Midwife-led care

Deborah Hughes and Ruth Deery

Where's the midwifery inmidwife-led care?

What makes midwife-led caredifferent? How do you know ifyou are doing it?Deborah Hughes RM MA DPSM PGDE is anIndependent Midwife. Ruth Deery RM RGNADM BSc (Hans) is a Senior Lecturer inMidwifery at the University of Huddersfield and abank midwife.

THE PURPOSE OF THIS ARTICLE isto share some of our insights and thoughtsabout midwife-led care (MLC) which havearisen whilst engaged in an action researchproject recently.As a result of a new hospital being built

locally where all current in-patient serviceswould be centralised, many concerns wereexpressed over the future of the midwife-ledunit (Deery et ai, 1999). This was accom-modated in separate facilities to the obstet-ric-led unit and enjoyed a good reputationand increasing use by local women and mid-wives. Part of the reconfiguration of ser-vices locally meant that this unit would,from 200 1, share the same geographicallocation with the obstetric-led unit.Following the expression of various con-

cerns about this, we are in the process ofundertaking an action research project witha local NHS Trust looking at MLC and waysto develop this further when the midwife-ledunit (MLU) moved into shared facilitieswith the obstetric-led unit in 2001. When westarted out on this research project, weassumed that we knew what MLC was andthat it clearly differed from obstetric-ledcare in its nature.Initially we thought that issues the project

would examine were:_ The current autonomy of the midwivesgiving MLC and what happens to thatautonomy in an altered environment

~ The territorial demarcations and powerrelationships that exist within midwiferyand how these impact on MLC

- Whether and how technology infiltratesMLC

- How and why midwives act in the way theydo when giving (or sabotaging) MLC.

However, not long after starting the projectwe began to realise that many of our assump-tions were inaccurate.

Some limitations of the literature

Whilst our literature search is ongoing, theconsiderable amount we have already col-lected and read begins to indicate some ofthe problems we have encountered in ourown project. There are many papers whichdescribe policies and protocols, booking andexclusion criteria for various ML U s (Walsh,1995; Campbell et ai, 1999; Jones, 1997).There is also a considerable amount of auditor quantitative research looking at outcomesin terms of neonatal and maternal morbid-ity and satisfaction (Campbell et ai, 1999;Shields et ai, 1998; Young et ai, 1997).There is, however, a complete dearth of arti-cles describing how these two are linked. Inother words, it is difficult to find any workdescribing the processes (what midwivesactually do in MLC) that connects the struc-tural characteristics with the outcome data.The papers we have read present the out-come data (e.g. Apgar scores, vaginal birthrates, episiotomy rates) as though it is solelylinked to the booking criteria and transferpolicies in place, rather than to the care actu-ally received (Woodcock & Baston, 1996;Tucker et ai, 1996; Law & Lamb, 1999).Recognising the lack of definition of mid-

wife-led care, Walsh and Crompton (1997)discuss the operational variations that existand call for a more standard operational def-inition of MLC. Whilst they are primarilyconcerned with structural issues (e.g. book-ing criteria lists), the lack of a clear defini-tion of midwife-led care also applies toprocess issues like communication and sup-port practices (Walsh & Crompton, 1997).

The invisibility of the processes ofmidwife-led careThere is little or no idea from the literatureof what MLC actually consists of or how itqualitatively differs from midwifery caregiven under the auspices of an obstetric-ledunit. If the success of midwife-led care issolely to do with structural issues (e.g. book-ing criteria and policies), it suggests thatmidwife-led care is mainly concerned withthe interpretation and implementation ofthese rather than the interpersonal qualitiesand skills the midwife herself may contributeto the process of care. The essence of mid-

wifery seems to be missing from most pub-lished work on MLC, together with anyinsights as to how midwifery care itself canfacilitate positive outcomes.There is a little descriptive work, which

begins to touch on what midwife-led careconsists of and how that care may actuallycontribute to the various differences in out-come independently to the booking crite-ria/transfer policies in force in any MLU.Walsh (1995) in outlining the Wistow mid-wifery project, attempts to articulate someof the factors essential to MLC. These are,he considers, a personal relationship betweenmidwife and woman and continuity of carer.It is also possible to deduce from some of thequantitative studies certain elements ofMLC, such as greater continuity of adviceand continuity of carer for women havingMLC (Turnbull et ai, 1999). Campbell andMacfarlane (undated) report that womengiving birth in the MLU they studied had ahigher incidence of intact perineums thanwomen in the obstetric-led unit. However,there is no comment on the midwifery careor actions that may have contributed to theirintact perineums. In a rare qualitative studyon the experience oflabour of women hav-ing MLC, Walker et al (1995) describe con-stant support during labour, midwiferyconfidence, help with breathing and relax-ation, lack of intrusiveness, respect for indi-vidual autonomy, feeling informed, beinggiven choices and being able to make deci-sions, being given a feeling of personal con-trol, friendliness, and a relaxed atmosphereas central to MLC. Whilst we are still unclearas to the processes of midwifery care wherebythese were achieved (e.g. how the midwivescreated a relaxed atmosphere, how theyhelped the women retain personal control),they nonetheless begin to point us to themidwifery skills and qualities that may under-pinMLC.Walker (1996) also includes some descrip-

tions of the nature of midwifery care in theMLC she studied. She reported midwivesenabled women to make their own deci-sions, were unobtrusive yet always available,were continuously present when wanted,involved women's' partners and left cou-ples alone with their babies after birtl1. Again,we do not know how midwives involvedwomen's partners nor how they facilitated

