Objective To identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.
Design Case studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.
Setting and participants NHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).
Main outcome measures Factors influencing MU use.
Findings The study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust’s overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.
Conclusions There are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women’s information needs. If these remain unaddressed, childbearing women’s access to MUs will continue to be restricted.
- organisation of health services
- health policy
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Contributors DW: chief investigator, associate professor in Midwifery, Denis.email@example.com, principal author; HS: coinvestigator, professor in Midwifery, Helen.firstname.lastname@example.org; CMC: coinvestigator, professor in Maternal Health, Christine.email@example.com; CG: research fellow, firstname.lastname@example.org; DC: early career academic fellow email@example.com; SB: coinvestigator, senior lecturer in Business School, Simon.Bishop@nottingham.ac.uk; MS: coinvestigator, Service User, Miranda.Scanlon@city.ac.uk; LC: coinvestigator, Emeritus Professor of Social Science & Health, firstname.lastname@example.org; JW: GP Commissioner, email@example.com; LP: head of Midwifery, firstname.lastname@example.org; JT: professor of Obstetrics, Jim.Thornton@nottingham.ac.uk. All authors performed drafting and revising content critically for important intellectual content, substantial contribution to the interpretation of data, final approval of the version to be published, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding This work was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme (Ref: 14/04/28).
Competing interests Professor Thornton reports being a member of the HTA and EME Boards. Dr Scanlon reports grants from NIHR, during the conduct of the study; personal fees from 'WHICH?', grants from NIHR, personal fees from National Perinatal Epidemiology Unit, personal fees from Rod Gibson Associates, personal fees from Midwifery Unit Network, outside the submitted work.
Patient consent for publication Not required.
Ethics approval Ethical approval was granted for phase 2 of the study the West Midlands—Solihull Research Ethics Committee (IRAS ID 200356) as phases 1 and 3 were deemed service development.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open access repository. Data Sharing Statement: Data are available in a public, open access repository: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/140428/%23/