last trimester of pregnancy | - Hospital A: 30 min. Then 45 min, every week day - Hospital B: 30 min. Two days/week - Last trimester of pregnancy | |
Room for consultation (Organizational level) | Difficult to obtain a room, lots of discussions | Hospital A: Room without a window | |
Organizational infrastructure (Organizational level) | - Good collaboration - between midwives and physicians. Consultation with physician on short notice, if needed. - Hospital B: 1/year meeting with physicians, 2–3/year monthly meeting of the midwives | Good collaboration between midwives and physicians. Consultation with physician on short notice, if needed | Good collaboration between midwives and physicians |
Routinization (pertains to cycles of repeated action in practice and organizational routines [ 6]) |
Structural organization (Organizational level) | Appointments by outpatient services Checking appointments Hospital A: Women fill in medical record and birth plan. Midwives add information if necessary Hospital B: Midwives fill in documents together with women during appointment. If necessary, consultation with physicians of outpatient services | If necessary, consultation with physicians of outpatient services. Documentation of consultation in maternal care record. Copy of documents stays in the delivery unit. Content of documents are discussed upon arrival between midwives in the delivery unit and birthing woman | Consultation with physician on short notice, if needed |
Characteristic of sustainability: (3) development
Development is defined as the continual enhancement of users’ abilities and resources to maintain an innovation [
29,
32,
33]. As the most important aspect to maintain the ML-AC managers, midwives, and physicians in both hospitals stressed that
reimbursement from health insurance funds is needed. According to managers, midwives, and physicians, the reimbursement of ML-AC by health insurances would induce hospitals to offer the ML-AC and support them in doing this.
All study participants pointed out that fluctuation of the head physician or head midwife and their willingness to support the ML-AC in the future will have a strong impact on its sustainability. This comment indicates a need to embed the ML-AC into the hospitals’ operational strategies.
On the one hand, offering the ML-AC every day leads to substantial experience of the midwife. On the other hand, routine may occur in a negative sense, with advice being given to all pregnant women in the same way, instead of the midwife tuning in to the special needs of the individual pregnant woman. This danger led to some managers in both hospitals reporting that they offer on-going special training in communication and consultation skills for midwives in the ML-AC team. Also, physicians and managers of both hospitals confirmed the need for the midwives to be committed if the ML-AC is to be offered in the future.
In both hospitals, managers saw the necessity to extend and adapt to new topics that arise in the ML-AC. In hospital B, midwives confirmed this need for adaptation to new topics. One midwife emphasized: “And we have to check that we are not stuck with old stuff, but that we are open to new stuff -- what women might also hear out there in prenatal care or do -- and then we have to be able to consult accordingly.” (Hospital B-midwife 2).
In contrast to midwives of hospital B, midwives of hospital A were content with the way things were, pointing out that they have everything they need: “Well, I think if we go ahead just like we do now, everything will be fine.” (Hospital A-midwife 5). Another midwife of hospital A confirmed this view: “I only need the pregnant women and they do come. Well, we have now almost optimal conditions.” (Hospital A-midwife 4).
The results of the managers, ‘midwives’, and physicians´ perspectives show concordance in the need for funding but differences between hospital A and hospital B in the perceived need for extending or adapting the topics of consultation (Table
6).
Table 6
Further development of ML-AC as reported by managers, midwives, physicians
Reimbursement | Long-term reimbursement through health care system | Permanent midwife positions to offer ML-AC | Financially feasible |
Leadership support | All managers have to support consultation | Head midwife has to support consultation | Hospital A: Leadership changes can threaten consultation |
Continuing education for ML-AC midwives | Necessary to support quality of consultations over time | Interest in taking classes | Hospital A: No need for education of midwives |
Development of consultation topics | Consultation topics have to be adapted over time | Hospital A: No changes necessary Hospital B: Evaluation of new topics on a regular basis | |
Discussion
This study advances the understanding and description of sustainability of the ML-AC as related to (1) benefits, (2) routinization and institutionalization, and (3) development in two hospitals in Germany.
Both hospitals still offer the ML-AC, thus showing that the ML-AC is being maintained, new ways of providing care have become routine, surrounding systems have been transformed in support, and the ML-AC may be developed further [
42]. All participants described manifold benefits of the ML-AC on a personal and unit level. The perception of
benefits by all stakeholders seems to be key for maintaining sustainability. The described benefits were achieved through the initial implementation [
43] and the following adaptations during routinization and institutionalization. If important stakeholders of an intervention perceive no benefits, maintaining that intervention is problematic. Especially administrative support and resources are crucial for long-term sustainability [
14,
44,
45]. For managers, their support can be ensured if benefits are perceived on an organizational level, such as saving time.
