This theme represented the stakeholders’ aim to provide women with the best care for each person, centred on their choices and preferences throughout their maternity journey. The ways in which they achieved this aim was represented by their ability to recognise the successful areas of their work where their vision of the person centred care they provided aligned with safe and effective care. The Seaview team did however find the pressure of a
perception of constant surveillance from their managers difficult to accept as a positive influence on the care that they provided. The Seaview team were undergoing a process of change and recognised the need to develop new skills to develop their competencies in areas that improved the women’s
experiences of maternity care within their own communities. This emphasis on care nearer to home had implications for the sustainability of Seaview within the wider provision of maternity care and refocused the Seaview team’s aspirations to improve the service they provided to women.
Focus on Women and Their Choices
All the stakeholder participants discussed the choices women made around where to give birth. Some felt that opinions on the suitability of Seaview as a place to give birth were polarised and women were either very wary of the OU, or very keen to be at the OU in case of emergencies occurring. The options of home birth were rarely mentioned by the midwives during the observation of clinical encounters, but featured in the midwifery manager’s considerations. The obstetrician presented the alongside midwife led unit at the OU as an
acceptable option for women who wanted to give birth in a midwife led unit but were at risk of experiencing complications during labour.
Awareness of the dynamic nature of risk assessment and the ability to change care pathways during pregnancy was indicated by the midwives, but the accommodation of requests by women to give birth at Seaview when they were not anticipating a normal care pathway seemed to be less well received. The process of referring women who made unusual requests described by the midwives appeared to bypass the team leader, despite her clinical leadership role, and move directly to the consultant midwife or obstetrician for an
individual plan to be made for the birth.
The midwives felt that they used a flexible approach to accommodating
women’s particular requests for maternity care, but possibly due to an adverse event to which they all alluded, any requests for unusual care in labour were met with grave concerns.
“I had one woman who put her hand over my hand and said you’re not calling (OU), I’m not going and you’re not going to write that in my notes. I got into trouble with that and I learnt my lesson to hell with that and now if the women come in, then they sit here until I document in the notes, so if I see them for ten minutes and it takes me half an hour to write it, then they’re waiting for half an hour. I’ve got more firm and strict about that because I have to protect myself, before I trust the women.” (Midwife 8, Interview).
The language used when describing women’s choices proved to be revealing. The Team Leader referred to a particular group of women who accessed Seaview to give birth when an OU birth had been planned as “monkeys” as she felt that they were putting her staff “at risk”. Another midwife described caring for women who were not clinically eligible but chose to access labour and birth care with the Seaview midwives.
“It can make you nervous if it goes to the stage where we actually have to provide the care.” (Midwife 4, Interview).
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This nervousness perhaps indicated a lack of clinical leadership and
support when women’s choices required a collaborative approach with the OU team and supervisiors of midwives.
Recognition of Success and Constant Monitoring
The midwifery managers and the obstetrician all identified successful areas of the Seaview team’s work. The team was described as very enthusiastic,
embracing of new ideas and open to new ways of working. A recent maternity services review had reaffirmed Seaview’s place within the NHS board provision for maternity services with future plans to expand the services offered to offer local care to more women experiencing some pregnancy complications,
indicating confidence at a strategic level in the model of care delivered at Seaview.
Recognition of the success of the Seaview team was given by the OU staff through feedback from the care of women who been transferred from Seaview to the OU. Where feedback was given from the OU team to individual
midwives, it was deeply appreciated. The Team Leader’s role in feedback was seen to be passing it on from other sources, at team meetings or on an individual basis.
“Yes, that really is appreciated, it is nice to know sometimes that you’ve done it right as most of the time we are doing it right, but you do get incidents.” (Midwife 7, Interview).
The risk management team at the OU encouraged the midwives to recognise their successes, but also contributed to them feeling under a spotlight.
