Modelos de Elaboración de Conceptos

So far, the majority of the findings have focused upon the midwives’ relationships with the women. However, the women’s birthing decisions and the midwives’ context of practice do not exist within silos. Maternity care in the NHS includes midwifery, obstetrics, paediatrics anaesthetists, primary care, maternity care assistants, and doulas. Some of the midwives reported negotiation strategies with the wider team. For some, negotiation with the wider multi-disciplinary team (MDT) was viewed positively and was a source of seeking specialist support and help. Conversely, other midwives appeared to position themselves as a mediator between the women and medical staff. These midwives reported a proactive stance of advocacy to facilitate women’s alternative birthing decisions. These issues are discussed in the subthemes ‘negotiating with the wider team’ and ‘balancing tensions’.

Negotiating with the wider team

In a number of circumstances, the midwives reported the involvement of the wider MDT such as the obstetric, paediatric or GP clinicians. In some situations, this was related to seeking permission to discharge women from consultant care back to midwifery-led care. For some midwives, they reported a straightforward procedure where the obstetric consultant worked alongside the midwives in a ‘flexible’ manner to support the women’s decisions:

‘…The consultants that we have working alongside us to tend to be fairly flexible as well and if a woman doesn't want something (..) that’s outside of the thing (.) they do tend to be fairly good at signing them back over to midwifery led. And we'll just write you know, 'understands that the risks are X, Y, Z and is happy to accept these risks' (..)’ [Claire (I):

49-49]

Other midwives perceived that ease or difficulty negotiating midwifery-led care with the MDT was dependent on the individual team member. Some obstetric doctors were viewed as more ‘supportive’ of women’s alternative decision-making than others. This is highlighted by Ginny below:

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‘… the Reg[istrar] she had the first conversation with was supportive… but this particular Reg I literally breathed a big sigh of relief, I never said to her that it was a

game changer…’ [Ginny (I): 10-10]

In other situations, midwives sought specialist support and advice from the medical teams due to the nature of the women’s health conditions such as ‘epilepsy’, ‘cardiac conditions’, ‘diabetes’. Recognising the limitations of their expertise, some of the midwives reported collaborative working to ensure the safe planning and care of the women. In other situations, the women’s health status could potentially cause health complications in the baby following birth i.e. ‘GBS+32_{’, ‘blood-borne virus’,}

‘medications’. In these circumstances, the midwife liaised with appropriate medical staff to coordinate a complex care plan that included expertise from all relevant professionals.

In one situation, Tracey cared for a woman wanting a homebirth but had GBS+. This is a potentially life-threatening situation for the baby, and intravenous antibiotics given within a hospital environment are normally recommended33_{. Tracey reported}

extensive collaboration with the MDT, including the GP and neonatologists, to explore a number of options that met the woman’s decision to homebirth. Whilst legally the woman could have declined any antibiotics, she was reported to accept an alternative solution of taking oral antibiotics prescribed by the GP. The care plan also included postnatal considerations to ensure the wellbeing of the baby:

‘so (.) what we did was, then (..) talk to the consultant uhm, (.) talk to the manager, talk to the uhm, the neonatal doctors and the GP and agreed that she could have a homebirth if she started oral penicillin a week before she was due (.) if she hadn't delivered. We had explored coming in to delivery suite and having her IV's and going home, we explored giving her IV's at home, and then the neonatal doctor said actually, uhm, if she was willing to do the baby's temperature and was aware and watch for signs

for infection then she could have a homebirth…’ [Tracey (I): 7-7] In another more complex situation, Kerry reported the extensive collaboration between herself, obstetricians, neonatologists and specialist doctors to support a woman with a blood born virus requesting a homebirth. In this circumstance, Kerry

32 _{Group B Strep explained in the glossary.}

33 _{However, the evidence on the efficacy of intrapartum antibiotics balanced with potential harms is}

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emphasised the value of working alongside the MDT, recognising both her areas of expertise and her limitations. She described:

‘Uhm (..) I think it is always the same thing, just the communication being really honest (.) and listening to them as well and making sure, cos (.) I'm not an expert in the follow-

up care … (.) but reassuring them that I am an expert in normal birth, our homebirth rate was 35% so I was very confident that if things weren't going to happen we would

transfer in (..) and definitely listening to them, and knowing I wasn't that expert because although we were happy to support her but there may have been specialist genuine reasons why we'd have to think of alternatives and stuff.’ [Kerry (I): 28-28] James raised concerns that medical consultants may be inclined to step back from women who opt outside of guidelines. To mitigate this, he reported continued engagement activities with the doctors:

‘I think there is a little bit of risk sometimes that when the women come in to the clinic and say no, they [consultants] do step back and say 'well, you're under the professional midwifery advocate (PMA) now' but we do do a lot of communication and engagement with them and say 'actually we appreciate they are choosing this care pathway and we have put a plan in place for them, but actually we still value your opinion and we still

need that input to ensure we are providing safe care' (.)… ’[James (I) : 23-25]

