Woman-centred care

Woman-centred care

Rosemary Popea,*, Lesley Grahama, Swattee Patelb

aSchool of Educational Studies, University of Surrey, Guildford GU2 5XH, Surrey, UKbSchool of Computing & Mathematical Sciences, The University of Greenwich, Wellington Street, Woolwich, London SE18 6PF, UK

Received 13 July 1999; received in revised form 22 November 1999; accepted 22 December 1999

Abstract

Changes over the past decade have emphasised the individual service user and their relationship with the health

service. Within the maternity services this has been interpreted as woman-centred care a result of key initiatives; theWinterton Report (House of Commons, 1992. Maternity Services. Second Report of the Health Committee(Winterton Report), Vol. 1. HMSO, London) and Changing Childbirth (DoH, 1993a, Changing childbirth: reports

of the expert maternity group parts 1 & 2. HMSO, London). Changing Childbirth outlined key principles of thematernity services and the need for the woman (and her partner, if she wishes) to be the focus of care. The keyprinciples are choice, continuity and control. High quality care depends on the recognition of individuals as havingunique needs which continues to be re¯ected within contemporary policy documents (DoH, 1997, The new NHS:

modern and dependable. HMSO, London).This paper presents ®ndings related to the provision of woman-centred care from a national research and

development study. The study design incorporated (i): a national survey which was undertaken with midwives,

midwife supervisors and doctors; and (ii): in-depth case studies in which information was obtained throughinterviews with midwives, midwife supervisors, educators, managers, doctors and mothers. Midwives, at all levels,are involved in changing maternity service provision and adapting to new systems of care which aim to increase

continuity of care and carer for the woman. The researchers sought to understand how woman-centred care wasinterpreted and experienced in practice. The ®ndings have been used to identify the continuing educational needs ofmidwives, and to develop an open learning educational package to meet identi®ed need. The curriculum was

designed to enhance the move towards the provision of a more integrated woman-centred service. 7 2001 ElsevierScience Ltd. All rights reserved.

Keywords: Individualised care; Research; Midwifery; Woman-centred care

1. Introduction

Radical changes occurred within the National

Health Service in the early 1990s, for example the

Community Care Act (DoH, 1990), Health of the

Nation (DoH, 1992a,b). These changes were driven inpart by the free market political ideology of the Con-servative government, including the growth of consu-

merism and in the individualisation of the statethrough the use of public policy, e.g. the Health of theNation (DoH, 1992a,b) and the Patient's Charter

(DoH, 1992b), including the Maternity Services Char-ter (DoH, 1994). The Labour government, since 1997,

International Journal of Nursing Studies 38 (2001) 227±238

0020-7489/01/$ - see front matter 7 2001 Elsevier Science Ltd. All rights reserved.

PII: S0020-7489(00 )00034-1

www.elsevier.com/locate/ijnurstu

* Corresponding author. Tel.: +44-1483-300800; fax: +44-

1483-300803.

E-mail address: [email protected] (R. Pope).

have developed the theme to encompass the strength-

ening of citizens' rights and responsibilities at an indi-vidual level and in participating in health andhealthcare decision making. `The needs of patients not

the needs of the institution will be at the heart of thenew NHS' (DoH, 1997).

These contemporary policy initiatives are under-pinned by the key concepts of individualised care andholism. These conceptual frameworks are based on the

assumption that high quality care depends on the rec-ognition that each individual will have a unique experi-ence of health and ill health which will de®ne their

own personal health care needs. It is increasingly beingrecognised that in order to e�ectively meet health care

needs, health care professionals must work in partner-ship with the patient/client. Within maternity serviceprovision this concept is interpreted as woman-centred

care. Health care professionals are required to havethe requisite knowledge, expertise and clinical skills tomeet these needs.

In the early 1990s maternity service provisionbecame the focus of government, public and pro-

fessional attention. In 1992 the Select Committee's Sec-ond Report On The Maternity Services was published(Winterton Report). Subsequently, the Changing

Childbirth Report (DoH, 1993a) was published as partof the government's response to the Winterton Report.Changing Childbirth (DoH, 1993a) proposed a radical

programme of change that is intended to provide aclear way forward for the development of the mater-

nity services into the next century. The Expert Mater-nity Group responsible for Changing Childbirthoutlined key principles of the maternity services and

the need for the woman (and her partner, if shewishes) to be the focus of care. The key principles arechoice, continuity and control.

Ten key indicators of success were identi®ed whichwere to be met within 5 years (DoH, 1993a, p. 70).