Routinization and institutionalization are rarely described [
46]. The participants of this study underlined changes and adaptations that were important to sustaining the ML-AC over a period of two to three years. These changes, e.g., allocation of working time, are essential to program survival [
29].
Hospitals implementing the ML-AC will need to be aware that adaptations of the NES are necessary to accomplish routinization and institutionalization. Routinization and institutionalization are adaptation processes that are on-going in both hospitals, indicating further effort that is needed to sustain the intervention. Also, the description of institutionalization and routinization shows why training alone is not enough to implement and sustain an intervention such as the ML-AC. Particularly establishing a structural organization means establishing processes and cooperation with other units, departments, and occupational groups. The effort and time needed for institutionalization and routinization are rarely planned and funded, with a subtle expectation that the work can be done on top of the tight workloads of managers, midwives, and physicians. This is a possible explanation of and can contribute to implementation and sustainability failure.
Also, further
development might be critical for the sustainability of an intervention. Awareness needs to be raised that evaluating and possibly adapting an intervention are essential and work needs to continue once an organization has succeeded in implementing the ML-AC. To evaluate an intervention such as the ML-AC, there has also to be clearly defined core and adaptable criteria of the intervention [
1].
Currently, German hospitals offering ML-AC at an NES level must finance the ML-AC with the budget they have. There is no reimbursement through the health care system, thus possibly impeding long-term sustainability. The importance of health care financing seems to be essential for sustainability in general [
14,
45,
47,
48]. This study contributes to the understanding of the role of initial funding and funding over two to three years, e.g., a midwife full time equivalent position, which is rarely described in published sustainability research [
46]. We found that, although both hospitals initially financed the ML-AC from various sources, permanent reimbursement by health insurance funds is the only way to secure long-term sustainability. To achieve permanent funding, further research is necessary to examine efficacy and effectiveness and to undertake health economic evaluations of ML-AC. Apart from funding stability Hunter et al. (2015) found also political support, e.g., rules and regulations that organizations require, important for sustainability [
48].
According to Leffers & Mitchel (2011), one key predictor for sustainability is on-going assessment across all organizational levels (person, unit, and organization) of the hospital [
43]. Another key predictor is the collaboration among stakeholders of the intervention [
43] which was seen between management, midwives, and physicians in our study. Other key predictors are appropriate resources, and on-going evaluation [
43,
45,
49]. On-going evaluation seems to be crucial, in addition to staff budget, and implies that sustainability is not just given but is a process that has no defined end.
Limitations
There are several limitations of this study that have to be considered. Only study participants from two hospitals that had implemented ML-AC were interviewed. It is possible that only staff who had a positive attitude to ML-AC chose to participate in the study. Pregnant women who had ML-AC potentially gave socially desirable answers since these women will come back to the hospital to give birth. Perhaps theoretical saturation of the data is not established due to the limited number of interview partners. Even though participants were asked specifically about ML-AC, some extended their explanations to all elements of the NES to promote physiological childbirth.
Conclusion
In summary, it is essential to monitor and evaluate benefits, routinization and institutionalization, and further development if an intervention is to be sustained. Table
7 offers some recommendations to promote the sustainability of the ML-AC.
Table 7
Recommendations to achieve sustainability of ML-AC
Recommendations to achieve sustainability of ML-AC |
√ Evaluate perceived benefits of all stakeholders, including the pregnant women. √ Establish and keep institutionalization of ML-AC through ○ securing of staff budget, ○ timeslots for appointments, ○ meetings for evaluation on a regular basis, ○ a designated room and ○ well established interprofessional collaboration. √ Establish and keep routinization through ○ agreed upon structural organization of e.g., appointments by outpatient services, ○ information flow and ○ documentation √ Embed ML-AC into the operational guidelines of the hospital. √ Secure long-term reimbursement. √ Secure support of management, midwives and physicians for ML-AC. √ Offer continuing education for midwives offering ML-AC. √ Evaluate and adapt topics of ML-AC on a regular basis with all midwives in the hospital. |
This study uses conceptual and operational definitions for sustainability and adds to the understanding of the relationship between the service system context and sustainability [
9]. It describes health intervention sustainability and addresses thus requisitions associated with sustainability research [
9]. Our findings suggest an intervention has neither a defined end of implementation nor a distinct beginning of sustainability. The process is more a transition between the two as described by Fleiszer et al. (2015) [
6]. Planning, monitoring, and evaluating all three characteristics of sustainability are probably necessary for long-term sustainability.
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