Childbirth Cultures Concerns and Consequences:
Creating a dynamic framework for optimal maternity care (COST Action ISO907)
Report of the STSM “An exploration of antenatal care guidelines, the development and culture of MLUs in
N. Ireland.”
DATE OF STSM: 15th April 2013 - 24th April 2013
HOST: University of Ulster, N. Ireland
Chief Investigator: Dr Maria Healy, Lecturer in Midwifery, University College Dublin
Host: Professor Marlene Sinclair
There has been a steady increase in the provision of midwife-led units (MLU) in Northern Ireland since the
first unit opened in 2001, with the most recent MLU opening on the 29th April 2013. This development has
provided a significant change in the overall landscape of maternity care services in Northern Ireland which
is strongly supported by the Department of Health, Social Services and Public Safety in their publication ‘A
strategy for maternity care in Northern Ireland 2012-2018’ (DHSSPS, 2012). Currently there are seven
midwife-led units, four which are adjacent to obstetric-led units and three which are freestanding MLUs.
This provision of midwife-led services is in stark contrast to only two MLUs in the Republic of Ireland, where
there is a population of 4.6 million in comparison to 1.8 million in N. Ireland.
Purpose of the STSM
Most care services are influenced by a culture which can permeate and affect the way people behave for
example, their beliefs or their working language. Emanating from this perspective, the aim of this STSM
was to increase understanding of the culture and the organisation of maternity care systems in N. Ireland,
in particular, the role of research, policy and practice. The main objectives included: gaining a deeper
insight into the organisation and cultural factors that impact on midwife-led care from the literature, policy
documents and from speaking to experts in the field; exploring antenatal care guidelines utilised in seven
Midwife-led units in Northern Ireland in relation to the admission and/or exclusion of women accessing
these services; identifying the rationale supporting the specific criteria adopted and to explore the context
and culture of the MLUs; learning from experienced midwives working in established MLUs how they
interpret these antenatal care guidelines in their practice and use this learning to inform other midwife-led
teams.
Description of the work carried out during the STSM
I commenced my work by officially contacting the Heads of Midwifery in four out of the five Health and
Social Care Trusts in Northern Ireland, (within the fifth Trust there is no MLUs currently operating, although
midwife-led care is practiced). Permission was sought to visit the MLUs for a guided tour and to interact
with experienced midwives providing the service. Three Heads of Midwifery permitted access while one
advised that I could visit the MLU later in the year.
In total I visited six MLUs in Northern Ireland, five
situated in an urban location and one located in a rural setting. I travelled by car, covering approximately
604Kms. I was warmly welcomed on arrival to each of the units and spent between 1.5 and 2.5 hours
conversing with the midwives, reading the policy documents and being guided around the midwife-led
units.
Description of the main results obtained
The MLUs in Northern Ireland opened in 2001, 2007, 2010 (two units open in this year), 2011, 2012 and
2013. From my research, the establishment of midwifery-led units in Northern Ireland appears to have
stemmed from a number of perspectives: in particular, individual midwife leaders who became champions
for women to improve maternity care, women’s groups lobbied for change, UK government policy and local
government policy which recently culminated in the publication of the maternity care strategy (DHSSPS,
2012).
Four of the MLUs visited were purpose-built with a contemporary, impressive design, while two were
refurbished and modernised. All of the units had comfortable furnishings and equipment to promote
normal birth including: water birth facilitates, birthing balls, floor mats, birthing stools, bean bags and
some of them had the Combitrac system which enables women to adopt natural childbirthing positions.
The number of midwives employed in each unit was predominately calculated using the measurement tool,
Birthrate Plus which analyses midwifery workforce requirements based on the needs of women (Ball and
Washbrook 1996). The policy in most of the MLUs was midwifery staff rotation into and out of the MLUs on a
periodic bases, as per the instructions from the Head of Midwifery. Midwives were also encouraged to develop
and maintain their competence in midwifery-led care.
Findings
The model of midwifery care provided, varied from unit to unit. Two of the units promoted continuity of carer,
by utilising a team midwifery approach. This involved a team of approximately eight midwives whom cared for
the women when they attended the antenatal clinic attached to the unit or local health centre, during labour
and birth and postnatally, in the MLU and on discharge home. This approach provided an excellent opportunity
for the midwives to build up a caring relationship with the woman and her family before the birth.
Fundamentally, the midwives could also assess if the woman and her foetus were low risk (i.e. fulfilling the
criteria for admission to the MLU) and thereby deemed appropriate to use the midwife-led service. In addition,
the woman and her newborn baby were cared for postnatally, at an extremely vulnerable time (Healy, 2012) by
a team of midwives who they already knew.
The other four MLUs utilised a continuity of care1 model rather than a continuity of carer model. Women using
these services are predominately risk assessed for their suitability2 to be admitted to the MLU by a midwife at
booking and at follow-up antenatal appointments; either in a health centre or hospital based antenatal clinic.
When the woman presents in labour to the maternity assessment unit of the hospital, she will be assessed again
for any potential adverse risk factors, for example a low haemoglobin. The midwives working in the maternity
assessment units thereby act as gate keepers for the midwife-led units deciding if women are eligible to enter
for their care, by following the criteria for admission. Subsequently, the midwives working on the MLU also
agree or disagree to accept the individual women into their care.
