Evidence Based Midwifery

Supporting midwife-led care through action research: a tale of mess, muddle and birth balls

2009-01-23 10:15

Explores the processes and outcomes of an action research project undertaken to support midwife-led care in a maternity unit in the north of England.

EBM: Dec 2004

Ruth Deery1 PhD, BSc, ADM, RM, RN. Deborah Hughes2 MA, PGDE, DPSM, RM. 1 Senior Lecturer in Midwifery, Division of Midwifery, Department of Clinical and Health Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH England. Email: r.m.deery@hud.ac.uk 2 Sure Start Midwife/Deputy Programme Manager, Sure Start Elland, The Wesley Centre, Eastgate, Elland HX5 9DQ England. Email: dhughes@surestartelland.nhs.uk

Abstract

Aim. To explore the processes and outcomes of an action research project undertaken to support midwife-led care in a maternity unit in the north of England. Objectives.To identify changes in care given by midwives, to offer developmental opportunities to midwives to support the continuation of a midwife-led ethos and to examine the process of cultural shift created by relocation to shared facilities. Method.Action research, with its emphasis on collaboration and participation, was considered an appropriate approach, because it facilitates understanding of, and is able to adapt to, changing situations within clinical practice. A variety of data-gathering methods, including telephone interviews, personal construct analysis and observation, were used to explore and consolidate midwife-led care in one setting during a time of transition. Findings/results.Key weaknesses were identified within a midwife-led unit (MLU) and actions agreed and taken to address these, with a resulting strengthening of midwife-led care. The reflective process, an integral part of action research, fostered a shared concept of midwife-led care and an expanded skill-base for the facilitation of physiological childbirth. Implications.Action research can stimulate change and development within a midwifery context providing common values are identified and participation is realised. Although the methodology can be complex, it has the potential to clarify and solve problems within a specific clinical context.

Key words: Action research, midwifery, participation, collaboration, values, change, practice-development, midwife-led care

Background and rationale

This paper explores the processes and outcomes of an action research project undertaken to support midwife-led care (MLC) in a maternity unit in the north of England. Concerns about the future of MLC, following a geographical merger with a medically-led unit, instigated the development of a collaborative action research project.

Prologue writing up action research

Jean McNiff, a renowned action researcher, suggests that in parallel with its aims and values, action research requires a specific approach to publication (McNiff, 2002). She and others (Schn, 1983; Edwards and Ribbens, 1998) argue that potential data can be rendered redundant and much of the research story lost as complexities are omitted from the established publication format. McNiff (2002: 71) suggests the following headings:

- Review of current practice - Identification of an aspect needing improvement - Imagining a way forward - Trying it out - Taking stock of what happens - Modifying the plan in light of findings and continuing with the action - Evaluating the modified action - Repeating until satisfaction is achieved with that aspect of the work.

This is not a radical departure from traditional headings and structure, but it captures more of the complex and changing nature of the real-life situations in which action research is located. We used McNiffs subheadings to relate a fuller and more accurate story of this midwifery action research project, and to try to present research in a more accessible way (Deery and Kirkham, 2000).

Review of current practice

Childbirth today would almost be unrecognisable to our predecessors. While mortality rates have improved over the last 60 years for a wide range of social and medical reasons (Tew, 1998), medicotechnical surveillance of pregnancy and childbirth has long since passed the point of optimal effectiveness (Murphy-Lawless, 1998). Ever-increasing rates of caesarean section (CS) in most western countries now contribute to morbidity and mortality rates rather than decreasing them (Kitzinger, 1998; Murphy et al, 2001; Rowe-Murray and Fisher, 2001).

Whilst considerable effort has been put into reducing the CS rate in the UK, the cultural expectations and experiences of both women and midwives have changed (Kitzinger, 1998). Birth is now largely expected to be normal only in retrospect and therefore has become pathologised (Murphy- Lawless, 1998; Downe, 2001). Unravelling this dominant view and its effects on midwives practice has proved difficult, and the UK CS rate has continued to climb, despite efforts to reduce it (Kitzinger, 1998).

More recently in the UK, it has been suggested that a more useful approach would be to concentrate on increasing the normal birth rate and rebuilding the skills that underpin physiological birth (Murphy-Lawless, 1998; Downe, 2001; RCM, 2000). From the late 1990s onwards, the midwifery profession, the Department of Health (DH) and user groups have supported the development of birth centres and midwife-led units (MLUs) (Nolan, 2001). These units are seen as an important way to rebuild a culture of normal birth and the midwifery skills necessary to facilitate this (Hughes and Deery, 2002; Kirkham, 2003). This approach demands personal, professional and organisational change that is hugely challenging, as well as rewarding (Walker, 1996; Jones and Walker, 2003). Such units throughout the UK are proving successful in increasing the normal birth rate among their clientele (Walker, 1996; Kirkham, 2003) although, outside them, the CS rate continues to climb ,(Paranjothy and Thomas, 2001).

