Midwives’ emotion and body work in two hospital settings : personal strategies and professional projects

Much has been written in recent years of a ‘crisis’ in the recruitment and retention of midwives in the NHS. The crisis has been attributed variously to burnout, a lack of professional autonomy, a bullying culture, and an ideological conflict between the way in which midwives wish to practise and the way they are required to practise within large bureaucratic institutions, such as NHS Trusts. Negotiating these experiences requires a significant amount of emotional labour by midwives, which they may find intolerable. This thesis explores the strategies NHS midwives deploy in order to continue working in NHS maternity services when many of their colleagues are leaving. It examines the extent to which working in a midwife-led service rather than a consultant-led service helps or hinders midwives’ capacity to manage the emotional and ideological demands of their practice. Ethnographic fieldwork was carried out in a consultant unit and an Alongside Midwife-led Unit (AMU) in two NHS Trusts in England. The findings from negotiated interactive observation and in-depth unstructured interviews with eighteen midwives were analysed using inductive ethnographic principles. In order to ameliorate the emotional distress they experienced, the midwives used coping strategies to organise the people and spaces around them. These strategies of organisation and control were part of a personal and professional project which they found almost impossible to articulate because it ran contrary to the ideals of the midwifery discourse. Midwives explained these coping strategies as firstly, necessary in order to deal with institutional constraints and regulations; secondly, out of their control and thirdly, destructive and bad for midwifery. In practice it appeared that the midwives played a role in sustaining these strategies because they formed part of a wider professional project to promote their personal and professional autonomy. These coping strategies were very similar in the Consultant Unit and the Midwifery Unit. A midwife-led service provided the midwives with a space within which to nurture their philosophy of practice. This provided some significant benefits for their emotional wellbeing, but it also polarised them against the neighbouring Delivery Suite. The resulting poor relationships profoundly affected their capacity to provide a service congruent with their professional ideals. This suggests that whilst Alongside Midwife-led Units may attempt to promote a midwifery model of care and a good working environment for midwives, their proximity to consultant-led services compounds the ideological conflict the midwives experience. The strength of their philosophy may have the unintended consequence of silencing open discussion about the negative influence on women of the strategies the midwives use to compensate for ideological conflict and a lack of institutional and professional support.EThOS - Electronic Theses Online ServiceEconomic and Social Research Council (Great Britain) (ESRC) (PTA−031−2006−00332)GBUnited Kingdo

Organising safe and sustainable care in alongside midwifery units: Findings from an organisational ethnographic study

Aims and Background: Alongside midwifery units (AMUs, also known as hospital or co-located birth centres) were identified as a novel hybrid organisational form in the Birthplace in England Research Programme. This follow-on study aimed to investigate how AMUs are organised, staffed and managed, the experiences of women, and maternity staff including those who work in AMUs and in adjacent obstetric units. This article focuses on study findings relating to the organisation and management of AMUs. Methods: An organisational ethnography approach was used, incorporating case studies of four AMUs, selected for maximum variation on the basis of geographical context, length of establishment, size of unit, leadership and physical design. Interviews were conducted between December 2011 and October 2012 with service managers and key stakeholders (n=35), with professionals working within and in relation to AMUs (n=54) and with postnatal women and birth partners (n=47). Observations were conducted of key decision-making points in the service (n=20). Findings: Managers saw four key areas as vital to developing and sustaining good quality midwifery unit care: finance and service management support, staffing, training, and appropriate guidelines. Development of AMUs was often opportunistic, with service leaders making use of service reconfigurations to achieve change, including development of MUs and new care pathways. Midwives working in AMUs valued the environment, approach and the opportunity to exercise greater clinical judgement but relations between groups of midwives in different units could be experienced as problematic. Key potential challenges for the quality, safety and sustainability of AMU care included: boundary work and management; professional issues; developing appropriate staffing models and relationships; midwives’ skills and confidence; and information and access for women. Responses to such challenges included greater focus on interdisciplinary skills training, and integrated models of midwifery and care pathways. Positive leadership and appropriate development and use of guidelines were important to underpin the development and sustainability of midwifery units. Conclusions: The units studied had been developed to form a key part of the maternity service, and their role was increasingly being recognised as valid and as maintaining the quality and safety of care in the maternity service as a whole. However, each was providing birth care for only about a third of women who had been classified as eligible to plan birth outside an obstetric unit at the end of pregnancy. Developing midwifery units involves aligning physical, professional and philosophical boundaries. However, this poses challenges when managing the service, to ensure it is sustainable, of high quality and safe. In order to fulfil evidence-based guidelines on providing midwifery unit care, further attention is needed to staff training and support; the development of integrated, continuity-based staffing models; and ensuring AMUs are positioned as a core service rather than a marginal one

