Background
Methods
Aim
Study design and setting
Ethics
Sampling and data collection
Participant Type | Number (Site 1/Site 2)a
|
---|---|
Women (postnatal) | 11 (4/7) |
Midwives | 10 (5/5) |
Obstetricians | 5 (2/3) |
General Practitioners | 5 (1 GP practice) |
Data analysis
Protecting normality | • Normalising • Respect • Public perceptions |
Education and decision making | • Decision making • Information sharing • Educational impact |
Continuity | • Continuity of service • Fragmented care • Staff continuity and availability |
Empowerment for WCC | • Genuine choice in WCC • Lack of choice • Promoting women’s autonomy • Individualised care |
Building capacity for WCC | • Not providing WCC • Staff competency • Practice organisation |
Rigour
Results
Protecting normality
These participants made an explicit link between Protecting Normality, specifically normalizing pregnancy and having care provided in smaller more accessible settings. This obstetrician participant echoes this view of normality, identifying the need to perceive pregnancy as a normal journey:“The way you can do that [normalizing] is by not doing things to women that they don’t need done to them, you know” (Midwife-3)
This view is supported by other participants who stress the importance of the environment in normalizing childbirth. This midwife notes the challenge faced in providing peaceful and quiet environments in busy, and potentially distracting, labour wards:“And this is important for the women to understand… that the pregnancy is not a disease, it’s not a special condition, it’s part of the normal healthy life” (Obstetrician-3)
Decentralizing the provision of services was identified as a means of protecting normality. This participant indicates that it is difficult to normalize pregnancy when services are inaccessible to women:“You’d be trying to create the right environment so lights really low, nice music on, the lavender going … it’s quiet, it’s dark, it’s peaceful... Where it’s [in the labour ward] bright lights and it’s busy and there’s noise” (Midwife-5)
A theme that emerged from the data and supported the concept of protecting normality was respect: respect for women, for the journey of pregnancy and for WCC. The women participants identified that respect meant being recognized as an individual with past experiences, preferences and potential fears about childbirth. These women participants illustrate the importance of feeling listened to as a component of respect:“If we valued women truly then we wouldn’t make them drive sixty miles to the nearest unit” (Midwife-1)
The midwife participants recognized the need for an ethos of respect. Importantly, this did not just refer to the outcome of pregnancy, but a respect for all stages of pregnancy and fertility. This datum identifies the need to establish a philosophy that normalizes and respects WCC, with midwives themselves having a role to play in implementing this philosophy into the care they provide:“you’re looking after the woman as well as just the mother of the baby …the woman is not just the mother like you know, she’s still just you know, like a person aside from being a mother” (Woman-2)“Sometimes it’s nice to feel that you’re listened to and that you’re unique” (Woman-5)
Respect for the principle of WCC was influenced by a range of societal factors, media influences and cultural beliefs about pregnancy. Professional participants consistently noted that a normal, safe pregnancy and birth could be accommodated within a MLU, with the proviso that there is a clear route to obstetric care and a labour ward should complications arise. What became clear from the data was that women themselves were unaware of this option due to the prevalence of the labour ward model in Ireland:“Midwives need to change their way of thinking to provide the opportunity to women to have normal births and normal birth environment. So, I sometimes find it just a little bit frustrating that people will put up all sorts of objections… the doctors won’t let us? When I think it’s the midwives not letting themselves… and not standing together. And that’s what would help achieve.. you know normal, natural labour and birth” (Midwife-2)
This lack of awareness of alternatives is also indicated when participants view greater levels of medical intervention, not only as the norm, but also as a safer option resulting in better outcomes. These following quotes; first from a midwife and then an obstetrician, indicate professional openness towards change along with the challenge faced:“it’s [awareness of MLUs] not still getting out into the community, into you know that there is another alternative to going to have your baby in the hospital. ” (Midwife-4)
While supportive of the principle of supporting WCC via the introduction of MLUs across Ireland this obstetrician goes on to articulate the status quo regarding risk and choice:“They (women) will always want to have the most high tech, and I think that will last for a long time, until the service is much more balanced, and the service and choices offered to women are more balanced. It will take a long time for the fear factor to disappear and for the education that comes from providing a fully rounded service actually pervades women’s psyche and they realise actually I don’t need every single scan.” (Midwife-1)“Well I think I would imagine that you know if it is explained to women what this (WCC) is, you know what the advantages are, that they would see that.” (Obstetrician-1)
