This review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) on the 18th of October of 2019 with registration number: CRD42019141443.
To conduct the search and screening, the PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses) were used (3) and the following inclusion and exclusion criteria were agreed (see Table 1).
Data analysis and synthesis
For the analysis The articles selected for the analysis were imported into NVivo 12 software for data analysis. Data in the abstract, findings and discussion sections were analysed thematically using a three-stage process approach: coded line-by-line, organised into categories to capture descriptive themes and analytical themes were then developed to answer the review questions (5).
Descriptive findings
The studies selected were conducted in England, Brazil, China, Canada, Iran and United States (US). Seven studies were published between 2010 and 2020 when more substantial evidence on outcomes of MUs was available, five studies took place between 1991 and 2010. Healthcare systems in different contexts and time varied quite significantly amongst the studies. A public system with universal coverage was present in countries like England and Canada whilst a mixed system with public governmental system, private sector, and NGOs was present in Brazil and China, Iran, and US.
Some studies were not purely focused on the implementation process of a new MU (14, 17–20), but had wider aims such as mapping MUs nationally or investigating how AMUs were organised. However, the team could identify interesting and relevant aspects related to implementation of new MUs in these studies and therefore included them in the analysis.
Midwifery was less regulated and less autonomous in countries like China, US and partially in Brazil with higher level of autonomy reported in England and Canada. No information on the status of midwifery was available in the Iranian study (19).
There was variability with MU model of care within different countries. The common characteristics across all sites were: an intrapartum unit (within the OU, alongside or freestanding but always physically separated from the main OU rooms) staffed by midwives (hospital or community midwives) who worked autonomously providing a midwife-led primary level of care and referring service users to the secondary level of care (in situ or via transfer) when needed.
In most of the studies, participants were mainly professionals, managers and commissioners. Service users were included just in four studies and three of them were based in England.
Synthesis findings
The discussion of the synthesis is presented here under two broad categories: drivers to open the new MU and barriers and facilitators to the implementation. The latter category included eight key themes, each of which could be placed under facilitators or barriers, and in some settings were found under both, depending on the context:
- Culture and perceptions
- Healthcare system
- Midwives’ identity and role
- Knowledge, skills and training
- Leadership
- Collaborative approach
- Integration
- Environment
Drivers to open the MU
In the included studies, a range of different reasons led to the decision to open a new MU:
-
Promoting more humanised care to reduce intrapartum interventions and medicalisation (China and Brazil) (21–24)
-
Negotiating a middle-ground service between homebirths and the medicalised OU (US) (25)
-
Increasing accessibility to perinatal care in areas with poor access to care (Iran) (19)
-
Implementing evidence into practice (Canada, England) (14, 20, 26)
-
Opportunistic or pragmatic reasons such as reconfiguration of the service, including centralisation (England) (17, 18, 27)
In the case of the opportunistic drivers, while the motivator might be service-improvement or implementing evidence in practice to support quality of care and support for physiological birth, the trigger or driver of change was often related to a wider service reconfiguration plan that opened up an opportunity for change. An example of this was contexts in which few small OUs were closed to centralise the service into a single larger OU: this represented an opportunity to keep a local service running by implementing a midwife-led unit (17). Table 4 in the additional file 3 reports an overview of different strategies used to implement the MUs and who initiated the process of change.
Table 4
Overview on different strategies used to implement the MUs
N
|
Country
|
Year
|
Who initiated/led the implementation
|
Strategy
|
1a
|
China
(A)
|
2009
|
Researchers
|
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
|
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
|
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
|
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
|
2013
|
Brazilian Ministry of Health (MoH)
|
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.
|
4b
|
Brazil
|
2009
|
Brazilian Ministry of Health
|
Normal Childbirth Centers or Childbirth Houses were implemented as consequence of a strategic governmental initiative to reduce medicalization in childbirth in Brazil.
|
5
|
Canada
|
2018
|
The Ontario Ministry of Health and Long Term Care
|
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’ privileges at the moment of transfer and to the continuous service evaluation.
|
6
|
England
|
2005
|
Consultant midwife
|
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)
|
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
|
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
|
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.
|
Barriers and facilitators
1. Culture and perceptions
Codes related to culture and perceptions were ubiquitous across the different articles showing that all participants discussed on some level aspects related to society, the local culture and how this affected the implementation process. Studies took place across seven countries with differing healthcare systems and periods of time when the implementation was attempted, however some consistencies were found.