The key indicators included several targets relating tothe need for continuity of care and for the manage-ment of care led by a midwife which would be necess-

ary if a woman was to have the proposed degree ofchoice and control regarding her care. Midwives' initial

education and training prepare them to undertaketheir full role and responsibilities. They are able to beresponsible for arranging and providing all maternity

care for women with uncomplicated pregnancies, andlegally they have the right to practise independently(UKCC, 1998).

Midwives, at all levels within the profession, areinvolved in changing maternity service provision and

adapting to new systems of care which seek to huma-nise the process and environment of childbirth. All sys-tems aim to increase continuity of care and carer for

the woman Ð to provide woman-centred care.It was against this background of policy develop-

ment that the English National Board for Nursing,Midwifery and Health Visiting commissioned a

national study in England with the following threeaims:

. to establish the current role and responsibilities of

midwives in a variety of settings with a range of cli-ent groups,

. to identify the changing educational needs of mid-

wives to ful®l their future widened role and responsi-bilities within the changing maternity services,

. to develop an educational package to facilitate mid-

wives in responding to the requirements of theirchanging role and responsibilities.

Although the study was undertaken during the 5 year

period in which Changing Childbirth (DoH, 1993a)was government policy, key concepts underpinning thereport regarding the facilitation of woman-centred care

have continued to be supported within successivereports on service provision (e.g., Audit Commission,1997; DoH, 1998; Standing Nursing and MidwiferyAdvisory Committee, 1998; ENB, 1999).

The ®ndings reported in this paper therefore con-tinue to be relevant within the current context formaternity service provision.

2. Methods

2.1. Postal survey

Initially a postal survey was undertaken. The follow-ing groups were included in the survey: midwives, `co-

ordinating' supervisors of midwives, consultant obste-tricians, obstetric registrars and general practitioners(GPs).Using statistical methods (the application of the stat-

istical formula for determining 95% con®dence inter-vals for proportions), sample sizes were calculated forvarious outcome measurements. Then, careful

sampling procedures were carried out to ensure repre-sentativeness of the sample.This paper reports data primarily from the midwives

and supervisors who participated in the study. There-fore the methods used for sampling these groups havebeen described below.

2.1.1. Midwife sampleThe National Health Service (NHS) is divided into

regions for the purposes of organisations of services.

At the time of the study was undertaken there wereseven regions within England which were demarcatedby geographical boundaries. Midwives in England are

employed on clinical grades (at the time the study wasundertaken these grades were between D and I, whereD denotes the lowest grade). In order to promote the

R. Pope et al. / International Journal of Nursing Studies 38 (2001) 227±238228

potential for the inclusion of a representative sampleof midwives, the sample was strati®ed by the following

variables: regional location (by NHS region and geo-graphical location within the region), grade of midwife,and size of maternity unit (in terms of number of mid-

wives employed and number of deliveries per annum).(See Table 1 below for detailed information on samplesizes and response rates.) Simple random sampling

methods were used to select the sample within thestrata.

2.1.2. Co-ordinating supervisor of midwivesMidwives in the United Kingdom are required by

law to notify their intention to practice on a regular

basis. There is one midwife supervisor at local levelwho is responsible for co-ordinating all the relevant in-formation on practising midwives and making it avail-able to the Local Supervising Authority in order that

accurate records may be kept. Several terms are usedfor this supervisor including `co-ordinating', `key',`prime' and `corresponding'. For the purposes of this

study the term `co-ordinating supervisor' has beenused. The co-ordinating supervisor is often, but notalways, the Head of Midwifery for the maternity unit.

The co-ordinating supervisor was selected for in-clusion in the study as she is one of the professionalsat local level likely to have a broad knowledge of both

policy and practice issues.As the number of co-ordinating supervisors in Eng-

land is relatively small, it was possible to send a ques-tionnaire to all co-ordinating supervisors in England.

The data available to the project team regarding thepro®les of responders and non-responders to the sur-vey does not indicate that there are any substantial

di�erences between these groups in relation to theirbackgrounds (e.g., size/type of maternity unit, mid-wife's grade, geographical location). We therefore have

no evidence to suggest that the results obtained fromthe respondents are likely to be subject to any particu-lar source of bias.

2.1.3. Questionnaire contentQuestionnaires were designed using a mixture of

closed and open-ended questions. Questions were

developed by drawing on the available literature, statu-tory instruments for midwifery education and practice

(UKCC, 1994, updated in 1998), and expert opinionfrom profession leaders. The questions were kept as

similar as possible for each of the groups in the studyfor comparative purposes. The questionnaires werepiloted with each of the groups.

The key areas covered by the questionnairesincluded:

. maternity service provision;

. the role and responsibilities of midwives.

