Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Autonomy, Clinical Freedom and Responsibility: The paradoxes of providing intrapartum midwifery care in a small maternity unit as compared with a large obstetric hospital. A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Midwifery at Massey University, Palmerston North, New Zealand. Marion Hunter 2000 Abstract Small maternity units are an important historical feature within New Zealand. Over time many of these facilities have been closed and birth has increasingly occurred in large obstetric hospitals with the availability of technology and on-site specialists . A qualitative study using Van Manen's (1990) method of hermeneutic thematic analysis has been designed to answer the question: How is the provision of intrapartum care by independent midwives different in a small maternity unit, as compared with a large obstetric hospital? Ten independent midwives were interviewed, and data were analysed to uncover the meaning of the differences when providing intrapartum care in both small and large maternity settings. There are two data chapters that contain substantial extracts from the midwives' transcripts in order to illustrate the themes identified from the analysis of their narratives. 'Real midwifery' shows that independent midwives feel more autonomous and are able to let the labour 'be ' when practising in the small maternity units . The midwives use their embodied knowledge and skills to support women to labour and birth without technological interference. In contrast, the midwives feel that employing technology such as fetal monitoring and epidurals at the large hospital, places the focus on the machines and the mid..yife does not use all of her skills . The second data chapter, called ' carrying the can ', illustrates the additional responsibility that can at times be a worrying responsibility in the small maternity unit. When practising in the large obstetric hospital, specialist assistance is nearly always at hand and the midwives are considered to be practising in the safest place according to the dominant medical model. The paradox for midwives practising in small maternity units is that while these are a setting for natural birth, the midwives need foresight and confidence to avert or manage any problems that might arise. When midwives practise in the setting of small maternity units, they are more autonomous and have the clinical freedom to practise unshackled by technology. The art of midwifery might be lost if midwives continue to practise midwifery only in medicalised environments. 11 Acknowledgements Firstly I would like to thank the independent midwives who generously shared their experiences with me and also showed a continuing interest in the completion of this thesis. The names chosen by the participants for inclusion in the thesis are: Bronnie, Cluain Meala, Elizabeth, Grace, Joyce, Kirsty, Mary Byrne (Mary) , Nettie, Rosemary and Tyrrell. Your narratives have been a stimulus to my enjoyment of this study. Thanks to my supervisor Cheryl Benn for her academic and midwifery wisdom She has provided ongoing guidance and inspiration. Cheryl's feedback assisted me to explore participant 's narratives further and to take time to dwell with the data. Cheryl guided me forward through the journey of this study. Thanks also to Elizabeth Smythe for her critique of my interpretation and her encouragement throughout this study. Liz generously gave her time and her expertise to review the process of thematic analysis . Jackie Gunn (my employer) has assisted me in every way she possibly could, and I appreciate her consideration and concern. To all of my colleagues and friends, thank you for the ongoing dialogue about midwifery practice and your support. My nephew Brent and niece Cara gave computer and editing assistance, and other family members have always been encouraging. Thank you to Massey University for assistance from the Graduate Research Fund. Finally, thank you to Glenn for his support and understanding of the time this study has taken. He has also assisted me with equipment and resources in order to undertake and complete this study. Table Of Contents Chapter 1: Orientation to the Study Introduction Research Question and Aims of the Study Justification for the Study Study Context Terminology Midwifery in New Zealand Historical Background Independent Midwifery Practice My Background Research and Midwifery Practice Challenges for Independent Midwives Structure Of Thesis Summary Chapter 2: Literature Review Introduction History Of Small Maternity Units Safety of Small Maternity Units Use of Small Maternity Units Midwives' Use of Small Maternity Units Women's Use Of Small Maternity Units Trend Toward Large Obstetric Hospitals Medical Versus Midwifery Model of Care Medical Model Midwifery Model Adoption Of The Medical Model 'High Technology' Versus 'Low Technology' Settings Summary 111 1 1 1 2 4 4 6 7 9 10 13 16 18 19 20 20 21 26 32 32 35 38 40 40 41 43 45 46 Chapter 3: Research Design and Method Introduction Research Design Philosophical Underpinnings Hermeneutic Circle Existentials or Lifeworld Themes Pre-understandings Research Method Ethical Considerations Recruitment Consent Anonymity and Confidentiality Concern for Participants Concerns of the Researcher Participants Data Collection Data Analysis Presentation of themes and use of the data Rigour Sununary Chapter 4: Real midwifery Introduction Practising More Autonomously Having Time Giving Time Tolerating Noise Managing Options Summary Chapter 5: Carrying the Can Introduction Being Solely Responsible 1V 48 48 48 49 50 52 53 55 55 56 57 57 58 59 59 60 62 64 65 66 68 68 72 75 80 83 87 91 93 93 94 v Making Reasoned or Risky Decisions 105 Being Judged 114 