On a macro-societal level, structural issues highlighted as barriers were related to gendered power dynamics, hierarchy in the health system and the hegemonic production logic in healthcare (14, 17, 18, 22). For example, in the study by McCourt et al. 2014, professionals described an unbalanced gendered dynamic as a barrier to implementation and to the existence of AMUs (17). Amongst the different countries, women have different levels of autonomy, respect and rights when it comes to childbirth. The case studies from Brazil, China and Iran discussed the issue of women’s rights in childbirth and obstetric violence acknowledging its presence in the respective countries (19, 21–23). Opening new MUs became an opportunity to tackle this issue and the following quotes from the Iranian and Chinese studies show how the MU was perceived by service users as valid alternative to avoid such mistreatments:
“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, (19), page 1078
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 both in the Chinese study (21, 23).
The medicalised and industrialised model of care was cited in the English and in the Brazilian studies as a structural problem that can become the key obstacle to implementation (14, 18, 22, 27). These studies identified that in a system that functions with a hierarchical structure and in terms of efficiency and productivity, the division between the Industrial/Medical model of care of the OU and the Bio-Psycho-Social model of care of the MU (12, 28) could lead to polarisation, with an imbalanced power dynamic.
“A normatively medical outlook persisted, that located midwifery units as marginal rather than as a core maternity service.” Authors, (18) page 18
In this scenario the OU represented the priority of the service and the MU an alternative which could be closed if need be.
1.2 Norms and perception of safety
A significant part of participants’ quotes was about perceptions of safety. The English studies identified that the MU being co-located in the same building was perceived to be safer than FMUs (14, 17, 18, 20). This was often mentioned by participants (both professionals and service users) even though it is not supported by existing literature that shows that FMUs are instead associated with better clinical outcomes than AMUs (2, 29).
“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, (14), page 5
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:
“(…) 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
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 MU on social and clinical outcomes and cost-effectiveness.
In the Iranian case study, choice was often about compromising on what was affordable (19). It was noted that women often reported perceiving the OU to be safer than the MU because of the availability of medicines and devices. However, they would opt for the MU to access a good level of care by experienced professionals at an affordable price.
“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, (19), page 1078
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 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, (19), page 1079
2. Healthcare system
2.1 Cost and financing systems
Study authors reported that the concept of cost effectiveness associated with MUs was not always clear to commissioners, managers and professionals (14, 17, 18). The concept of MU being “cost-saving” was often mentioned together with the status of financial constraint and the urgent need for healthcare organisations to save money (14, 17–19, 21–25):
“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, (14), page 7
Studies identified two threads of opinions: one perceived MUs as expensive and unaffordable luxuries, or small and so inefficient (14, 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” (22).
Managers, commissioners and professionals’ perceptions and willingness to implement the MU was also dependent on the type of healthcare system and commissioning environment of the local context. Where there was a ‘payment by results’ tariff in which the organisations were paid for the interventions provided, normal births were often seen as a “loss making activity” by commissioners and obstetricians (17, 18, 21). In the US, where hospitals were paid by number of births, the strategy used by nurse midwives to convince physicians and commissioners that the MU would attract more women to their service was considered one of the most effective approaches (25). In China, midwives were asked to take more responsibility working in a MU without an economic incentive, they were tempted to prefer working in the OU where for the same salary they had less responsibility (21). In Iran, where service users had to pay depending on the place of birth they chose (MU or OU attended by professionals or homebirth attended by SBA), the MU offered services which were more affordable to them while ensuring good quality of care.
A financial system that was perceived working better in promoting midwife led provision and normal births was the one based more on assessment of risk level and service users’ needs at booking (17, 18):
“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
2.2 National guidelines
In all the case studies contexts, giving birth in an institutionalised unit even if outside the main traditional OU was legal and this represent an important first step towards the readiness for the change. A clear example of positive impact, as reported in one English study, were the NICE Intrapartum guidelines published in 2014 that were promoting MUs and the possibility for each woman to choose between 4 places of births based on the findings of the Birthplace Study (1, 14, 20, 30).
Similarly, in Canada and Brazil, the new national guideline promoting the MU model of care was reported as a key trigger for an implementation process towards MUs (22, 24, 26).
Guidelines also played an important role in professionals’ perception of safety and for the collaborative work of the multidisciplinary team (17, 18).
“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
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.
2.3 Local policies
The opportunity for a MU came often from the idea of revising or creating a new local protocol for physiological labour and birth. This promoted integration, as this example from an English study highlights:
“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, (McCourt et al., 2018), page 18
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 practises (as will be further discussed in point 4.2 of this review).