. perceived competency/con®dence of midwives toundertake their full role,

. the continuing education and training needs for mid-wives and the most appropriate means for meetingoutstanding need.

2.2. Case studies

In order to follow up key issues raised in the ques-tionnaires, and to obtain detailed information concern-

ing the development of the educational package casestudies were undertaken in three sites across England.The case study sites were chosen to re¯ect the mix of

geographical locations and types of populations withinEngland as well as the size and type of maternity unit.Semi-structured topic guides were prepared for the

case study interviews to allow the opportunity for in-depth exploration of the issues raised through thequestionnaire.

All midwives employed in the case study sites wereinvited to be interviewed either in groups or individu-ally. A total of 90 midwives were interviewed, mostlyin focus groups, which provided the opportunity for

discussion between the midwives. Midwives wereo�ered individual interviews, and the small numberwho chose this option did so as they were not free at

the time of the focus groups. All co-ordinating supervi-sors were interviewed individually. The midwives whowere interviewed came from the range of backgrounds

in terms of their grade and area of practice (e.g., hos-pital, community). Interviews were tape-recorded and®eld notes taken by a researcher who was present at,but not conducting the interview.

In addition a sample of managers, midwife tea-chers, doctors and mothers were interviewed from

Table 1

Questionnaire distribution and response rate

Group Number of questionnaires Number of questionnaires returned Response rate (%)

Midwives 1100 771 70

Co-ordinating supervisors of midwives 205 172 83

R. Pope et al. / International Journal of Nursing Studies 38 (2001) 227±238 229

the case study sites in order to illuminate the dataobtained from the midwives and supervisors. How-

ever, the methods used for these groups have notbeen fully described here as these data are not com-prehensively reported in this paper.

The methods used for each aspect of the study havebeen described in full in the research report (Pope etal., 1996).

3. Data analysis

Quantitative data were analysed using descriptiveand inferential statistics. Data which have beenreported in this paper were obtained primarily from

the midwives, and comparative analysis between theprofessional groups have not been presented. Infer-ential statistics have therefore not been reported.

Data from the open-ended questions included in thequestionnaire and the interview data were analysedusing methods of content analysis. Interview datawere transcribed verbatim from the audiotapes

which were recorded during the interview. The casestudy data were analysed using methods of latentand manifest content analysis (Field and Morse,

1985). The major themes and signi®cant meaningswere identi®ed from the transcripts, which werecoded and interpreted in relation to the question-

naire data and relevant theoretical and empirical lit-erature. The multiple use of case study sites and offocus groups within each site enabled the research-

ers to con®rm and re®ne themes and issues. Find-ings from each site were drawn together to providean overall picture of the themes and issues thatemerged.

In exploring the current role and responsibility ofmidwives, the researchers were also seeking to under-stand how contemporary concepts underpinning care

provision were interpreted and experienced in practice.Therefore the concept of individualised or woman-centred care was chosen to underpin the framework

for data collection.For the purposes of this paper the data which have

been reported focus mainly on issues related to the or-ganisation of midwifery services, and the extent to

which the Changing Childbirth indicators of success re-lated to individualised care were being met nationally.However, both the questionnaire and the interviews

undertaken in the case studies covered a broad rangeof issues related to maternity service provision, the roleand responsibilities of midwives, con®dence/compe-

tence of midwives to undertake their full role; and thecontinuing educational needs of midwives (Pope et al.,1996).

4. Results

4.1. Questionnaire results

The context within which midwifery care is deliveredwill a�ect to a greater or lesser extent the ability ofmidwives to practise within their full role and responsi-

bility and impact on their ability to provide continuityof care, and carer (Wraight et al., 1993). Therefore the`co-ordinating' supervisors were asked to provide in-

formation regarding an overview of the service pro-vided at local level. Seventy two per cent (n = 123) ofsupervisors indicated that targets were outlined forattainment by the maternity services with just under a

quarter (n = 33) indicating that targets related toChanging Childbirth had been set in order to providewoman-centred care. A range of systems of care were

either in place or were actively being planned for deliv-ery.For the purposes of this study, `systems' of care was

used as an umbrella term to cover ways in which mid-wifery (and sometimes broader aspects of maternitycare) is provided. Some of these systems may operatein conjunction with other (for example, domino care

or home births might be provided by midwives work-ing within a team or carrying a caseload, and thenamed midwife might operate within a team arrange-

ment, etc.).Of all the available systems, the named midwife was

identi®ed by 49% of midwives (n= 377) as the system

they were currently involved with, with 48% (n= 370)indicating they worked within some type of team.Fig. 1 shows the systems of care with which midwives