“When risk management audits our notes, there’s not usually much to complain about, but we get picked up on very quickly when we do things wrong, trust me.” (Midwife 7, Interview).
The manager’s views on the spotlight shone on Seaview differed in how representative they considered the incidents were of the general standard of the safety of the care provided.
“When incidents happen in a CMU, because they’re midwife led and low risk, they can take on a level that is out of proportion to something that can happen in a tertiary unit that can be very similar.” (Manager 2, Interview).
“When you look at that in comparison with the very small number of births that they (CMUs) have, you have to think that’s significant.” (Manager 1, Interview).
Records were kept by one of the midwives at Seaview of monthly figures about the births at the CMU, transfers and the reasons for these but not the outcomes, and the number of unplanned visits. They were available for the staff to consult, but the records are kept in raw data form, so descriptive conclusions were not drawn for the staff to see the trends in the data. The staff made varying guesses at Seaview’s rate of the transfer of women in labour, and all referred back to the book where the information was gathered but were unable to draw on any analysis of that information.
The perception of increased scrutiny caused frustration amongst some of the midwives allowing it to define their practice as more defensive in their
approach to transferring women to obstetrician led care.
“Hopefully we are transferring them in plenty of time so it doesn’t become a problem” (Midwife 3, Focus Group).
Some of the midwives turned this spotlight into a positive.
“If anything we have to think faster because we haven’t got a buzzer, we have to rely on our own intuition, and training and guidelines [….] you are the one who is in charge of her care so it is your decision, make your own decision.” (Midwife 5, Interview).
This midwife used the perceived scrutiny as a way of enhancing the team’s decision-making, confidence and use of the unit’s guidelines.
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Developing and Sharing Knowledge and Skills.
The need to develop the knowledge and skills of the staff at Seaview has been recognised by the team and their managers. Plans have been made to
enhance Seaview’s sustainability by developing and extending the local maternity services provided there. The linked obstetrician has clearly noticed improvements in the way that the skills of the midwives in antenatal risk assessment and appropriate referral have developed.
“I think they’ve got much better at intervening at the right time and picking up the risks […] I used to get a lot of referrals saying is she OK to deliver here, but they make that decision themselves now a lot of the time. They now know the protocols they work with and I think these have helped.” (Obstetrician, Interview).
The sustainability of Seaview was at the time of the research predicted to be improving, as the understanding from the service review was that whilst birth numbers were important, local access to most maternity services for most women was also of great importance.
“All that sort of stuff you can do out there that prevents women coming in to a tertiary unit makes a huge difference, that also makes a huge
difference to the tertiary unit (OU) because it is bursting at the seams and we’re fully well aware of that but until we can push some of that back out very appropriately, back into the community, then we’re not going to be able to make the changes in the tertiary centre.” (Manager 2, Interview). The staff at Seaview were aware that if they were to be more accessible to all women and provide the day assessment and services that they understood had been proposed, changes in their networks of governance and
communication would have to be made. These changes primarily involved a closer relationship with the wider maternity care team. The team leader had reservations about how these changes would happen and the support she would be given.
“I’m not sure how they are going to work that out. That is a plan that they have and I welcome that but we need…there isn’t enough staff to deal with
that at the moment although my manager thinks there is. I just don’t think so…I don’t know what they’re going to do, how are they going to achieve that? It’s a terrific unit, it works well, the patients like it and I am proud of it.” (Midwife 6, Interview).
The midwives also noticed an issue around support for access to training, but attributed that to its limited availability in the local area.
“Even certain training things as well, there are a lot more dates and a lot more things that midwives will get regular access to being in the busy hospital, […] whereas being more isolated you would think that it would be more of a priority to make sure our skills are up to date.” (Midwife 1 Focus Group).
One midwife identified opportunities to share the contextually appropriate skills with OU staff when developing an emergency ‘skills and drills’ course, to share the transferable skills that the midwives used when there was no
emergency buzzer to pull for help to arrive immediately.