Summary 119 Chapter 6: Discussion 121 Introduction 121 Research Question and Aims 121 The Lived Body: The Midwife in Different Settings 124 Lived Time: The Meaning of Time in Different Settings 129 Being Bound to a Timeframe 129 Being Vulnerable as Time Slows 131 Time and Foresight 132 Past Time 134 The Difference in the Meaning of Space 135 Re la ting to the 'Other' or 'They' 13 8 Conclusion: The Paradoxes 140 Limitations Of This Study 142 Implications From This Study 143 Implications for Practice 143 Implications for Education 144 Implications for future Research 144 Concluding Statement 145 References 121 Appendix I 164 Information Sheet for Midwife Participants 164 Consent Form 167 Appendix II 168 Letter sent to each participant with return of transcript 168 Appendix III 168 Non Disclosure Form for Typist(s) 169 V1 Non Disclosure Form for Academic Colleague 170 1 Chapter 1: Orientation to the Study Introduction This study explores the expenence of independent midwives providing intrapartum care in small and large maternity facilities . Ten independent midwives who practise within the region of Auckland were interviewed during a four-month period between 1999 and 2000. The research question, aims and method are overviewed in this chapter, and background information that prompted this study is provided within the justification and the study context. While acknowledging that readers are likely to be familiar with midwifery phrases, terminology is clarified with respect to different maternity settings. A brief history of midwifery in New Zealand and of independent midwifery practice is given to place this study within a current context. I share my background as a midwife to make explicit my pre-understandings as part of Van Manen 's ( 1990) method. Research that has contributed to the background for this study is discussed alongside the challenges to the practice of independent midwifery. Finally, an overview is given of each of the following chapters. Research Question and Aims of the Study The research question is: How is the provision of intrapartum care by independent midwives different in a small maternity hospital, as compared with a large obstetric hospital? Participants were asked to describe their experience of providing labour care to women, both in a small maternity unit and a large obstetric hospital. The aims of the study are: • To describe the expenences of independent midwives providing intrapartum care in both a small maternity unit and a large obstetric hospital • To highlight the differences m providing labour care m the different settings 2 • To identify issues that influence independent midwives' choice of environment for provision of intrapartum care No studies were located in the literature that addressed the differences experienced by independent midwives providing intrapartum care, between small maternity units and large obstetric hospitals . It therefore seems important to establish what is the experience of independent midwives within New Zealand, in relation to the research question. To achieve this, I have undertaken a qualitative study using Van Manen's hermeneutic thematic analysis . The philosophical underpinnings of this study are Van Manen's (1990) research method and Heidegger's (1927/1962) hermeneutics. The 'existentials' of lived body, lived time, lived space and lived other are used as a guide for reflection in the research process. Crotty (1998) described existentials as "structures of being that make human existence and behaviour possible-and on to a grasping of Being itself' (p. 98). Heidegger used the term 'Dasein' the 'being-there' to describe our being in the natural world, and he used the existentials. of time and space to assist our understanding of 'being-there' . This study explores the meaning of independent midwives practising differently in small maternity units as compared with a large obstetric hospital. Ten independent midwives were interviewed and willingly shared their experiences of providing intrapartum care. Being a midwife is essential to the conduct of this study and my role as a researcher is influenced by my experience as a midwife practitioner and teacher. Further detailed description of my pre-understandings and the research method are provided in chapter three. Justification for the Study Three midwife managers had indicated that the number of women birthing in small maternity units is not increasing, while the pressure on the base obstetric hospital, which is becoming increasingly overcrowded, has not been relieved. The midwife managers and I are interested in reasons why the small maternity units are under-utilised for intrapartum care. The uncovering of differences experienced by independent midwives who provide intrapartum care in both small and large 3 hospital environments, may assist understanding of the midwifery skills required to practise in each of the settings. Although small maternity hospitals have been shown to be 'safe' by a variety of research studies, the number of women birthing in small hospitals has declined. Thus occupancy frequently consists of women who have birthed in a large obstetric hospital, and then transferred to a small hospital for postnatal care (R. Kerins, personal communication, May 5, 1999). The Health Funding Authority report ( 1999) showed that in 1997 there were 4,285 New Zealand births that occurred in 'primary maternity hospitals' (small maternity units) and birthing units . This figure represents only eight percent of the total births occurring in hospitals . The Health Funding Authority report did not reveal data concerning birth outcomes with relation to place of birth. During 2001, Conroy will publish quantitative research concerning outcomes of births occurring in selected