Tensions and barriers in improving maternity care : the story of a birth centre

136 Pages·2018·6.94 MB·English

by  Deery, Ruth, Hughes, Deborah, Kirkham, Mavis, Kitzinger, Sheila

Tensions and Barriers in
Improving Maternity Care

Tensions and
Barriers in Improving
Maternity Care
THE STORY OF A BIRTH CENTRE
RUTH DEERY
Reader in Midwifery
Centre for Health & Social Care Research
The University of Huddersfi eld
DEBORAH HUGHES
Community Midwifery Team Leader
Bradford Teaching Hospitals NHS Foundation Trust
and
MAVIS KIRKHAM
Emeritus Professor of Midwifery
Sheffi eld Hallam University
Foreword by
SHEILA KITZINGER
Radcliffe Publishing
Oxford • New York
Radcliffe Publishing Ltd
18 Marcham Road
Abingdon
Oxon OX14 1AA
United Kingdom
www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.
© 2010 Ruth Deery, Deborah Hughes and Mavis Kirkham
Ruth Deery, Deborah Hughes and Mavis Kirkham have asserted their right under the
Copyright, Designs and Patents Act 1998 to be identifi ed as the authors of this work.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission of the copyright owner.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
ISBN-13: 978 184619 425 2
The paper used for the text pages of this book
is FSC certifi ed. FSC (The Forest Stewardship
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Typeset by Pindar NZ, Auckland, New Zealand
Printed and bound by TJI Digital, Padstow, Cornwall, UK
Contents
Foreword viii
Preface ix
About the authors xi
Authors’ note xiii
1 BIRTH CENTRES 1
Background to the study 1
Background and context 3
References 6
2 THE RESEARCH STORY 10
Aims of the research 11
Anonymisation of the research site 11
Negotiating ethical hoops 12
Methodology 13
References 14
3 THE STORY OF THE BIRTH CENTRE 15
The early days 15
Recruiting the midwives 16
Widening cracks 17
The road to closure 18
Birth Centre fi gures 19
References 22
4 THE DREAM JOB: NICHE PRACTICE IN MIDWIFERY 23
Autonomy and freedom 24
Shared philosophies 25
The dream job: niche practice 26
Niche practice versus the organisation 29
References 34
5 OPPOSITION TO THE BIRTH CENTRE 36
Alliance of the unwilling 36
Midwifery opposition 38
General practitioner opposition 41
Obstetric consultant opposition 44
Managerial opposition 46
The role of midwifery managers 47
Professional dissonance in midwifery management 50
References 53
6 THE EXPERIENCE OF THE BIRTH CENTRE MIDWIVES 55
Working in a fragile service 55
Recruiting from ‘outside’ 56
Isolation and frustration: pain and powerlessness at work 57
Battle by attrition: the operationalisation of non-support 62
References 64
7 SPIRALLING DOWNWARDS: INTERVENTIONS
IN THE BIRTH CENTRE 66
Integrating the Birth Centre 66
Staffi ng by community midwives: working in an alien culture 68
Staffi ng by community midwives: overload, fragmentation
and burnout 72
Closure by stealth: reducing continuity of care 76
Closure by stealth: the loss of the 24-hour service 77
Closure by stealth: the curtailment of postnatal care 79
Closure by stealth: falling birth numbers 80
References 82
8 THE WRITING ON THE WALL 84
Doomed from the outset? 84
A political and fi nancial exercise? 86
The impact of constant change of senior managers 88
The political impediments to closure: pawns in a game 90
‘A luxury we can’t afford’: the fi nancing and under-fi nancing
of the Birth Centre 93
References 96
9 THE BIRTH CENTRE: IDEALS, MODELS AND TENSIONS 97
The ideal service: the midwives’ vision 97
Why birth centres? 99
A social model for maternity care 101
Place and territory 102
The social role of the birth centre 103
Uniforms: a symbol of the tensions relating to the Birth Centre 105
Power, authority and management 107
References 110
10 CONCLUSION 112
Recommendations 114
References 115
Index 117
Foreword
Here is a remarkably detailed analysis of the politics of a birth centre trapped
in a medicalised system that threatened and rapidly destroyed it. It is a vivid
example of how autonomous midwifery is undermined by an organisa-
tional structure in which management focuses exclusively on one model
of care, namely midwifery training in obstetric emergencies and rescuing
women from their inherently defective bodies, rather than safeguarding
normal birth.
It tells of how midwives were pitted against each other, the failure to
stimulate widespread support from the local community, and the use of
already overworked community midwives to staff the birth centre. The
centre restricted its opening hours to daytime only, and put severe limits
on the time mothers and babies could stay there postpartum. It was not the
birth centre that failed, but an authoritarian and bureaucratic hospital-based
maternity system that was insensitive both to women’s experiences there and
to midwives’ values and relationships.
This is an object lesson in how not to do it.
Sheila Kitzinger
April 2010
Sheila Kitzinger is a social anthropologist of birth, and her 24 books on
pregnancy, childbirth and midwifery have been published around the world.
viii
Preface
We have written this book because the story that it tells warrants a wide
audience. The data that we collected from the midwives and others whom
we interviewed were both more moving and more depressing than we had
expected when we set out to inquire into why this birth centre had not
been a success. To condense the narrative into the strictures of one or two
academic papers would have meant that the full story would lose its place
in the bigger world of maternity care. We also wrote this book because we
know that there are many birth centres being established, and that both the
literature and conferences tend to present the ‘success stories’ rather than
the fuller picture, from which many equally valuable lessons can be learned.
However, this book is not just about one particular birth centre. Many of
the issues and behaviours that we present here are echoed in other maternity
services and midwifery experiences, and are replicated in situations where
no birth centre exists. The maternity services and the experiences of all too
many midwives working in them share many of the elements described here.
Lack of leadership, support, vision and plain dealing is widespread, and
as a result many midwives are thwarted from practising midwifery as they
would wish. As a result, women are prevented from having the choices and
services that they are entitled to expect from the National Health Service.
We know that these problems are not unique to the UK. Our conversations
with midwives from many countries highlight the fact that this is a very
widespread problem, and demonstrate the tensions between bureaucracy
and woman-centred care.
We see the purpose of this book as informing discussion and decision
making around reconfi gurations of maternity care, so that planning, com-
munication, management and recruitment can be improved, and shared
vision can be articulated and understood. It demonstrates the dangers of
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