worked across England. Enormous variation existedregarding the way the named midwife system operated.It was quite common for a midwife based in the com-munity to be the named midwife and to provide a sub-

stantial amount of the antenatal and postnatal care(with back up as necessary from other team or grouppractice members). Sometimes intrapartum care was

provided by this midwife. However, mostly hospitalbased intrapartum care was not provided by thenamed midwife. Some hospitals allocated women a

named midwife on a `visit to visit' or `shift by shift'basis, without any real evidence of continuity being fa-cilitated by such a process.The midwives were also asked to indicate whether

the Changing Childbirth indicators of success had beenimplemented in their service. Of particular interest arethe indicators that relate to the provision of individua-

lised care. In addition, midwives were asked whetherwomen were fully informed concerning their care, andwhether women had a full range of choice regarding

the place of birth. Although these were not speci®callyindicators of success outlined in Changing Childbirth,they were key concepts running throughout the report.


Only a quarter of the midwives (n=193) reported

that at least 75% of women know the person whocares for them in delivery. The majority of midwivescommented that invariably the mother met the midwife

who cared for her during delivery for the ®rst timewhen she was in labour. Issues related to systems of

care were most commonly cited with indications that ifa woman had a home birth, domino delivery, commu-nity midwife delivery, gave birth in a GP unit or was

cared for by a small team of midwives, it was verylikely that she would know the midwife who cared for

her. It is interesting to note midwives' comments thatmothers have reported in surveys that it is not essentialto know the midwife before delivery as long as she is

kind and caring.Although the majority of midwives reported that

women had the full range of choice regarding placeof birth, the majority of comments made related todi�culties arranging home-births, with GPs being

viewed as a potential barrier to women being ableto choose the home as the birthplace.

The majority of midwives indicated that all womenare fully informed concerning their care. Some

examples given were that there may be language di�-culties which a�ect communication, some mothers arenot interested, particularly those from low socio-econ-

omic groups, and some mothers are not assertive

enough to ask for information. Some midwives indi-cated that their caseload was too large for them to

give full information to women.Midwives were asked to provide examples from their

practice of ways in which they facilitated the choices

the woman/her family had made for childbirth.Three quarters of the sample (n = 578) provided

examples of ways in which they facilitated the woman's

choice. (See Tables 2 and 3 below).

4.2. Case study results

4.2.1. Implementation of changing childbirthThe Changing Childbirth report (DoH, 1993a,b) was

seen to be generally helpful by midwives in terms of

re-empowering the profession, with some considering ita `midwife's charter', but there were concerns, regard-ing how it would work in practice, particularly in re-

lation to the e�ects on midwives hours of work andconditions of service.There was wide discussion in all three sites concern-

ing whether the percentages cited in relation to the in-dicators of success were realistic, and research-based.The ambiguity with which some of the indicators

could be interpreted was considered a problem. Thisbeing particularly relevant in relation to:

Fig. 1. Systems of care (n=771).


at least 75% of women knowing the person whocares for them during their delivery.

It was considered that the concept of `knowing' themidwife could be widely interpreted, and was likely to

vary in its importance from client to client. Midwivesgenerally considered the priority was to ensure thatwomen were cared for by someone they considered`caring, kind and competent'.

The safety aspect of delivery was considered para-mount. It was widely considered that provided themidwife was skilled and had a caring approach then it

was possible to build up a rapport in a relatively shortspace of time, with one midwife describing it as `thequickest made friendship'.

4.2.2. Systems of careOn the whole, midwives and their managers thought

that once the system of care was organised properly,women would be introduced to the team and deliveredby one of the midwives within that team. The size of

the team was considered fundamental to how well itwould work, and for the avoidance of stress on indi-vidual midwives. With regard to the `named midwife',

similar discussions tended to ensue as for the indicatorrelated to `women knowing the person who care forthem during delivery'. It was not always consideredpossible (nor necessary) for women to consistently see

one `named midwife'.Long discussions took place about the best way of

organising team midwifery, without any clear con-

clusions emerging. It was generally considered thatteams should have about ®ve or six midwives in them,if mothers were to stand a reasonable chance of meet-

ing them all throughout their care. However, this wasnot considered feasible in two of the study sites in the

light of the large number of women needing care froma relatively small number of midwives. In one site,where the team approach had been introduced some-

time earlier, there were up to 40 midwives in a team Ðwhich did nothing to facilitate women being cared forby a midwife she had previously met.

The following quotes from midwives illustrate someof the perceived di�culties associated with the pro-vision of care by a team, as well as the more positive

aspects:

We had a small team here and we were on ourknees within a year

I ended up delivering 2 women, and I did notbelong to that team and that caused hassle actually,because the person was so hyped up to expecting to

be delivered by one of the team and she wrote aletter of complaint.