small maternity units in New Zealand (C. Conroy, personal communication, November 28, 2000). Historically, despite good birth outcomes, many small maternity units in New Zealand have been closed. Rosenblatt and Reinken ( 1984) reported that approximately one third of rural maternity units in New Zealand were closed between 1970-1983. Initially these 29 small units were closed because of concerns about the quality of care provided, while in later years cost saving was the driving force. The authors reported two major factors related to the likelihood of a unit's closure; namely low utilisation and proximity to another obstetric facility. The authors reported that 28% of births in New Zealand occurred in small general practitioner maternity hospitals during 1982 and "the most remote hospitals serve counties with relatively high Maori populations" (p. 24). Rosenblatt and Reinken described three types of maternity facilities existing in New Zealand at the time of their study: Level 1 hospitals 82 in total, designed for normal deliveries and healthy newborn babies Level 2 hospitals 18 in total, providing specialist obstetric and paediatric staff, and acting as limited obstetric and neonatal referral centres Level 3 hospitals 4 5 within New Zealand, that are major referral centres for difficult obstetric and neonatal cases (p. 5). In comparison, data from 1997 revealed six birthing units, 38 primary maternity facilities, 20 secondary facilities and six tertiary facilities (Health Funding Authority, 1999). From the time of the unpublished report by Rosenblatt and Reinken (1984), almost half of the small maternity units have been closed, whereas an additional three secondary and tertiary hospitals have been established. A study from the United Kingdom also reported declining numbers in small units where less than 10,000 women delivered in isolated general practitioner units, representing less than 1. 6% of all deliveries reported to the survey (Smith & Jewell, 1991). Study Context The study was conducted within the Auckland region where four small maternity hospitals exist in rural and urban areas. One of the small maternity hospitals was built in 1991 (against the trend of centralisation) to relieve the pressure of overcrowding at the nearby large obstetric hospital which accommodates around 5, 000 live births per annum (Health Funding Authority, 1999). Three of the small maternity units are public facilities and 925_ births were recorded in these three units during 1997 (Health Funding Authority, 1999). The Health Funding Authority (1999) released data for the year 1997 that showed 17, 782 births occurred in tertiary and secondary hospitals within the Auckland area, representing 95% of all births. The disproportion of births occurring in the secondary or tertiary facilities is evidence of the culture of births occurring in high technology environments. Terminology Clarification of terminology used in this thesis enables the writer and reader to be sure of shared meaning. Throughout the thesis there is reference to phrases peculiar to midwifery and childbirth. I assume that most readers will be familiar with such words and I have not clarified their meaning. All midwife participants are women, hence the terms 'her' or 'she' may be used during this study in 5 relation to a participant. Participants used the words 'consultant' and 'specialist' interchangeably and this referred either to an obstetric and gynaecology specialist or, less commonly, to a specialist paediatrician. Maternity settings Various tenns have been and are currently used to describe maternity settings within the New Zealand context. Selected tenns related to this study are defined. The Health Funding Authority (1999, p. 24) published the following definitions: Birthing Unit - Inpatient service during labour and delivery; no postnatal stay. (In contrast, American birthing units tend to provide for postnatal stay). Primary maternity facility - Inpatient service during labour and delivery and the immediate postpartum period until discharge home. (These units may also be referred to as Level 0 or Level I units, cottage hospitals, rural maternity units, satellite units, General Practitioner units, isolated/stand alone general practitioner units or attached/integrated general practitioner units). Secondary maternity facility - Provision of additional care during antenatal, labour and birth and postnatal periods for mothers and babies who experience complications and have a clinical need for referral to the secondary maternity service. (These hospitals may also be called Level 2 facilities , with availability of epidural analgesia and theatre facilities for caesarean section operations) . Tertiary maternity semce - Service supplied on a regional basis for women/fetuses with complex and rare maternity needs who require access to a multidisciplinary specialist team. (These facilities may also be known as Level 3 facilities, specialist units, or base hospitals that provide care for normal and abnormal birth with provision of a special care baby unit and theatre facilities) . 