Working in MLUs involves resisting both external and internal pressures to comply with the dominant model of birth. The midwives working in these units are committed to skill development and helping women to give birth in a satisfying and physiological way. This can be stressful, but proper support for midwives can alleviate such stress (Sandall, 1998; Page, 2000; Kirkham and Stapleton, 2000).

Identification of an aspect needing improvement

The study setting is a mixed urban and rural area in Northern England with a population of 192000. There are 2300 births per year, 98% of which take place in the district hospital, the remaining 2% being planned home births. The district hospital has both an obstetrician-led unit (80% births) and a MLU (18% births) staffed by community midwives. In the old hospital (demolished in 2001), the MLU was on a separate floor, had no technological gadgets other than hand-held Dopplers (for fetal heart auscultation) and no obstetricians ever entered the unit.

When a new hospital was planned (opened 2001), the MLU and the obstetrician-led unit were located in the same area and on the same floor. Midwives expressed many concerns about the future for MLC in shared geographical surroundings, given the hegemony of the medicotechnical model of childbirth. These concerns centred on decision-making processes, the use of technology and interventions, the loss of skills to facilitate physiological birthing, and working relationships with medical and medically-led midwifery colleagues. The fear was that, as in a nearby maternity unit that had opted for shared facilities, this would lead to the sinking without trace of MLC and the ethos and skills that underpinned it, and that the CS rate would increase further.

Imagining a way forward

At a meeting between community midwives who staffed the MLU and midwifery lecturers, the idea of proactively safeguarding MLC was mooted. Action research was suggested as an appropriate means to this end, as one of us had previously undertaken a project using this approach in a different midwifery setting. Financial support was obtained from monies ring-fenced for collaborative research ventures involving university and NHS staff. The project ran from spring 2000 to autumn 2002. The aim of the project was to support MLC by:

- Identifying changes in care-giving by midwives - Offering developmental opportunities to midwives to support the continuation of the Changing childbirth (Department of Health, 1993) ethos - Examining the process of cultural shift, if any, created by relocation to shared facilities.

Action research

Action research is an approach that tries to identify and address the complexities of clinical practice situations. Waterman et al (2001) in a systematic review of action research studies in healthcare settings, confirm its appropriateness in rapidly changing clinical situations. Action research allows a research team to pick and mix methods and take actions based on findings to achieve change. Decisions as to which methods and actions are appropri- ate are based on the research teams experience and understanding both of research and the field in which they are researching. There is no clear divide in an action research team between researchers and practitioners all actively participate in the study and decision-making regarding research methods and actions.The principles of democracy, participation, reflection and change are central to most action research (McNiff, 1988; Stringer, 1996) and these principles, combined with an action-reflection spiral of cycles, distinguishes the approach from other forms of research (Elliot, 1991). McNiff et al (1996) describe action research as a process that moves through systematic cycles of planning, executing and fact-finding. A more fitting approach for our study was the observe, plan, act, reflect cycle (Atkinson, 1994: 397), although we found that we could be involved in all four of these components at any one time. This has led us to adopt McNiffs suggested headings in this paper, as a means of more authentically conveying the reality of this action research project (McNiff, 2002).Midwifery is a research-orientated profession with experience of a wide range of quantitative and qualitative approaches (Oakley, 1993, 2000; Page, 2000). Despite the complexity of its sphere of practice, midwifery has only recently turned to action research as an approach and only a few midwifery action research studies have been reported or published (Henderson, 1997; Fraser, 2000; Munro et al, 2002; Deery, 2003). We suggest one reason why midwifery has been slow to embrace action research is because of a long-term dominance by a medical profession that favours the certainty promised (but rarely delivered) by positivist approaches (Murphy-Lawless, 1998). The cyclical and participatory nature of action research, as opposed to the linearity of more positivist methods, means that action research projects are often experienced as unpredictable and complex the muddle and mess of our title.

The growing interest in action research (International Confederation of Midwives, 2002) is because it can investigate clinical practice issues in a way that parallels the non-hierarchical and collaborative relationships between women and midwives that midwifery aspires to (Deery and Kirkham, 2000). It also mirrors the value the profession places on knowledge that is grounded in practice.