“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
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.
“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, (26), page 545
The multidisciplinary exchange in the production of these criteria became an opportunity for collaborative practice and a facilitator to the MUs implementation.
3. Midwives’ identity
Most studies discussed the importance of a midwifery identity and the role that this profession had in those contexts. Midwifery and midwifery-led care was established with different level of autonomy. England and Canada had midwives that could practice autonomously in these units (14, 17, 18, 20, 26, 27); Brazilian midwives went to Japan to gain more exposure of the midwifery model of care as they were not used to work with that autonomy (24), whilst China, US and Iran (19, 21, 23, 25) reported not having a well-established and autonomous midwifery workforce in the healthcare system at that time.
Contexts in which midwifery was not established as an autonomous profession seem to struggle more, especially in the first phase of the implementation when the idea needed to be accepted by other stakeholders (21, 24, 25). In the Chinese case study, the opportunity of implementing a MU was reported to be the means to achieve a proper and recognised professional status (21).
The need of having obstetricians to promote a midwifery led model seemed important in all contexts but particularly so where midwifery was more marginalised in the decision making of the service configuration. However, it could have a ‘boomerang’ effect in which once the MU is implemented, the obstetric component could claim the leadership. In the American study, for example, marginalisation of the midwifery profession became apparent when nurse midwives who promoted and initiated the project of MUs had to fight with the obstetric component for the recognition and the credit of their actions:
“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, (25), page 266
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:
“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, (26), page 5462
4. Knowledge, skills and training
All studies identified that an appropriate set of knowledge, skills and training was required for midwives to work autonomously, even though midwifery regulations and background of midwives had significant differences from one context to another. Even studies located in countries were midwives worked more autonomously (England and Canada) reported a lack of confidence in physiological birth among midwives often due to a more predominant obstetric-led practice in the last decades:
“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, (14), page 6
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.
4.1 Training
A strategy identified in all studies was offering training to the staff as an enabler of the change. In some cases, midwives identified their own educational needs prior the implementation of the MU model of care and this helped engaging them in the project and create sense of ownership (21, 24, 26, 27). The autonomy and skills gained via the training helped increasing not just the clinical confidence but also the confidence in the midwifery scope of practice, the vision of the MU and its implementation (24, 26).
Ad hoc and pre-implementation training for midwives was promoted, but also the concept of regular training, the so-called continuous practice development (CPD), was addressed in several studies (14, 17, 18, 26). Studies highlighted not only its importance to keep professionals’ skills up to date but also the need of covering more midwifery topics and move away from the concept that only training on obstetric emergencies needed regular updating:
“(…) 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, (14), page 5 and 6
“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
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 (14, 17, 18, 21).
4.2 Exposure to MU model
In some studies, the importance of exposure to the MU model of care for professionals before the opening of a new MU was also discussed (17, 18, 21, 24, 26).
“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, (24), page 197
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 (26). 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.
“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, (26), page 547
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.
“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
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 in the OU some MU philosophy of care (17, 18, 24).
5. Leadership
As showed in Table 4 in the Additional file 3, those who moved forward the idea of the implementation of MU were often midwives, nurse midwives or midwifery managers highlighting the importance of the midwifery component in leadership for this type of change. Senior midwifery support was often mentioned and in the English studies this was identified in the figure of the consultant midwives (14, 17, 18, 27).
Good leadership was sometimes showed in group or by a single professional who could either be a senior midwife or an obstetrician depending on the context. The role of one charismatic and motivated leader was often mentioned as key ingredient to start a conversation and to initiate the adoption process.
“-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)
-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, (14), page 6
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:
“Management respondents emphasised the importance of senior midwifery, obstetric and general managers working together to support and sustain the development.” Authors, (17), page 24
Overall, the studies in this review identified the key functions of leadership to support the implementation of a new MU:
-
Inspire and start a conversation about the change and promote a vision
-
Advocate for the team and for the service users
-
Promote participation of different figures for planning and developing the change
-
Ensure integration within the service
-
Negotiate and move strategically with inside knowledge
-
Support training and establish a learning culture
6. Integration
On a similar note, when discussing the importance of a multi-layered change, the concept of integration was described as an essential feature. With the term “integration” studies referred to the collaboration on an organisational level between different departments of the maternity service and on a professional level between different team members.
Sometimes, the change towards a MU model of care became a useful opportunity to reflect and improve integration in the maternity services:
“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, (26), page 546
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).