I've worked in team and primary nursing on the

general side, and the morale you get from workingin a team and pulling together was brilliant.

4.2.3. Facilitating choice and promoting woman-centred

careIn all of the sites there was lengthy discussion

regarding how to ensure that all women could make

the choices that they wanted regarding the type ofmaternity care received, and what constituted goodmidwifery care. Midwives generally indicated the im-

Table 2

Indicators of success related to individualised care

Indicator Midwives report indicator is met

75% of women know the person who cares for them in delivery n=193: 25%

Do all women have full range of choice regarding place of birth n=494: 64%

Are all women fully informed concerning their care n=671: 87%

Table 3

Facilitating the woman's choice

Examples of ways in which midwives facilitated the woman's

choice

Number and percentage of midwives (based on the number of

midwives who commented (n=578))

Discussion with woman and family to provide information re.

available choices

n=231: 40%

Encourage woman to write a birth plan n=190: 32%

Enable woman to labour and deliver in alternative positions,

and choose range of methods of pain relief

n=144: 24%


portance of understanding the needs of women from a

diversity of social and cultural backgrounds, however,

some indication of rather stereotyped views was appar-

ent. On the whole a lack of resources and the attitudes

of some midwives were seen to be the main barriers to

meeting the needs of all groups.

The following quotes from midwives illustrate some

of the di�culties they perceived existed:

Racism is rarely mentioned, but I feel that midwives

are sometimes insensitive and irritated by necessary

di�erences in caring for women from di�erent reli-

gious, cultural and ethnic backgrounds Ð it is

often regarded with ¯ippancy.

Women want to do it (breastfeed their baby) and

one of the biggest reasons they can't is bad inter-

vention by midwives and lack of understanding by

English professionals.

Midwives discussed the issues with each other, gen-

erally concluding that being a good communicator and

listener, empathetic, ¯exible and approachable were

most important. Being knowledgeable and clinically

competent were also identi®ed as a priority in most

groups. The need for care to be suitable for each indi-

vidual was discussed with the following quote from a

midwife in a senior management position exemplifying

the point:

My personal example is a woman who had an epi-

dural, who was from a background where the

whole thing terri®ed her. She wanted it all to be

very medical, because that made her feel safe. She

wanted the CTG beside her, she wanted the sound

up. That was not the way I would deliver care, but

by delivering it in the way she wanted, she felt at

the end of it that she had a great experience. If I

looked at that on paper I would think òh, that

poor woman' Ð but good care is about adjusting

what I am doing to meet her needs.

However, not all opinion was in the same direction

and one midwife considered providing high quality

care meant:

knowing we are right when the patients tell us that

we are wrong.

Midwives, supervisors and managers discussed simi-

lar issues, often indicating very similar views. There

was a great deal of convergence about the actual phil-

osophy of care that interviewees believed ought to

underpin midwifery. Generally, the move towards a

more woman-centred service was supported, although

not very often in such explicit terms.

4.2.4. Choice of place of birthLengthy discussion took place at each site regarding

how to ensure that clients could make the choices thatthey wanted concerning the place of birth.Midwives from all three sites discussed how the

GP's opposition to home births was almost always abarrier to women's choice. In all the interviews under-taken with the midwives, there was only one example

given where the GP was seen to really facilitate choicein this respect Ð and the midwives considered this GPtook control of the care and prevented midwives from

undertaking their full role. Midwives indicated thatsome GPs refused to provide care for those wanting ahome birth, whereas others made it clear they did notfavour this option, thereby exerting a pressure on

women not to pursue the matter for fear of `ò�end-ing'' their doctor by e�ectively going against his/heradvice.

One midwife indicated strong tactics would comeinto play if a woman persisted with the wish to have ahome birth:

Once they have written a letter to the woman say-ing I am taking no responsibility for this and youmight die at home, if the woman still says OK, then

they say all right, we will accept that and not takeyou o� our list.

The public's lack of knowledge regarding the role of

the midwife was highlighted by both midwives andtheir supervisors as a barrier to choice. Women gener-ally went to the GP initially and expected doctors to

be involved throughout the pregnancy.

5. Discussion

5.1. Implementation of Changing Childbirth

The midwives and supervisors (approximately three-quarters of the samples), were much more likely than

doctors (approximately one third of the sample), toconsider that the implementation of the ChangingChildbirth indicators of success would improve the

quality of the maternity service. This view wasexpressed with minimal reference to the principles out-lined in Changing Childbirth and how these re¯ectedthe broader context of care of the contemporary health

service.