We used the same framework of critical ethnography employed in an earlier project (Hughes et al, 2002) as issues of culture, power and institutional working were fundamental in the problems identified during early discussion (Grbich, 1999). Critical ethnography shares much in common with feminist ethnography and action research in terms of exploring hierarchies of power and hegemonic practices (Grbich, 1999), and therefore was a suitable framework for a project examining the workings of a MLU in relation to its obstetric-led counterpart.

The researchers insider role

Action research deals with situations that are complex and unique and the change it aims to engender depends on participants understanding of the situation being studied (Winter and Munn-Giddings, 2001; Waterman et al, 2001). This understanding is interwoven with the beliefs and values of the participants and researchers themselves (Lomax, 1995; McNiff, 2002). One of the main aims of the project, namely to support midwife-led care, was embedded in our own professional beliefs and values and shared by the other participants. Therefore we were not detached, objective researchers as in mainstream research paradigms, but involved insiders (Reed and Proctor, 1995) with personally-and professionally-vested interest in the change we hoped would occur (McNiff, 2002).

Waterman et al (2001) found that action research projects were more likely to be successful where researchers had an insider role and perspective. In this project, the researchers either worked in the unit or had a close relationship with the unit as link teachers and through previous research projects (Deery et al, 1999; Hughes et al, 2002).However, our relationship to the project was not solely as insiders. Researcher reflective sessions were an important opportunity to adopt a more outsider stance to the data that we were generating. We examined our data in the context of midwifery literature, visits to other units and internet discussion groups to try to gain more objective understanding of the local situation of the project. These discussions were one of the most fruitful parts of the project as they generated key ideas for change and cemented relationships in the research team. Our positions were predominately insider, but the project was enhanced by adoption of outsider perspectives in reflective discussions, constantly comparing the local situation to the broader midwifery picture.

Trying it out

A research team was established comprising university staff (two psychologists, three midwives and a business administrator) and maternity service staff, including community midwives involved in MLC and hospital midwives from the obstetric unit. This collaborative aspect of the project is crucial to an action research approach (Winter and MunnGiddings, 2001; Waterman et al, 2001). The perspectives of different participants enriched the data analysis process and accords with the impetus to encourage multidisciplinary working (Department of Health, 1996a, 1996b). Initially we opted to do some observational data collection of the working practices of the MLU, in order to understand better the situation we were exploring.

We agreed that it was undesirable to observe direct care-giving, that this would be an intrusion on birthing women and possibly interfere with the physiological birth processes we wanted to protect (Odent, 1992). Therefore, we decided to carry out the initial observation in the offices and corridors of the MLU and obstetric-led unit, listen to the interactions of midwives with each other and with doctors, watch the comings and goings, and identify emergent themes.

The local research ethics committee gave permission to proceed on the agreement that clients would not be approached. We acknowledge that research governance (Department of Health, 2001) would now demand that consent would have to be regarded as a process for constant renegotiation (Hollway and Jefferson, 2002), obtained from all participants at various stages of the study, given the fluidity of the action research process.

Face-to-face meetings with community midwives took place to explain the aims of the project and invite those interested to join the research team. All midwives were informed by letter that observation of the MLU would take place and that this was part of an action research process to support MLC. Permission was obtained for the use of participants words in report-writing, publications and conference presentations and the midwives were reassured that all data would be anonymised, and that no information would be able to be traced back to them.

At this stage, the midwives appeared unsure about the project despite their concern for the MLU. This failure to fully engage the midwives as participants was largely due to our inexperience as action researchers. However, participation quickly developed and the increasing engagement of the midwives with the project reflected the dynamic of action research for change and development (Winter and Munn-Giddings, 2001).

Four members of the research team carried out a total of 40 hours of observation, including one 24-hour period. No observational tool was used we agreed to log and note (verbatim as much as possible) all verbal and non-verbal interactions, all movements within and in and out of the unit, all telephone conversations and all physical movements and expressions. All observation took place in the corridors and office space and no client was approached.

The researchers typed their observation notes without any editing, other than anonymisation, and then exchanged them among the research team. Recording all activity in this way minimised subjectivity, because the researchers did not have to select what to record or edit their notes. A large amount of rich data was collected about the workings of the MLU and was used as a basis for future actions.

Analysis of the observational data was done through individual reading of each transcript by the research team and making notes. One of the researchers pulled out main themes, grouped the data into categories according to these, and presented these to the research team (Burnard, 1991). The team considered their own notes and experiences in light of these and the categories were further developed through collective discussion. Findings were consistent and the same issues emerged from most observation periods. The issues to emerge are shown in the flow-chart (see Figure 1).

