Simulación

This section provides specific contextual information regarding the participants working context and relationship with the women. As highlighted in Chapter 5 (section 5.4), the participant's big story provided the most detail regarding the processes of facilitation which also included the immediate context of the midwives. The subsequent stories that were generated in latter parts of the interviews included different working contexts, job roles and/or different relationship contexts with the women. Therefore, for clarity, this section relates contextual information with regards to the participants’ initial story/account that directly informs the findings in Chapter 7.

Working context

This section reports the participants’ working context. The ways in which midwives’ work can directly impact the type of relationship they have with women. This includes, for example, whether they provided a fragmented model of care, or were able to provide a caseload model. Whilst meaningful relationships can and do occur in fragmented care models, the evidence outlined in Chapter 2 (section 2.3) strongly demonstrates increased benefits for women who received caseloading care/continuity of care. Figure 12 presents an overview of the different ways in which the midwives worked. Nine worked within a traditional community model, only in the community setting (antenatal, homebirth and postnatal care). Continuity across the childbirth continuum could not be assured where the number and type of on calls for

homebirth, were normally shared amongst large teams of community midwives. This reduced the opportunities for midwives to know the woman they attended during a homebirth and was a potentially fragmented model of care. The exception to this related to three participants who worked within a traditional community setting but did offer ‘informal’ caseloading to women under their care. This generally related to being on call for specific women and/or seeking permission from management to do so, thereby, increasing the chance of offering a full continuity model of care. A further nine midwives worked within a defined caseload model of care, but mostly related to women seeking homebirths (as opposed to other potential models of caseloading women across all birth settings). These nine midwives had defined caseloads of self- selecting women and were able to offer full continuity with some exceptions, such as annual leave.

133

Three midwives worked within an integrated community model which involved working in the community providing antenatal, intrapartum (homebirth or birth centre) and postnatal care. Generally, the integrated model increases the chance of continuity of care but it was unclear as to the extent to which this was achieved. Three midwives worked in a birth centre primarily to provide intrapartum care, thus, largely working in a fragmented model.

Seven midwives were based solely in the hospital providing intrapartum care, thus, largely working within a fragmented model. The remaining 10 midwives, who were either in specialist or senior or management roles, worked across the different settings and were mostly involved in the care planning aspects of women’s decision- making (discussed further below).

Figure 12 Participant working context

Traditional community: Tracey, Zoe, Becky, Katie, Kate, Kim, Alice, Edna, Amy

Traditional community +informal caseloading: Sam, Kelly, Stella

Community caseloading: Laura, Delilah, Anna, Caz, Ginny, Maria, Jess, Kerry ,

Rose

Integrated community & birth centre: Alex, Jane, Claire

Birth centre: Leanne, Susan, Meg, Lucy

Hospital: Seana, Jayne, Clara, Brigid, Georgina, Beatrice, Margot

Specialist/senior – working across all areas: Rachel, Jenny, Emily, Isabel, Catherine,

134

Mother-midwife relationship in the main story

Connected to and in relation to the participants working context is the nature of the relationship they had with the women. As previously stated, particular models of care offer more or less likelihood of the woman knowing their caregiver. Here, I present the context of the mother-midwife relationship as reported in the participant’s initial stories (see Figure 13).

Eighteen participants provided full continuity of care across the childbirth

continuum. As such, these participants were involved in both the woman’s antenatal decision-making and her intrapartum care. Three midwives provided continuity of antenatal care, but they were not present at the birth due to either not being on call at the time the woman went into labour, or due to the woman’s change of mind as to what kind of care she wanted. Two midwives working within the traditional

community model provided antenatal care to women they did not have a prior

relationship with but provided support or facilitation of the woman’s alternative birth choices. Twelve midwives cared for women during the intrapartum period in a range of settings i.e. home, birth centre or hospital, whereby they either facilitated a woman’s pre-existing antenatal birth plan or supported/facilitated a woman’s decision-making during unfolding clinical events.

Six midwives were in clinical roles in which they received referrals from midwives to provide specific care planning for women requesting alternative birth choices. As such, they would see the woman in addition to her receiving antenatal care from the community midwife(s). Here, the participant’s role was to discuss the woman’s birth options and to formulate a care plan. For these particular midwives, this was a specific and expected part of their role. An additional two midwives were also within a care planning role, however, they opted to be on call for the women in their stories and were involved in intrapartum care. Two midwives offered stories of wider practice and service changes, rather than speaking of particular or specific cases but also provided clinical examples that were captured as small stories (discussed in Chapter 5, section 5.4).

135

Continuity of carer across continuum: Alex, Laura, Delilah, Sam, Jane, Kelly, Tracey,

Anna, Caz, Stella, Becky, Claire, Ginny, Maria, Jess, Kim, Kerry, Amy

Antenatal continuity during woman’s decision-making: Edna, Lucy, Rose

Non-continuity but facilitated woman’s antenatal decision-making: Katie,

Kate

Non-continuity, provided intrapartum care (any setting): Seana, Leanne,

Jayne, Clara, Brigid, Zoe, Susan, Georgina, Beatrice, Margot, Meg, Alice

Woman referred to for support/care planning (not intrapartum care):Rachel, Jenny, Isabel, Catherine, Hannah, Trish

Woman referred to for support/care planning (with intrapartum care): Lauren,

Jenna

n/a not individual stories but related to wider practice change: Emily, James Figure 13 Midwife-mother relationship during care episode as related to the ‘big’ story.

136