5.2. Systems of care

A wide range of methods of organising and provid-

ing midwifery care were evident countrywide. The pic-ture that emerged was broadly similar to otherrelevant data (Wraight et al., 1993).


Various types of team systems were in operation at

the time data were collected for this study and theoverall picture emerged of community based teamsfunctioning quite well. They were reported to be fairly

small and to provide continuity of care to women inthe antenatal and postnatal periods. The named mid-wife system appeared to operate well within this frame-

work in many cases, with women having a namedmidwife who was responsible for planning and deliver-

ing a substantial part of the care with support fromother team members. However, there was not muchevidence of the teams providing a substantial amount

of intrapartum care, although there were someexamples where this did seem to be happening e�ec-tively and other units were making plans in this

respect.The picture that emerged of hospital care was gener-

ally less organised. In some places large teams existedbut did not provide a high degree of continuity ofcarer, and in many cases there was no indication of a

clear philosophy of care in operation to enhance conti-nuity of caring either (where continuity of carer refers

to care being provided by the same person, and conti-nuity of care/caring, denotes care that it is under-pinned by shared philosophies so that all those in

contact with women provide the same care (Murphy-Black, 1993)).Furthermore, the named midwife system had also

been implemented in some places, sometimes operatingwithin these large teams, and there was no indication

that this improved continuity of carer or caring in anyway either.It is perhaps interesting to note at this point that the

issues related to continuity of care, and continuity ofcarer continue to be much debated. Recent reports by

the Standing Nursing and Midwifery Advisory Com-mittee (SNMAC) (1998), and the English NationalBoard for Nursing, Midwifery and Health Visiting

(ENB) (1999) refer to the concept of continuity ofcarer, and discuss the progress which has been made inthis respect.

The SNMAC report concluded that midwives maybe found practising at any point along a continuum

which extends from the established pattern of provid-ing care linked to one stage of childbirth, to the holis-tic approach of providing most of the care throughout

the maternity episode. Three `transition contexts' aredescribed which include structural issues regarding themodel of care; the range of knowledge and skills used

by the midwife; and the degree of responsibility whichthe midwife exercises. Similarly, the ENB report ident-

i®ed that the extent to which continuity of carer is pro-vided within maternity services varies, but the majorityof services are operating a variety of approaches to

team or caseload practice, although it was also notedthat some schemes are only able to provide continuity

for antenatal and postnatal care. The ®ndings of these

reports are interesting as they accord with thosereported in this paper regarding the extent to whichcontinuity of carer schemes are in operation.

The ®ndings reported above in the results sectionindicate that the midwives were generally uncertain

about the importance, particularly of continuity ofcarer to the quality of care received by the woman.They were also uncertain about the feasibility of or-

ganising e�ective systems to enhance continuity ofcare, often for resource related reasons.The literature generally supports this ùncertainty,

and the concern about resourcing issues (Murphy-Black, 1993, Flessig and Kroll 1997; McCourt et

al., 1998; Waldenstrom and Turnbull, 1998). Rela-tively few research studies have so far been underta-ken regarding the outcomes of continuity of care

and carer during the maternity episode, with ques-tions being raised about the reasons for positivee�ects when these have been reported. For example,

some studies (Flint et al., 1989; Rowley et al.,1995) compared continuity of care by a small group

of midwives with care provided by several midwivesand doctors. It is not therefore possible to drawany hard and fast conclusions about whether di�er-

ences in outcome were attributable to continuity ofcare or the background of the professionals provid-ing the care.

In addition, it has also been pointed out that someschemes for continuity have deliberately selected mid-

wives who choose to work within such a system, andthis process of self-selection may of itself give rise tofactors which may in¯uence the care provided, such as

the personality and professional commitment of themidwives involved (Flessig and Kroll, 1997; Sandall,

1997).A further interesting addition to the literature was

reported by Waldenstrom and Turnbull (1998) who

undertook a systematic review comparing continuity ofmidwifery care with standard maternity services. Theyconcluded that continuity of midwifery care is associ-

ated with lower intervention rates during labour thanstandard maternity care, but no statistically signi®cant

di�erences were observed in maternal or infant out-comes. They identi®ed the need for further research tobe undertaken to investigate issues of safety for infant

and mother.This echoed the evaluation of One-to-One Midwifery

practice undertaken by McCourt et al. (1998) whichfound a strong demand for continuity of care andcarer from women receiving maternity care. The

women valued highly the supportive presence in labourof a midwife in whom they have con®dence and trust,although this may not necessarily be a midwife they

already knew. There were no statistically signi®cantdi�erences in mortality rates between those women


receiving One-to-one midwifery care and those receiv-ing conventional care, however they also reported

lower intervention rates during labour. It is interestingto note that this study also drew attention to the conti-nuing development needs of midwives throughout the

service.The implications of the above discussions for the

®ndings reported in this paper are that care is not

necessarily going to be improved by just ensuring thateach woman has a named midwife, or is cared for bymidwives working in a team and/or carrying a case-

load. It will be important for local assessments to bemade of how the systems of care are operating, andwhat the bene®ts of such a process are likely to be onthe quality of care provided, as well as the e�ects on

the midwives who are providing the care. The meetingof indicators is not necessarily synonymous with pro-viding the type of care the indicators have been set to

promote.