6 For the purpose of this study the tenns 'small maternity unit' and 'large obstetric hospital ' will be used to differentiate between a low technology unit (primary maternity facility) and a high technology hospital (tertiary facility) . The small maternity units referred to in this study are public hospitals with provision for antenatal visits, labour and birth facilities and postnatal care. The small units do not have any specialist medical staff on site and general practitioners ( GPs) would only be present when attending a woman booked under their care. At the time of this study there was at least one hospital-employed midwife on duty as 'core staff' , and independent midwives remained with women throughout their labour and would attend the small unit to conduct postnatal visits . The small maternity units referred to in this study are low technology units and do not offer epidural analgesia, syntocinon augmentation, anaesthesia for manual removal of placenta, caesarean section operations or sick baby neonatal services. Large hospitals may be secondary or tertiary facilities according to the Health Funding Authority ( 1999) definitions. For the purpose of this study, a large hospital is classified as one of the 'tertiary level facility' hospitals situated within the geographical region where the midwives practise. If women do not wish to go to the small maternity unit, or require the facilities of the large hospital, then the closest hospital is one of two tertiary facilities . Midwifery in New Zealand In this study, the words 'independent midwives ' are used to represent the participants . The historical background of midwifery in the New Zealand context is described prior to discussion concerning the term 'midwife' . The New Zealand College of Midwives (NZCoM) has adopted the World Health Organization definition that determines that a midwife must have completed a prescribed course and achieved the qualification. Murray ( 1995) explored various definitions of a midwife and applauded the NZCoM philosophy of midwifery which recognises that a midwife derives knowledge from the arts and sciences "tempered by experience and research" (New Zealand College of Midwives, 1993, p.7) . Pelvin ( 1996) believes that midwives develop with experience yet, being a midwife frequently means "being in a state of not knowing and ready for any eventuality 7 .. . some of them traumatic and life-threatening, some profound and wonderful (p. 15). Historical Background New Zealand midwives have experienced a loss of status over the years (prior to 1990), and through hospitalisation of birth, midwives themselves have become increasingly medicalised (Donley, 1986). The 1971 Amendment to the Nurses Act ended autonomy for midwives by requiring all births to be supervised by a doctor. According to Donley, the reality at that time was that few midwives were working in domiciliary practice, therefore few midwives were practising autonomously. Donley commented that midwives working in large obstetric units were simply members of the medical team where there was little opportunity for individual accountability to the mother and baby. In contrast, according to Donley ( 1986), "Midwives working in smaller maternity hospitals have retained a modicum of independence, even though their 'patients' are under the supervision of a doctor" (p. 16). Donley expressed concern for student midwives ' opportunities to learn normal childbirth if small maternity units closed and homebirth experience was limited. Donley stated adamantly that midwives would not get experience of normal birth in an obstetric unit in a large hospital where women are subjected to unnecessary interventions. It was initially consumers who challenged the loss of normal childbirth and the need for interventions. Pairman (1998b) reported that midwives were slower to grasp the implications of medicalisation and hospitalisation for their profession. In 1983 the Nurses Act had been further amended to allow pregnant women to be cared for by nurses who might or might not be midwives. This change highlighted the need for political activity if midwives were to survive as a profession. Fortunately, domiciliary and hospital midwives united to oppose any further subsuming of midwifery by nursing. Donley ( 1986) and other midwives protested against the declining number of midwives, midwives' lack of autonomy, and the acceptance of the medical model of birth by some consumers and midwives. With Donley, Guilliland, and other charismatic midwives leading the charge, consumers and midwives united to press for legislative change to restore 8 midwifery autonomy. There was a united realisation that women need midwives and midwives need women. Independent midwifery practice came about after much lobbying of government and opposition Members of Parliament by consumer groups and midwives to amend the 1977 Nurses Act. The Nurses Amendment Act was passed in 1990 and enables a midwife to take responsibility for the care of a woman throughout her pregnancy, childbirth and postnatal period (Department of Health, 1990). A midwife has professional responsibility for maternity care and does not need to consult with a doctor unless there is undue concern for either the woman or the baby. Donley ( 1990) stated, "Outside of Holland which has never wavered in its support of midwives, this legislation is probably a world leader in the industrialised world in restoring midwives to their proper and traditional role" (p. 7). Page ( l 995a) wrote, "New Zealand developed radically new systems of midwifery care that recognise the midwife as an autonomous practitioner" (p. 228). Thus the change in legislation that enabled midwives to provide sole care during childbirth is considered to be a landmark for midwife1y practice internationally. Clark (Department of Health, 1990), as Minister of Health hoped that the implementation of the Nurses Amendment Act would increase the choices available to women and their families in childbirth services. She acknowledged that a change in legislation on its own does not necessarily bring about change. A change in attitude on the part of consumers and health professionals was necessary. Guilliland and Pairman (1994) stated, "midwifery accepts its responsibilities as an emancipatory change agent" (p. 5). Midwives and women/families were ushered into a new era of maternity care where changes were rapid. With the exception of a small group of domiciliary midwives who had effectively been practising as sole providers of maternity care, midwives had to learn different ways of practice. The change to various acts enabled midwives to access laboratory tests, prescribe drugs as necessary, admit women to hospital, and claim for services provided from the Maternity Benefit schedule (Pairman, 1998b). 