Another key topic that could play the role of either a barrier was the staffing level. Shortage of staff experienced was due to either a permanent lack of appropriate recruitment of midwives for the MU team, or occasional due to the “pulling away” of staff during shifts who were meant to work in the MU but had to cover shortage of staff in other departments like the OU (14, 17, 18, 20, 21). The staff shortage had implications even in the service users’ perception of the service:
“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, (23), page 525
Factors that could help developing and planning a functional staffing model were identified in having a core team that would allow continuity of philosophy or care and consistent management of the MU even in case of emergencies and rotation of a part of the staff to allow exposure to this model of care of other midwives (14, 17, 18, 26).
7. Collaborative approach
In all case studies, the planning and opening of the MU involved communication, negotiation and coordination between different stakeholders within the same organisation or part of different ones. This highlights the importance of a collaborative approach to the change. When the importance of interdisciplinary work is acknowledged, included in the in-service training and constitutes part of the team vision, this aspect was found to be a significant enabler of the change (17, 18, 20–22, 25–27). Conversely, the lack of an interprofessional approach could make the MU service isolated and lead to a lack of confidence and trust amongst professionals of the same team (14, 17, 18, 20).
“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, (26), page 544
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 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, (26), page 546
This also helped the strategic planning during meetings held to gain support of the managers and organisational leadership.
In more than one occasion the need of “compromising” and “negotiating” was mentioned when discussing the change (25, 27). This was, however, most of the times endured by the midwifery component and not by the medical staff:
“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, (25), page 264
This illuminated an imbalanced power relationship when it comes to planning a change, even towards a model that is midwifery-led.
7.1 Professional relationships
The opening of a new midwifery led setting may create a separation amongst midwives and polarisation of the work. This could lead to the scenario in which midwives might be ‘othering’ colleagues for working in the other setting or for being either too medicalised or too pro-physiology. This nourished the “them and us” culture and constituted a main barrier to the integration of the maternity team.
“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
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, 25).
Rapport with obstetricians varied across the different case studies and it seemed to be related to how well midwifery led models of care were already established in the respective context. In the more recent English studies, obstetricians were overall in favour of the idea of a new MU (17), whereas in the Brazilian study a great deal of tension was reported with the medical corporation, which actively opposed the initiative of the new MU (22).
Across the studies, support from the obstetric component (whether active or passive) was found to be an important, and even fundamental, facilitator to the implementation of new MUs.
“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, (25), page 263
“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, (27), page 754
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.
7.2 Communication
Effective, respectful and appropriate communication, both verbal and non-verbal, was identified as having a central facilitator role in positive stakeholders’ relationships. In some cases, educational activities were used to solve some communication issues and this helped to pre-empt or overcome tensions amongst the team. For example:
“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, (26), page 546
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, 26, 27).
Appropriate information about the MU to the service users and the definition of a clear pathway of care outlined was reported to be a key facilitator for the successful implementation:
“Successful implementation was also dependent on a clear clinical pathway from the beginning of pregnancy until the onset of labour.” Authors, (14), page 6
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. (14, 18).
However, communication with service users was not mentioned much in the studies, suggesting a lack of attention to this issue. In the Chinese and Iranian case studies, the MU was perceived as a good alternative to receive better verbal and non-verbal communication and avoid mistreatment (19, 21). The Brazilian case study reported how an organised civilian movement for birth rights was successful in influencing the governmental spheres (22).
8. Environment
All studies discussed of concept of the MU as a distinct built environment separate from the OU as a prerequisite of an effective implementation plan. In some cases, the refurbishment of the physical environment or a reconfiguration became the means to promote a change in clinical practice and in the birth culture of the local context (17, 18, 22–25, 27). The new physical layout was the most visible feature of the wider change that was being promoted and implemented:
“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 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 (14, 17, 18, 27).
On the other hand, if the planning of the change does not consider all the different layers implied, including the shift in culture, practice and integration required, then there is the risk that the physical layout case alone could become a trap in which energy and resources could be wasted. Focusing just on the MU physical layout and not on the MU model of care was reported as a potential barrier to effective implementation (17, 18, 25, 27):
“I’m afraid we could end up with a room that’s just decorated differently; that’s about all that would be different” Midwife, (25), page 265
The clear physical separation from the OUs was also mentioned as facilitator for the implementation of the new MU:
“We thought it would be easier to do it outside the hospital due to institutional resistance.” Manager, (22), page 872
And when it was not, it became an obstacle to the MU model of care:
“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, (27), page 754