5.3. Facilitation of woman-centred care

Several examples that have been outlined illustratethe e�orts midwives had made to ®nd out what the

woman wanted in respect of her care and to providethat, such as continuous monitoring during labour,even if the midwife herself did not necessarily think

that was the best way to provide care. A range ofstrategies were used by midwives to facilitate women'schoices for their pregnancy and the birth. One of the

most frequently mentioned ways was through the useof care plans and/or birth plans but this was generallynot speci®cally linked to ensuring continuity. No one

spontaneously mentioned the concept of the lead pro-fessional as a potential means of ensuring continuity,despite the fact that large numbers of midwives andsupervisors considered the midwife should be the lead

professional for low risk women. The Lead Pro-fessional is de®ned in Changing Childbirth (DoH,1993a,b) as the professional who will provide a sub-

stantial part of the care personally and be responsiblefor ensuring that women have access to care fromother professionals as appropriate.

An interesting point that may have implications forthe provision of a woman-centred service relates to theway professionals view their role in relation to thewoman. There is an extensive literature focusing on

the way power dimensions may in¯uence communi-cation between professionals and service users, whichmay limit the potential for a truly woman-centred ser-

vice (e.g. Fraser, 1995; Kirkham, 1989).There was some evidence of this happening in this

study. For instance, when providing examples of ways

in which they facilitated women's choices some mid-wives indicated that they àllowed' women to choosecertain options Ð such as the person they wanted to

have with them during labour and delivery. The use ofthe word àllow' indicates the existence of a power re-

lationship, with the midwife being ultimately in controlof what the woman may or may not choose to do.However, on the whole, there were many positive

examples of midwives working towards a morewoman-centred service, although inevitably there was aconsiderable amount of individual variation in the

extent to which this appeared to be occurring. The im-portance of individually tailored education and devel-opment programmes was clearly indicated, which

midwives, supervisors and educators together may bebest placed to negotiate.

5.4. Choice of place of birth

There was considerable discussion during the case

study interviews about home births, and in the light ofthe importance of these issues in relation to currentpolicy developments. The main barrier identi®ed bymidwives, supervisors, consultants and registrars to

women having home births was the attitude of GPs.There was general support from midwives for

women's right to choose a home birth. Safety issues

were considered paramount but for low-risk women,home birth was not considered a high risk event, aview which is generally supported by the available evi-

dence (Cavenagh et al., 1984; Campbell and Macfar-lane, 1994). Some midwives considered it to be ashame that GPs prevented women from taking up thisoption but did not consider they could really do a

great deal about it. However, other midwives did what-ever was necessary to support the woman's decision,including helping her to look for another GP if that

was what the woman wanted.

5.5. Implications for service

Many midwives and supervisors indicated theirstrong commitment to providing the best possible ser-

vice, in the face of enormous structural and organis-ational change, in often very di�cult resourcingcircumstances. Many examples were provided of ways

in which midwives facilitated woman-centred care in acaring and sensitive manner. However, often this didnot appear to occur within a formal quality monitor-ing framework, and there was a strong indication that

the extent to which women's needs were beingaddressed was subject to a considerable degree of vari-ation.

The implementation of e�ective quality assurancemechanisms and the underpinning of care with morestructured frameworks at local level may enhance the

potential for meeting the needs of all service users. Themove towards more widespread use of knowledge-ledpractice within the maternity service appears to be of


considerable importance in assuring quality, andincreasing the impetus for such developments will

remain a priority.There was very little spontaneous discussion regard-

ing the types of knowledge that may be used to under-

pin quality care, and ways of drawing on clinicalexperience and research-based information to informknowledge-led or evidence based practice, in line with

current developments, were not discussed (DoH,1993a,b; Sackett et al., 1996). There was also no realdiscussion about `midwifery knowledge' or the poten-

tial that midwifery models might make in relation toinforming woman-centred care, despite there being alot of recent literature debating such issues (Bryar,1995; Midgley, 1995).