In summary, protecting normality identifies that participants believe pregnancy and childbirth can and should be perceived as normal, also that there should be a minimum of intervention in support of this normality. While all of the participant groups aspired towards this they were also clear that the current systems with emphasis on safety and the timely processing of women in labour wards meant that there would need to be significant change if normality is to be re-instituted in the face of near ubiquitous medical intervention. Inherent in any approach to protecting normality is the need to educate women and respect women’s primacy in decision making during pregnancy via a WCC philosophy.“There’s an assumption that something had happened, or there’s bad publicity, or that you feel safer in going to urban. You know so it was seen as a continuum, and that you know if you are low risk care you go to your local hospital, the higher risk, a certain amount can be handled in your local hospital with input maybe from the tertiary centre, and then you have people who need the tertiary level care, full stop.” (Obstetrician-1)
Education and decision making
The information sharing sub-theme describes the need for and potential benefits of professions improving understanding of each other and being educated in each other’s approaches to care. This midwife participant makes the case for different stakeholders having a common skill set:“if you empower them (women) with all the information…, risks and benefits of certain treatments and ultimately you know, if they’re well informed, women can make their own decision about what kind of management they want. So I guess it’s trying to give them all the information so they can make decisions themselves about their own management. ” (General Practitioner-5)
This datum reflects the view voiced across participant types that there was a need for greater inter-professional understanding and emphasis on a shared ethos of WCC. The educational impact sub-theme provides additional understanding by relating the information women are given to professional knowledge, organizational systems (in the example below whether the woman was consistently seen and comprehensively assessed) and individual confidence to provide individualized rather than generic advice. This midwife participant illustrates the range of components that must be in place along with education to ensure that decision making is woman-centred:“we need to introduce something called an obwife (laugh) instead of an obstetrician in isolation, not a midwife, maybe an obwife... I think the problem is nobody is the enemy here, the obstetrician is not the enemy, the women, the midwife is not the enemy but the poor woman should not fall between 2 egos. The women should get the care based on the best.” (Midwife-10)
The theme education and decision making represents the finding that professionals need to develop their own knowledge, along with developing a shared ethos of pregnancy and child birth. The lack of a shared ethos is currently viewed as limiting choice by women and for women and as a barrier to WCC. Raising inter-professional knowledge was viewed as a means of enhancing access to other models of care as trust between the professions was seen as a requirement for change.“co-sleeping is one example, I would find it very hard to say to a mother not to co-sleep with her baby in the first 8 weeks. But as a professional I have to be aware of giving her the correct information. And I think currently the correct information is not to co-sleep. But I would find that very hard. But I cannot do a disservice to the woman because I don’t know if her bed is big enough. I don’t know if her home is properly heated, if her partner or herself smokes or takes recreational drugs or takes any prescribed medication.” (Midwife-1)
Continuity
All participants noted that MLUs provide greater continuity of carer. This midwife participant, based in a labour ward, articulates their view of continuity as a potential benefit of a MLU service:“...if we could manage to be a little more consistent regarding who is getting seen, or that there is a smaller group of people that might see the woman, so that she is getting the impression that she’s been seen by a team rather than by nobody in particular. ..I think that’s about consistency”. (Obstetrician-1)
The sub-theme, fragmented care, extends the understanding of the implication of inconsistent service provision. This GP participant notes how different professionals are involved in caring for the pregnant woman and how they tend to work parallel to rather than communicating effectively with each other. In this example, they view failures in communication as fragmentation:“if you look at other models of care then like midwife-led clinics, maternity, midwife-led units, where you have smaller teams, you have a chance of obtaining continuity of carer” (Midwife-7).
This midwife views service fragmentation as a feature of having three layers to the perinatal service; antenatal, labour and postnatal care:“[I have] had patients who, em, have attended a hospital with a miscarriage but haven’t come through you so you’re not aware and then they arrive in a couple of weeks later and you say oh you’re in for your check-up. And they say well actually no” (General Practitioner-5).
The staff continuity and availability sub-theme emphasized the importance of relationship building between women and professionals. These midwife participants viewed this as maintaining the woman at the centre of care:“the current service does an awful lot to prevent continuity of care, in terms of… the organization of our services, we have antenatal, we have labour ward, we have postnatal, we have fragmented what is a continuous process of pregnancy…if you look at obstetricians, midwives, GPs, public health nurses…we all function again almost independently or separately from each other... So the first thing you have to do is prioritize it, because all the literature would say it was important” (Midwife-6).