Criteria for admission into and transfer out of MLU
In general, the high risk exclusion criteria relating to maternal medical history, previous obstetrical and
current complexities in pregnancy were similar from one unit to the other. Other admission and transfer
criteria nevertheless, were not clearly defined and differed in each MLU. In particular, women could be
admitted following induction of labour for post maturity, with one vaginal pessary while other units
excluded these women from their care. Some women were admitted, at full term and in labour with light
meconium while other MLUs either didn’t admit them or transferred them to the obstetric-led unit.
Women who were over the age of 40 on booking were excluded in most units while others were lenient
and allowed them admission. This variation in eligibility was mirrored in one MLU in relation to accepting a
mobile women with a raised BMI >35 and <40. Two MLUs also accepted women with asymptomatic Group
B Streptococcus and administered intravenous antibiotics in labour, while the other units refused these
women admission.
The annual number of women cared for in each of the MLUs in N. Ireland also varied, although it was
apparent that a number of factors may influence this data, including: the length of time the unit was
opened and established within the general community, the referral personnel and process, the location of
the service and from consultation with senior midwives the actual criteria employed on admission. This
was evident in one unit which reported a decrease in their numbers, as some women were excluded from
the service because of a change in the admission and transfer criteria. Saunders et al (2000) in an
evaluation of the Edgewater Birth centre also found that using eligibility criteria as a screening tool is not
always accurate, as it rules out many women who go on to have a normal birth and at the same time may
1
2
Continuity of care refers to a similar pathway of care used in each unit to promote normal birth.
Women are deemed suitable for midwife-led care when they are deemed low risk from factors which may adversely affect their
pregnancy outcome.
include women who need their care transferred to a consultant-led unit. In reality, some women
inadvertently entered the MLUs who were outside the criteria, this left midwives feeling challenged and at
times scrutinised for their decision which had an obvious impact on their subsequent midwifery practice.
The development and re-drafting of criteria for a MLU is processed through formal channels in each Health
and Social Care Trust. This involves approval from obstetric consultant colleagues. From my discussions
with the staff the majority of the midwives described their working relationship with the consultant
obstetricians as very supportive and felt they were ‘on an equal footing’ to themselves. Midwives in other
units unfortunately reported that they had a structured working relationship with their obstetric colleagues
which at times manifested in hierarchical discourse.
Conclusion of Findings
This STSM uncovered a number of interesting findings including, the historical development of the MLUs in
Northern, MLUs which provided an extremely conducive and competent environment for women to labour
and give birth and a variation in the criteria for admission into, and transfer from. The variation in criteria
may have been influenced by a number of factors depended on the status of the unit, whether adjacent to,
or freestanding; the length of time the unit was opened; the competence and experience of the midwives,
the midwifery management leadership and support and ultimately the working relationships between the
midwives and the obstetricians. The numbers of women who received care in the MLUs has increased
which undoubtedly has significant socio-economic impact (Devane et al., 2010) for the women and their
families and public expenditure. Criteria is essential in the day to day running of a MLU, however as new
knowledge is developed criteria needs to be re-assessed and updated so that women are not excluded
from care in a midwife-led unit or inadvertently included as safety is paramount.
Future collaboration with host institute
Further research is planned to develop the findings of this STSM to provide more guidance for Midwife-led
units in the future.
Future publication
A publication relating to the historical development of MLUs in N. Ireland is planned and will be drafted and
forwarded for publication over the next academic year
Funding will be sought to attend the COST Action conference in 2014 and present the findings of this STSM
Confirmation by the host institute of the successful execution of the STSM
Professor Marlene Sinclair
Maternal, Fetal and Infant Research Centre
Institute of Nursing and Health Research
University of Ulster
Jordanstown
Newtownabbey
BT370QB
28th May 2013
Re: STSM candidate Dr Maria Healy
I wish to confirm that Dr Healy achieved all of the objectives set out in her STSM application. Furthermore,
the work was undertaken with great sensitivity and immense professionalism.
I can also confirm that we have planned a publication to describe the historical process of midwife led care
in Northern Ireland and discussed further collaboration to secure additional funding to progress the
research. These outputs will contribute to the portfolio of organizational outcomes for WG1.
Dr Healy’s paperwork demonstrates the variation in midwife-led practice within a small but clearly defined,
geographical area and the politics of changing cultural practices. The organization of maternity services is
inevitably enmeshed in policy, politics and financial limitations.
In conclusion, it was a pleasure to have the opportunity to facilitate Dr Healy in achieving her STSM
objectives.
Kindest regards
Professor Marlene Sinclair 28th May 2013
References
Ball, J.A. and Washbrook, M. (2007 updated May 2009) Ratios for Midwifery Workforce Planning at
National, SHA and Local Level www.birthrateplus.co.uk
Devane D, Brennan M, Begley C, Clarke M, Walsh D, Sandall J, Ryan P, Revill P, Normand C. (2010) A
systematic review, meta-analysis, meta-synthesis and economic analysis of midwife-led models of care.
Royal College of Midwives: London.
Healy, I.M. (2012) Rethinking postnatal care: A Heideggerian Hermeneutic study of postnatal care in Ireland,
Unpublished PhD thesis. University of Central Lancashire
National Institute for Health and Clinical Excellence (2007) Intrapartum care: Care of healthy women and
their babies during childbirth Care Guideline No. 55. www.nice.org.uk
Saunders et al (2000) Evaluation of the Edgware Birth Centre. London: North Thames Perinatal Public
Health.