Social Service Professional or Market Expert? Maternity Care Relations under Neoliberal Healthcare Reform

Recent developments in the organization and practice of healthcare, driven by the introduction of (quasi-) markets and privatization, are altering traditional forms of professionalism found in high- and middle-income countries. Yet there remains debate about whether these neoliberal trends are universal or country specific, and whether they have any effect (positive or negative) on health service delivery. This article develops a comparative analysis that focuses on changes in maternity service systems in four countries in Northern Europe and the Americas with primarily publicly financed healthcare systems: the UK, Finland, Chile and Canada. The article begins with a discussion of the continuum of professional forms found in the post-Second World War period and their relationship to different kinds of welfare e states. It then focuses on the impact of recent neoliberal reforms on the ideological projects of the medical and allied health professions in the four case examples. The results show that variation across time and place is mainly the result of structural/ economic factors and that various forms of professional discourses are the result of the public/private ways that healthcare systems are organized. The article concludes with suggestions for further comparative sociological research

Key influences on the initiation and implementation of inclusive preschool programs

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The efficient use of the maternity workforce and the implications for safety and quality in maternity care : a population-based, cross-sectional study

Background: The performance of maternity services is seen as a touchstone of whether or not we are delivering high-quality NHS care. Staffing has been identified in numerous reports as being a critical component of safe, effective, user-centred care. There is little evidence regarding the impact of maternity workforce staffing and skill mix on the safety, quality and cost of maternity care in the UK. Objectives: To understand the relationship between organisational factors, maternity workforce staffing and skill mix, cost and indicators of safe and high-quality care. Design and methods: Data included Hospital Episode Statistics (HES) from 143 NHS trusts in England in 2010–11 (656,969 delivery records), NHS Workforce Statistics, England, 2010–11, Care Quality Commission Maternity Survey of women’s experiences 2010 and NHS reference costs 2010/11. Ten indicators were derived from HES data. They included healthy mother and healthy baby outcomes and mode of birth. Adjustments were made for background characteristics and clinical risk. Data were analysed to examine the influence of organisational factors, staffing and costs using multilevel logistic regression models. A production function analysis examined the relationship between staffing, skill mix and output. Results: Outcomes were largely determined by women’s level of clinical risk [based on National Institute for Health and Care Excellence (NICE) guidance], parity and age. The effects of trust size and trust university status were small. Larger trust size reduced the chance of a healthy mother outcome and also reduced the likelihood of a healthy mother/healthy baby dyad outcome, and increased the chances of other childbirth interventions. Increased investment in staff did not necessarily have an effect on the outcome and experience measures chosen, although there was a higher rate of intact perineum and also of delivery with bodily integrity in trusts with greater levels of midwifery staffing. An analysis of the multiplicative effects of parity and clinical risk with the staffing variables was more revealing. Increasing the number of doctors had the greatest impact on outcomes in higher-risk women and increasing the number of midwives had the greatest impact on outcomes in lower-risk women. Although increased numbers of support workers impacted on reducing childbirth interventions in lower-risk women, they also had a negative impact on the healthy mother/healthy baby dyad outcomes in all women. In terms of maximising the capacity of a trust to deliver babies, midwives and support workers were found to be substitutes for each other, as were consultants and other doctors. However, any substitution between staff groups could impact on the quality of care given. Economically speaking, midwives are best used in combination with consultants and other doctors. Conclusions: Staffing levels have positive and negative effects on some outcomes, and deployment of doctors and midwives where they have most beneficial impact is important. Managers may wish to exercise caution in increasing the number of support workers who care for higher-risk women. There also appear to be limited opportunities for role substitution. Future work: Wide variations in outcomes remain after adjustment for sociodemographic and clinical risk, and organisational factors. Further research is required on what may be influencing unexplained variation such as organisational climate and culture, use of NICE guidelines in practice, variation of models of care within trusts and women’s choices. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Sustainability and resilience in midwifery: A discussion paper

Background midwifery workforce issues are of international concern. Sustainable midwifery practice, and how resilience is a required quality for midwives, have begun to be researched. How these concepts are helpful to midwifery continues to be debated. It is important that such debates are framed so they can be empowering for midwives. Care is required not to conceptually label matters concerning the midwifery workforce without judicious scrutiny and diligence. Aim the aim of this discussion paper is to explore the concepts of sustainability and resilience now being suggested in midwifery workforce literature. Whether sustainability and resilience are concepts useful in midwifery workforce development is questioned. Method using published primary midwifery research from United Kingdom and New Zealand the concepts of sustainability and resilience are compared, contrasted and explored. Findings there are obvious differences in models of midwifery care in the United Kingdom and New Zealand. Despite these differences, the concepts of resilience and sustainability emerge as overlapping themes from the respective studies’ findings. Comparison between studies provides evidence of what is crucial in sustaining healthy resilient midwifery practice. Four common themes have been identified that traverse the different models of care; Self-determination, ability to self-care, cultivation of relationships both professionally and with women/families, and a passion, joy and love for midwifery. Conclusions the impact that midwifery models of care may have on sustainable practice and nurturing healthy resilient behaviors remains uncertain. The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives ‘to toughen up’ in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife. The findings invite further examination of contextual influences that affect the wellbeing of midwives across different models of care

Too few staff, too many patients: A qualitative study of the impact on obstetric care providers and on quality of care in Malawi

Background: Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi's efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers' perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi's women. Methods: A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants' experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software. Results: Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care. Conclusion: This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi

The effects of a parent-implemented intervention on social-communicative behaviors of prelinguistic handicapped infants

Thesis (Ph. D.)--University of Washington, 1986Effective interactions between parents and infants are essential for infant development. Social interactions between parents and infants provide the basis for language, cognitive, and social development. When the infant is handicapped, effective interactions may be jeopardized, and the development of social-communicative behaviors is delayed.The purpose of this study was to examine the effects of a parent-implemented intervention on the social-communicative behaviors of prelinguistic handicapped infants. An additional purpose was to examine the effects of the training procedure on the parent's use of the intervention as measured in weekly classroom observation sessions.In a multiple-baseline design, six parent-infant dyads were first observed in a baseline free-play situation. These observation sessions, which were videotaped, continued throughout the study.During intervention, parents met weekly with a parent trainer. The parent was given an information packet which included the infant's target behavior, descriptions of suggested activities, and a description of the turn-taking intervention. The turn-taking intervention consisted of 3 strategies: Follow the child's lead, establish turn-taking, and elaborate. The weekly parent training sessions included a review of the strategies, viewing of videotapes, modeling, and feedback from the parent trainer.Measurement of intervention effects was assessed on multiple levels. Infant behaviors measured were social-communicative behaviors, initiations of topics, and percentage of turns. Parent behaviors measured were imitations of infant, percentage of turns, responsivity and use of turnabouts. A maintenance probe was conducted.During the intervention phase, four infants increased their use of social-communicative behaviors. A fifth infant, who previously demonstrated productive use of social-communicative behaviors demonstrated increases in her use of a more sophisticated type of turn (turnabouts). The results did not show an overall increase in the initiation of topics by the infants, however infants became more active partners in the interaction as indicated by increased percentage of turns.Five of six parents increased their use of imitation. Changes in parental responsivity were observed. Two parents demonstrated increased use of turnabouts. The intervention was effective in enhancing more equally balanced dyadic interactions. The percentage of turns taken by parents decreased. Implications for teaching and future research are discussed