The continuity theme highlights the need for women to have ease of access to services, good communication between service providers and consistent contact between women and staff. In practice, much care is noted to be fragmented with care being received in parallel and limited communication between primary care, hospital services and MLUs.“[The MLU is] excellent in involving women a lot more and I think the fact that they tend to see the, say midwife, or generally speaking see the same midwife for each hospital visit has been huge... they seem to discuss a lot more, and they seem to develop a very, or foster a very good relationship between the midwife and the, the woman” (General Practitioner-5)
Empowerment for WCC
The sub theme, lack of choice, describes how limited the services are when it comes to flexibility and how participants identify that enforced changes to daily routine are also related to lack of choice:“I suppose its focusing on the woman’s care and the baby as opposed to what a clinical led care, you know you’d have a say in what you would like, you know what women would want themselves for their maternity, what they feel, I presume that’s what it means”. (Woman-3)
The sub-theme ‘promoting women’s autonomy and empowerment’ describes the participants’ experiences of power, control, knowledge and their influence upon informed decision making. The participants provided examples of the importance of listening, partnership working and shared decision making which places women at the centre of their care:“And even the diabetic ladies coming in and they say well I don’t usually take my insulin till ten when I’m at home. But they’re getting their breakfast at eight o’clock here and then they’re saying their blood sugars are out because she’s not in her normal routine”. (Midwife-10)
The final sub theme ‘individualized care’ describes how important communication is in sharing of information and partnership working, and providing emotional and practical support in order that informed choices can be made. This was strongly stated by the women participants, with the following two quotes illustrating different aspects of ‘individualized care’:“...you go for your antenatal visits and you’re kind of like powering through the system in five minutes and out the door again, you’re kind of, you walk by feeling there’s no one really listening to you, you don’t feel they care……. you know it would be nice to have that sort of, feeling that someone actually is listening to you and kind of cares what happens to you, it’s the woman as well not just the baby”. (Woman-5)
The theme Empowerment for WCC describes how providing a woman with choices is a key principle of maternity care and the lack of empowerment diminishes WCC. All of the participant groups were generally critical of the failure of services to empower women in current Irish maternity services. Participants identified limited resources, lack of choice over location of care, and clinician’s’ application of rule structures within the services as inflexible, hierarchical and disempowering to both women and professionals. This theme also represents a consensus between the participant groups on the importance of individualized care, the need for better communication, sharing of information and partnership working. Empowerment may also be enhanced by providing emotional and practical support to facilitate informed choice.“I suppose it’s because you’ve never looked after, a hundred percent of the time, a newborn infant before, so it just gives you a heads-up, and they show you how to care, how to bathe a newborn, how often to feed them. Nothing can prepare you for holding that newborn in your arms, but it does go some way towards helping. And as well you get to meet other women who are in the same boat as you, and you get to, you know, chat with them as well”. (Woman-1)“And they were saying relax, everything is fine, you’re doing perfect, you’re doing great. And they just talked me through so, it was just the easiest labour I ever had with this specific midwife I had at that time. And that was definitely woman centred care. You know she was there with me, she was talking through with me, you know she was telling me everything was fine, we’re here, we have everything, you know don’t worry, nothing else is going to fall out (laugh)”. (Woman-5)
Building capacity for WCC
These data are consistent with other data indicating a preference for, but lack of continuity of carer. The data also demonstrates that the organizational structure and emphasis on safety within stretched labour ward environments limits WCC:“They’re kind of having to retell their story I think each time that they go in for this (outpatient appointments). There’s a lack of continuity there I think”. (General Practitioner-2)
The second sub-theme, staff competency, refers to the ability of professionals to work with women in a manner that provides a range of choices. Communication, both with women and inter-professionally is shown to impact upon the provision of WCC. This midwife datum suggests that where there is a lack of common ethos and understanding between the professions, particularly obstetricians and midwives, it can impact on quality of care reducing WCC:“one midwife to fourteen mums and fourteen babies, if you eventually get to the stage where you can mention anything about those things [general care such as varicose veins or sciatica], then you are doing amazing in that environment. So, yea, I think the art is getting squashed out for us, and we could do more for women” (Midwife-1)
While organization and resources are often noted as impacting on capacity, staff experience is also indicated. This midwife participant notes that individual experience, professional knowledge and confidence can add to the potential for WCC to occur:“nobody is the enemy here, the obstetrician is not the enemy, the women, the midwife is not the enemy but the poor woman should not fall between 2 egos. The women should get the care based on the best evidence.” (Midwife-4)
In addition, analysis of these data indicate that WCC arises from the capacity to provide women with a range of informed choices. Importantly, these choices need to be underpinned by common ethos and capacity across professions, as summed up by this datum:“But then you know the levels of experience and what levels then do you allow to make those decisions, would be up for, that’s another discussion in itself, who makes the final management plan? Because like you might have someone who has years of experience and they have the knowledge that they can push a woman that bit further in order to maintain normality and a safe outcome. As opposed to someone else who might be having fear of well we can’t push her, let’s deliver” (Midwife-6)
An opposing view is presented by this obstetrician participant who suggests that women’s choice is and should be limited on practical grounds:“And like that I don’t feel that it’s always going to be midwifery based, someone with a history of two previous sections, knows she’s not going to have a normal delivery. But what’s the safest way for her; I think it’s about safety and informed choice” (Midwife-6)
That the obstetrician refers to ‘current’ systems reflects the understanding, prevalent within the data, that achieving WCC will require significant change and investment. The final sub theme, practice organization, describes how current organizational structures can serve to diminish or enhance WCC. This midwife compares public and private care suggesting that private care can offer more continuity and therefore be more woman-centred:“So if you are too liberal with the woman deciding the choice, it’s hard to work it (an outpatient clinic) in the way that our system works currently” (Obstetrician-1).
In summary, building capacity for WCC describes how WCC is currently negatively impacted by a range of factors including organizational structures, professional differences in ethos, experience and skills. While this data is largely negative, there is a common view that there is a need to raise capacity, specifically the degree to which women are offered choice in models of maternity care and continuity of carer.“When you’re in you’re in and out in 5 and 10 minutes. However if you attend a midwifery led clinic you know there might be, let’s say 15 women attending one midwife as opposed to 140 women attending 3 obstetricians. And like midwives will give women time and give them the opportunity to ask questions and all of that” (Midwife-5)