Balancing tensions

Conversely, other participants reported that negotiating with the wider MDT was problematic. Some midwives reported that other members of staff (supervisors, managers, and medics) raised concerns regarding ‘accountability’ and ‘responsibility’ should an adverse outcome occur [Margot, Catherine, Susan, Ginny, Kelly]. For example, Kelly reported a negative response by the supervisor of midwives who had been called to write a care plan for a woman having a homebirth, but who had multiple obstetric complicating factors. The supervisor was reported to be anxious, inferring she would be held responsible if anything went ‘wrong’ during the birth. In these circumstances, some sought to provide ‘reassurance’ to staff members to alleviate their concerns as a means to continue facilitating women’s alternative birthing decisions. This was highlighted by Margot who had been supporting a woman who had experienced ruptured membranes (SROM) at term with no labour. The woman had declined a recommended course of antibiotics and augmentation of

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her labour, making the decision to ‘await events34_{’ to continue her homebirth plans.}

Here, Margot is mutually supportive of the woman and the doctor who had voiced concerns regarding accountability:

‘…the doctor was worried that it would be her fault (.) if something happened with the baby (.) and couldn't understand why the woman wouldn't accept it and it would come

back on her, so I tried to explain to her this was the woman's choice and as long as we had documented the conversation we'd had and that she (.) had explained to her the pros and cons of both, it was up to her, the responsibility was with the woman, it wasn't

with the doctor, she couldn't force, she'd done her best and any court in the land could see that (.) so I think she felt reassured by that, it wasn't on her (.) uhm it wasn’t' going

to come back on her (.)…’ [Margot (I): 60-60]

In other circumstances, the midwife participants reported that dealing with concerned managers was more stressful than caring for the woman, for example:

‘…I didn't want her to hear everyone phoning and asking for updates, every half an hour 'what's going on?' (..) so that was more stressful than just looking after her, if I'd been

left alone to look after her that would have been fine, it was more the stress of people going 'why isn't she in? why isn't she in? when would she have been induced?... [Alice

(I): 17-17]

In some situations, the midwife participants experienced direct confrontations with medical colleagues who disagreed with either the woman’s decision-making or the midwife supporting her. On occasion, this was reported to lead to ‘arguments’ [Seana] or reports of comments that suggested the midwives were putting women in danger. For example, Beatrice described the conflict she encountered when she advised a doctor that she was looking after a woman with gestational diabetes in the birthing pool:

‘… this time [when handing over the woman’s information to the medical consultant] I got a look like I was something on the bottom of his shoe (.) and practically saying I

was leading her down the path to obstetric disaster (.) and you and I know that obstetric disaster is more often iatrogenic then not (.) and uhm he said 'when she is pushing her luck in the second stage' and I thought 'she'll just be pushing sweetie' (.)

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and of course this exchange is taking place in front of at least another four people with the door of the office open…’ [Beatrice (I): 21-22]

For Alex, she was enabled to support a woman’s alternative choice, only if she was on call for the woman. She reported that her manager considered it unacceptable for other midwives to provide intrapartum care for the woman:

‘…I have had a discussion with my manager and she kind of bluntly said 'if you'd like this lady to birth on the birth centre you need to come in and deliver her'…’ [Alex (I): 20-20] As a pre-emptive measure, some midwives reported accompanying women to their consultant or maternity assessment (scans/antenatal checks with perceived problems like postmaturity) appointments. In some situations, the women had made the request, in others midwives offered it as part of routine care. In either circumstance, accompanying women appeared to serve as a method of support, advocacy and where necessary an opportunity to directly challenge medical opinion. For example, Jess adopted a challenging approach when faced with a consultant she felt was likely to be less supportive of the woman’s decision to decline a recommended induction of labour:

‘…when we asked about the options she [consultant] was saying 'this is the option, being induced in the option' (.)…I was able to challenge (.) a consultant or just be quite firm and say 'what are the options? She is not keen to do that, what are the options? Can we

try this? Can try that? Can we leave it until 41 weeks? Or yep we make an appointment with the consultant midwife and make a plan with her'…’ [Jess (I): 32-32] In other situations, a few midwives reported preparing women for their obstetric appointments. These midwives described adopting a diplomatic approach to subtly forewarn women of what the medical team might say. The midwives appeared to be careful to not undermine their medical colleagues but set up cues of what the discussions with the medics would entail as a way of preparing them. For example:

‘…with this lady I did warn her really that actually the obstetricians might have a different view, she was happy to go see them and uhm but your kind of feel that you

have to prepare them for that as well as the actual (..) discussing all the risks and benefits and things cos otherwise they go to their consultant appointment and they're just completely and utterly (..) knocked back aren't they? ...’ [Catherine (N & I): 14-14]

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