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MLC appeared weakbecause there was noconsistent or coherentideologydifferentiating it fromthe midwifery careoffered on theobstetric-led unit

women's decision making. We need to iden-tifY these skills and we need to be able todevelop and propagate them if MLC is toexpand successfully.Shields et 011 (1997) looked at the impact

of MLC on psycho-social outcomes post-natally. Women who had MLC felt preparedfor parenthood, had better support andadvice regarding infant feeding and had lessposU1atal depression. Given that this was arandomised controlled trial it must be con-cluded that it was what the midwives givingMLC actually did that was different to whattheir colleagues working Lmder obstetric ledcare did, that made the difference. Whatthat was is not stated (Shields et al, 1997).If the successes of MLC are to do withaltered patterns in midwifery behaviour, skilldevelopment and ethos, then these need tobe taken into account when setting upMLUs. The only preparation that midwivesreceived prior to the setting up of one MLUwas a talk by a consultant anaesthetist onintravenous cannulation and another by aconsultant paediatrician on neonatal resus-citation and intubation (Atkins, 1997). Thisunfortunately reinforces the notion that theonly valuable and effective midwifery skillsrelate to their mastering (sic) of medicaltechnologies.

Putting the midwifery back intomidwife-led careThis takes us back to the MLC project thatwe are currently engaged in. We undertooksome observational data collection to iden-tifYwhat tlle tllreats were to MLC in accor-dance Witll tlle aims listed above. However,what emerged from these observationepisodes was tllat tllreats to MLC were lessexternal (e.g. the imperialism of doctors, tlleinfiltration of technology) than we hadassumed. MLC appeared weak because therewas no consistent or coherent ideology or setsof practices differentiating it from the mid-

wifery care offered on tlle obstetric-led LUlit.MLC was defined by its booking criteria, itsgeographical location, the midwives carryingit out and an absence of certain teclmologies,namely epidurals, intravenous infusions andcardiotocograph machines. Outside of tlllSlistwe could observe very little that made MLCqualitatively different from nlldwifery care inan obstetric unit. The rooms in and the poli-cies governing tlle MLU were tlle same as intlle obstetric lllllt.In our opitllon MLC should be grounded

in an ideology of normal physiological child-birth and skills, attitudes, education andfacilities should all centre on tllis. We wouldbe very interested to hear whether othermidwives feel that there must be an essen-tial quality tllat defines MLC as different toobstetric-led care, and what the nature ofthat quality might be. We would like to seetlle skills described more fully so tl1:lt tllesecan be passed on. If you are a midwife work-ing on MLU we would really like to knowhow your practice is different from when youworked on an obstetric unit.Contact: lVorkathome@jreenetname.co.uk

REFERENCES

Atkins J. 1997. Midwife-led care at the GilchristMaternity Unit. Midwives, 110(1313), 138-40Campbell R & Macfarlane A. Undated. Evaluationof the midwife-led maternity unity at the RoyalBourrtemouth Hospital. Final report. University ofBristolfNPEUCampbell R, Macf:'lrlane A, Hempsall V &Hatchard K. 1999. Evaluation of midwife-led careprovided at the Royal Bournemouth Hospital.Midwifery, 15, 183-193Deery R, Hughes D, Lovatt A & Topping A.1999. Hearing Midwives' Views: Focm Groups onMaternity Care. Unpublished Report, PrimaryCare Research Group, University ofHuddersfield

Midwife-led care

Jones O. 1997. Setting up a midwife managedbirth centre. MIDIRS Midwifery Digest, 7(4),514-7Law Y & Lamb K. 1999. A randomised controlledtrial comparing midwife managed care andobstetrician managed care for women assessed tobe at low risk in the initial intrapartum period.Journal of Obstetrics & Gynaecology Research,25(2),107-12Shields N, Reid M, Cheyne H et al. 1997. Impactof midwife managed care in the postnatal period:an exploration of psycho-social outcomes. Journalof Reproductive and Infant Psychology, 15,91-108Shields N, Turnbull D, Reid M, Holmes A,McGinley M & Smith L. 1998. Satisfaction withmidwife managed care in different time periods: arandomised controlled trial of 1299 women.Midwifery, 14,85-93Tucker J S, Hall M & Howie P. 1996. Obstetricianled shared care was not better than care fromgeneral practitioner and commullity midwives inlow risk pregnant women. Evidence BasedMedicine, September/ October, 190-1Turnbull D, Shields N, McGinley Met al. 1999.Can midwife managed units improve continuity ofcare? British Journal of Midwifery, 7(8), 499-503Walker J. 1996. Interim evaluation ofa midwiferydevelopment ullit. Midwives, 109(1305),266-9Walker J, Hall S & Thomas M. 1995. Theexperience of labour: a perspective fi'om thosereceiving care in a midwife led unit. Midwifery, 11,120-9Walsh D & Crompton A. 1997. A review ofmidwifery led care - some challenges andconstraints. MIDIRS Midwifery Digest, 7(1),113-7Walsh D. 1995. The Wistow Project andIntrapartum Continuity of Carer. British Journalof Midwifery, 3(7), 393-6Woodcock H & Baston H. 1996. Midwife-ledcare: an audit of the home from home scheme atDarley Maternity Centre. MIDIRS MidwiferyDigest, 6(1), 20-3Young D, Lees A & Twaddle S. 1997. The costs tothe NHS of maternity care: midwife managed vsshared. British Journal of Midwifery, 5(8), 465-72

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