It is interesting to note that many of the issueswhich were raised by midwives and supervisors in thisstudy have continued to arise in other sources of evi-

dence. For example, the Changing Childbirth Develop-ments Projects (NHS Executive, 1998) show that thechallenges related to the provision of a woman-centred

service through the promotion of choice, continuityand control continue to be identi®ed and addressed ina variety of ways by service planners, providers and

users.

5.6. Implications for continuing education

The overall aim of the study was to investigate the

role and responsibilities of midwives in order to ident-ify continuing educational need, and develop edu-cational materials to meet outstanding need. Although

it has not been possible within the scope of this onepaper to discuss in detail all the ®ndings which arosefrom this study regarding the continuing educationalneeds of midwives, it is perhaps useful to summarise

how the ®ndings were used to inform the developmentof an open learning educational package and to makerecommendations for future developments.

It was clear that one of the priorities was to enablethe individual needs of midwives to be identi®ed, andaddressed within a framework which supported their

development in line with contemporary policy in bothpractice and education.The impetus for the development towards a woman-

centred service led the midwives and their supervisors

to identify a range of priority areas for continuing edu-cation including research, clinical skills, communi-cation, counselling skills, and general issues related to

professional practice, such as ethico±legal issues andaccountability. The clinical skills which were identi®edas a priority related to areas of practice often con-

sidered as ènhanced role' activities, e.g. intravenouscannulation, perineal suturing, ultrasonography, labourand delivery in water, interpretation of cardiotoco-

graphs. The emphasis on research related to developing

a better understanding of knowing how to determine

which research ®ndings should be used to inform prac-

tice, and how research can best be used in conjunction

with other information in relation to practice. In par-

ticular, the need for a balance between clinical and

technological skills and other types of knowledge

required to inform optimum quality care was raised an

important issue. Issues related to communication and

counselling skills focused primarily around communi-

cating with, or counselling women in relation to the

choices they may wish to make for pregnancy and

childbirth and/or informing them of the likely outcome

of their pregnancy. Other areas identi®ed less often

included counselling for bereavement, HIV/AIDS, pre-

conceptual and genetic counselling, counselling for

antenatal screening tests and smoking cessation.

As the issues outlined above were identi®ed as

national priorities for continuing education, there is a

clear need for courses to be more widely available to

midwives who want to develop their range of clinical,

technological and specialist counselling skills.

In addition to identifying these specialist areas of

continuing education, the ®ndings were used to

develop an open learning educational package: New

Dimensions in Midwifery Care (ENB, 1996) which has

been designed to enhance the move towards the pro-

vision of a more integrated, woman-centred service.

The development of relationships for e�ective prac-

tice, and the context in which care is delivered are the

key themes covered by the package. The importance of

midwives' capacity to negotiate their own practice

from a sound knowledge base in the best interests of

those using the service underpins the activities that

have been developed throughout the package.

The importance of continuing education need being

addresses within contemporary frameworks which sup-

port a ¯exible approach to lifelong learning was clearly

identi®ed in the study ®ndings. This approach remains

relevant to the most recent policy developments, for

example, Making a Di�erence (DoH, 1999). The open

learning educational package has been developed to be

used for a variety of purposes, including statutory pro-

fessional updating, the award of stand-alone academic

credit and the accumulation of academic credit which

may be used towards gaining either a generic or pro-

fessionally accredited award.

Similarly, it is recommended that the approach

taken to the development of courses for `specialist'

skill development provides a range of opportunities

including the development of practice skills, the ac-

cumulation of professional/academic credit, and the

more formal mechanisms for developing such skills

within the framework of professionally accredited pro-

grammes of study.


6. Conclusions

This paper has presented ®ndings from a nationalresearch and development project in which the conceptof individualised care within the maternity service was

explored from policy: Changing Childbirth, through towoman-centred midwifery practice. The principles ofchoice, continuity and control, which underpin

woman-centred care, are explored through the reportsof quantitative and qualitative data. There are manypositive examples of midwives working towards a

more woman-centred service, although inevitably therewas a considerable amount of individual variation inthe extent to which this was occurring. Continuity ofcare and/or carer as a means of delivering a woman-

centred service remains an area for discussion with thedata and additional literature indicating uncertaintyabout the importance of continuity of carer to the

quality of care received by the woman and her family.The importance of individually tailored education

and development programmes was clearly indicated

which midwives and supervisors may be best placed tonegotiate locally. The content and approach of theopen learning educational package aims to enable mid-

wives to identify and address their own continuingeducation needs.

Acknowledgements

This study was commissioned by the English

National Board for Nursing, Midwifery and HealthVisiting.

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