Taking stock of what happens

The main finding at this stage was that many of our preconceptions were erroneous MLC was not threatened so much by medical hegemony as by the community midwives themselves. The data showed that there was no common understanding or shared vision of MLC. The midwives (the unit was staffed by one community midwife on each daytime shift) interpreted policies on an individual basis and had different ideas of what they were trying to achieve in terms of MLC. For example, the policy was that women should be transferred to the obstetric-led unit when complications arose and that midwifery care was handed over at this point. A significant minority of midwives felt that continuity of carer was paramount, and would transfer to theatre or the obstetric unit with the client continuing to provide midwifery care. This left the MLU unstaffed and all midwives confused as to their role and skill base. If another woman was admitted to the MLU, the community midwife on-call would be called in and this disrupted continuity of carer in the community.

Another example was in the use of electronic fetal heart monitors. The policy was that these had no place on the MLU and that any concern about the babys heart rate indicated transfer to obstetric unit care. Some of the midwives however, brought monitors from the obstetric unit to get a tracing before making a decision regarding transfer. This sometimes resulted in women on the MLU having continuous fetal monitoring and a blurring of understanding about risk and decision-making. Furthermore, there was very little evidence that midwifery care was proactively facilitating physiological birth women were apparently, from what the observers could ascertain, on beds and the rooms had nothing in terms of lay-out or equipment to encourage alternative approaches.

These issues were not the only ones to emerge from the observational data, but they were probably the most crucial. Other issues were examination of the newborn, the postnatal examination of mothers of babies on the neonatal unit, support for MLU midwives and night cover of the MLU. It is not within the scope of this paper to address these issues in further depth.

The observations discovered that there was a lack of clarity about what MLC was, other than it being, in a general way, care led by midwives. That is to say, MLC appeared to be defined by structure (booking criteria, organisation, geography) rather than process (skills, decision-making, communication) (Hughes and Deery, 2002) or a common philosophy and goals. There were many models of MLC operating, with the result that womens experiences were dependent on the values and practices of the midwife on duty. This was entirely unexpected we had thought that there was something consistent called MLC that we simply had to find a way of protecting from medical encroachment locally. Instead the concept of MLC was contingent on midwives personal models, and individually negotiated by midwives using a range of rationales.

Following a meeting to feedback the findings of the observation, one of the team leaders in particular was disbelieving and shocked by the data we presented. She had earlier expressed anxiety about the future of the MLU in shared geographical space, but had otherwise thought that MLC was strong and thriving locally. At this stage she became very negative about the project, feeling it was creating further problems. This is a good example of how action research can become unpredictable and messy (Mellor, 1998; Cook, 1998). It was decided to distribute the observation notes to the community midwives so that they could comment on the data and contribute their own insights in counterbalance to the research teams interpretation of the data. This proved to be crucial the midwives recognised the problem we had identified and their reading of the data confirmed ours. The team leader, who had been anxious and angry about the data presented, joined the research team and actively engaged in addressing the issues about which she had previously been sceptical.

It was only at this stage that the participation crucial to action research (Waterman et al, 2001) began to be realised and the project came alive and moved towards achieving its aim. The action research approach was flexible enough to be able to respond to the muddle (midwives various models of MLC) and the mess (the emotional responses to the data) of the situation that it was addressing.

Modifying the plan in light of the findings and continuing with the action

It is difficult to have a clearly formulated plan in action research, because the participants steer the course of the project (Hart and Bond, 1995; Waterman et al, 2001) and because the project is constantly informed by its own data. While the aim of the project was to support MLC through the objectives listed earlier, how those objectives were to be achieved would be determined by the issues that emerged from the data (see Figure 1).

An action plan was formulated to address the emergent issues and the contributions and suggestions of the participating midwives were found to be the most successful. The various strands of this plan can be seen in the middle section of Figure 1. It is not possible to explore all of them in this paper, so we will limit discussion of actions taken to those that relate to the issues we have discussed already, namely discordant models of MLC and the skill-base for the facilitation of physiological birth.

One member of the research team undertook 25 telephone interviews with a randomised, stratified sample of the community midwives, eliciting their views on what MLC comprises through a semi-structured interview format. Personal construct analysis of the transcripts of these interviews led to the development of a number of statements. These were distributed to all community midwives for validation using a Likert scale, the results analysed, and the areas of philosophical agreement and disagreement identified (Robson, 2001).

These findings were presented and discussed with the community midwives at a series of pre-arranged sessions, and a common view that all could subscribe to developed. This meant that the midwives agreed what MLC was all about in the local context. It subsequently became possible to explain or sell MLC to local women more cohehently, and to develop the service. Among the issues settled was that of the transfer of care it was agreed that the care of transferred clients would be handed over to the obstetric-unit midwives.