The WASS Collective: Gender Transformations in Higher Education

This paper offers a critical perspective on issues around gender and sexual transformation within the context of UK Higher Education. Drawing on qualitative data carried out by undergraduate and postgraduate students, the analysis explores some of the diverse and often challenging ways in which young/er women and men are thinking and talking about gender, sexuality and feminism, as well as their strategies for turning ideas into political action. The research focuses on the activities and opinions of students belonging to an anti-sexist organisation within one UK university, who are engaged in campaigns to raise awareness about the damaging effects of gender and sexual inequalities, as well as promoting the popular appeal of contemporary feminisms. Locating the voices and research findings of the students themselves at the centre of the discussion, the paper is produced collaboratively between students and teachers who are involved in both the activist and research elements of this project. The paper also argues for (and provides evidence of) the transformative potential of alternative and critical forms of student engagement and student/ staff collaboration in relation to gender informed academic activism.Feminism, Post-Feminism, Anti-Sexism, Higher Education, Activism, Academic Activism, Praxis, Critical Pedagogy, Collaborative Methods

'It makes sense and it works': maternity care providers' perspectives on the feasibility of a group antenatal care model (Pregnancy Circles)

Aim To test the feasibility of introducing a group antenatal care initiative (Pregnancy Circles) in an area with high levels of social deprivation and cultural diversity by exploring the views and experiences of midwives and other maternity care providers in the locality before and after the implementation of a test run of the group model. Design (i) Pre-implementation semi-structured interviews with local stakeholders. (ii) Post-implementation informal and semi-structured interviews and a reflective workshop with facilitating midwives, and semi-structured interviews with maternity managers and commissioners. Data were organised around three core themes of organisational readiness, the acceptability of the model and its impact on midwifery practice, and analyzed thematically. Setting A large inner-city National Health Service Trust in the United Kingdom. Participants Sixteen stakeholders were interviewed prior to, and ten after, the group model was implemented. Feedback was also obtained from a further nine midwives and one student midwife who facilitated the Pregnancy Circles. Intervention Four Pregnancy Circles in community settings. Women with pregnancies of similar gestation were brought together for antenatal care incorporating information sharing and peer support. Women undertook their own blood pressure and urine checks, and had brief individual midwifery checks in the group space. Findings Dissatisfaction with current practice fuelled organisational readiness and the intervention was both possible and acceptable in the host setting. A perceived lack of privacy in a group setting, the ramifications of devolving blood pressure and urine checks to women, and the involvement of partners in sessions were identified as sticking points. Facilitating midwives need to be adequately supported and trained in group facilitation. Midwives derived accomplishment and job satisfaction from working in this way, and considered that it empowered women and enhanced care. Key conclusions Participants reported widespread dissatisfaction with current care provision. Pregnancy Circles were experienced as a safe environment in which to provide care, and one that enabled midwives to build meaningful relationships with women. Implications for practice Pre-registration education inadequately prepared midwives for group care. Addressing sticking points and securing management support for Pregnancy Circles is vital to sustain participation in this model of care

Better together: a qualitative exploration of women’s perceptions and experiences of group antenatal care using focus groups and interviews

Problem. Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes. Background. Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes. Aims. To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women’s experiences of pregnancy and antenatal care, and inform further development and testing of the model. Methods. A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically. Findings. Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions. Conclusions. Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners

Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies

Objective: the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. Design: organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. Setting: a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring ‘best’ or ‘better’ performing in the Health Care Commission survey of maternity services (HCC 2008). Participants: professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. Findings: each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a ‘hub and spoke’ model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. Key conclusions and implications for practice: maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries

Place of Birth and Concepts of Wellbeing: An Analysis from Two Ethnographic Studies of Midwifery Units in England

This article is based on analysis of a series of ethnographic case studies of midwifery Units in England. Midwifery units are spaces that were developed to provide more home-like and less medically oriented care for birth that would support physiological processes of labour, women’s comfort and a positive experience of birth for women and their families. They are run by midwives, either on a hospital site alongside an obstetric unit (Alongside Midwifery Unit – AMU) or a freestanding unit away from an obstetric unit (Freestanding Midwifery Unit – FMU). Midwifery units have been designed and intended specifically as locations of wellbeing and although the meaning of the term is used very loosely in public discourse, this claim is supported by a large epidemiological study, which found that they provide safe care for babies while reducing use of medical interventions and with better health outcomes for the women. Our research indicated that midwifery units function as a protected space, one which uses domestic features as metaphors of home in order to promote a sense of wellbeing and to re-normalise concepts of birth, which had become inhabited by medical models and a preoccupation with risk. However, we argue that this protected space has a function for midwives as well as for birthing women. Midwifery units are intended to support midwives’ wellbeing following decades of professional struggles to maintain autonomy, midwife-led care and a professional identity founded on supporting normal, healthy birth. This development, which is focused on place of birth rather than other aspects of maternity care such as continuity, shows potential for restoring wellbeing on individual, professional and community levels, through improving rates of normal physiological birth and improving experiences of providing and receiving care. Nevertheless, this very focus also poses challenges for health service providers attempting to provide a ‘social model of care’ within an institutional context

Midwives’ emotion and body work in two hospital settings : personal strategies and professional projects

Much has been written in recent years of a ‘crisis’ in the recruitment and retention of midwives in the NHS. The crisis has been attributed variously to burnout, a lack of professional autonomy, a bullying culture, and an ideological conflict between the way in which midwives wish to practise and the way they are required to practise within large bureaucratic institutions, such as NHS Trusts. Negotiating these experiences requires a significant amount of emotional labour by midwives, which they may find intolerable. This thesis explores the strategies NHS midwives deploy in order to continue working in NHS maternity services when many of their colleagues are leaving. It examines the extent to which working in a midwife-led service rather than a consultant-led service helps or hinders midwives’ capacity to manage the emotional and ideological demands of their practice. Ethnographic fieldwork was carried out in a consultant unit and an Alongside Midwife-led Unit (AMU) in two NHS Trusts in England. The findings from negotiated interactive observation and in-depth unstructured interviews with eighteen midwives were analysed using inductive ethnographic principles. In order to ameliorate the emotional distress they experienced, the midwives used coping strategies to organise the people and spaces around them. These strategies of organisation and control were part of a personal and professional project which they found almost impossible to articulate because it ran contrary to the ideals of the midwifery discourse. Midwives explained these coping strategies as firstly, necessary in order to deal with institutional constraints and regulations; secondly, out of their control and thirdly, destructive and bad for midwifery. In practice it appeared that the midwives played a role in sustaining these strategies because they formed part of a wider professional project to promote their personal and professional autonomy. These coping strategies were very similar in the Consultant Unit and the Midwifery Unit. A midwife-led service provided the midwives with a space within which to nurture their philosophy of practice. This provided some significant benefits for their emotional wellbeing, but it also polarised them against the neighbouring Delivery Suite. The resulting poor relationships profoundly affected their capacity to provide a service congruent with their professional ideals. This suggests that whilst Alongside Midwife-led Units may attempt to promote a midwifery model of care and a good working environment for midwives, their proximity to consultant-led services compounds the ideological conflict the midwives experience. The strength of their philosophy may have the unintended consequence of silencing open discussion about the negative influence on women of the strategies the midwives use to compensate for ideological conflict and a lack of institutional and professional support