Secondly, one midwife decided to investigate the rates and reasons for transfer to obstetric-led care. The research team supported this work by employing a research assistant to undertake a computer analysis of the statistics. The main issues to emerge were meconium-stained liquor, slow progress in labour and epidural analgesia. Evidence-based guideline development around these areas took place to minimise unnecessary intrapartum transfer or inappropriate booking for MLC.

Thirdly, a bid was successfully made to the local NHS Trust for money to enable a series of active-birth workshops to be held, attended by all community midwives. These not only developed and reinforced the skill-base of the midwives, but also gave them valuable time together to discuss and share their vision and understanding of what they were trying to achieve together with the MLU. These workshops also inspired the midwives to collate a list of equipment to encourage and aid active, physiological birth. This equipment, including a number of birth balls, was purchased with money that was allocated to all NHS wards at that time.These interventions were unique to this situation, locality and project. They were successful because of this and formed an important part of the change process the project aimed to achieve. By this stage, the midwives were playing a more important role in the action aspect of the project than the research team. This occurred during months seven to 11 of the project, and shows how an action research project gathers momentum as it progresses through its cycles (McNiff, 1988).

Evaluating the modified action

After 18 months of the project running, many changes had already taken place and still were (see Figure 1). At this stage it was decided to employ a research assistant to undertake a further 40 hours of observation, as a basis from which to assess the situation and what further needed to be done to support MLC. Again no observation tool was used, but the principles of the first observation round were adhered to.

One of the key findings was the existence of a culture of active birth and the widespread use of the resources, such as birth balls, purchased after the active-birth workshops. The observer evidenced that physiological birthing was well-established, and most of the previous issues were resolved. Difficult working relationships with obstetric unit staff remained an issue and were subsequently readdressed.

Two further areas for development were identified at this time. The first related to staffing the difficulties of staffing the unit with community midwives with many community-based commitments were evident. Continuity of care in the community was being compromised by the staffing demands of the MLU, causing disruption to clients and conflict with the underlying aspirations of the midwifery service (Lipsky, 1980). A commitment to offer MLU contracts to suitable midwives was made by the midwifery manager.

The second was the identification by the midwives of fetal malposition as an underlying cause for intrapartum transfer (Sutton and Scott, 1996; Sutton, 2002). Two workshops on optimal fetal positioning were organised and all community midwives attended.

Repeating until satisfaction is achieved with that aspect of the work

The action research cycle could have been repeated any number of times in this project. However, funding was running out, the original time-frame (two years) had passed, the midwives themselves had taken over many of the functions of the research team regarding the facilitation of change, the research team had other projects to develop and members of the research team were changing jobs. Overall we felt satisfied that the project had achieved its aims and objectives during the period of transition in the service. The MLU was thriving, difficulties being encountered were continuously identified and addressed and relative stability and consolidation had been attained. Following discussion, the research team decided to draw the project to a close rather than a conclusion.

Conclusion

In the end, the project turned out not to be just about the MLU. The collaborative nature of action research, and the discussions that took place between all participants built important relationships between clinical, managerial and university-based staff. Common values were identified, articulated and developed, and then amalgamated into the organisation of the maternity service. For example, community midwives no longer had to update on the obstetric-led unit instead, emphasis was put on developing and maintaining the skills necessary for MLC. The development of a common philosophy alongside shared learning experiences, led to a culture of active physiological birth that all participating midwives could own. The extension of night shift cover for the MLU was decided largely because of the shared desire to consolidate this approach across 24 hours.

Action research therefore has the potential to change profoundly and extensively the culture and practice of a clinical environment. To achieve that potential, participation and collaboration are crucial and central to the successful action research process. The experience of these can enrich the midwives partnerships with their clients through parallel processes.

The limitations of this study are embedded in the method itself, in that action research projects are unique to the place and time of their setting and are therefore not generalisable. In an obstetric culture that values positivist approaches, non-generalisability is often seen as a negative quality. However, as a method of problem-solving within a specific midwifery context, the specificity of action research can be seen as strength. A limitation of this study is that we did not address all the problems we identified, particularly the need for more support for midwives. Midwifery practice environments are complex, messy and ever-changing. Action research has the potential to manoeuvre within that environment. This study is grounded in one place, during one period, and its nature is unique to that situation. However, the principles and cycles of action research can be applied to any setting, although the end story would be different. Action research cannot achieve its potential for change and development without the true participation we have described.

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