9 Independent Midwifery Practice The Nurses Amendment Act (1990) has enabled practising midwives to be self­ employed, or alternatively to be employed by an independent provider contracting with a government funding agency. Practising midwives can also continue to be employed by various hospital services and either provide continuity of care ( eg. Know Your Midwife/Team1 midwives) or be employed on a rostered shift basis. Hospital employed midwives perform many other roles including specialising in maternal mental health, diabetes, fetal assessment and management. Returning to the notion of independent midwifery, Pairman ( l 998a) said: The midwifery profession has defined independent midwifery as the practice in which the midwife works in partnership with the woman to provide all care throughout pregnancy, labour, birth and the postnatal period on her own responsibility. The critical elements of 'independent practice ' therefore, are the midwife 's partnership with the woman, autonomy and continuity of care (p. 7) . Pairman ( l 998a) stated that independence is defined by the way in which the midwife practises and not by her employment status . Pairman described self­ employed midwives as those who are paid for their work by the state funded system, and added that not all self-employed midwives are recognised as practising independently. However, Stewart ( 1999) alleged that being an independent midwife enables the midwife to be the primary care giver or lead maternity carer (LMC). This involves considerable responsibility for midwives who provide antenatal, intrapartum and postnatal care, but it also allows for true autonomy. The participants in this study practise as lead maternity carers and all participants provide continuity of care to their clients. The participants are therefore 1 Know Your Midwife (KYM) or Team scheme midwives differ from hospital-employed shift midwives in that they provide continuity of care during pregnancy, labour and the puerperium. These midwives continue to be employed by a hospital (as opposed to being self-employed) and generally care for 50-60 women per year, being on call for their intrapartum care. 10 independent and self-employed. For practical purposes they will be referred to as independent midwives. A choice was made to interview independent midwives only within this study in order to achieve homogeneity with regard to employment of the participant sample. Homogeneity in this regard refers to the fact that the independent midwives are free to select where to provide intrapartum care, as they are not affiliated to any particular hospital. Midwives in this study have a choice to provide intrapartum care in the woman's home, at a small maternity unit, or in a large obstetric hospital. All self-employed independent midwives in New Zealand are state funded and receive reimbursement from Health Benefits Limited, a government appointed funding authority. The Health Funding Authority ( 1999) indicated that more than half of women ( 57%) registered with a midwife as the Lead Maternity Carer in 1997. My Background I am currently working as a midwife teacher and work with midwifery students in large hospital settings and in small maternity units . I hear students say that the environments are different; some student midwives have great affinity for the small maternity units while others prefer the experience at the larger hospital. I have worked in both small and large maternity hospitals and attended homebirth over my 18 years of midwifery experience. A number of years were spent in a large hospital delivery unit where I developed skills of rapid assessment and being able to adapt to a busy environment where many women might be labouring simultaneously. As midwives, we felt we worked hard, provided the best care possible to women within the resources available and we were proud of our midwifery culture. During my own midwifery education, I recall a midwife teacher asking, "What would you do if you were at Te Puia Springs hospital?" She was trying to make us think as independent midwives, as opposed to thinking about practice in the large hospitals flush with medical staff We were predominantly placed in large hospitals however in order to 'catch' sufficient babies to register as midwives. In 11 1982 as student midwives we could not imagine a time when midwives would legally be allowed to be responsible for the care to women. However, a few student midwives including myself were able to contemplate working in small maternity units, or homebirth, at some stage of our career. We were aware that this would mean making decisions on our own and providing care when all was normal, as well as providing care when situations became abnormal or an emergency arose. My time as a midwife in a small unit was prior to the 1990 legislative change that enabled midwives to provide care to women without the involvement of a doctor. Hence, all the women who birthed at the small maternity unit were booked under the care of GPs . Women were encouraged to attend the small unit for at least three antenatal visits in order to meet the midwives and feel familiar with the environment. Some GPs expected the midwife to undertake all assessments as part of providing labour care, while other GPs attended women routinely throughout their labour. The GP might or might not have been present at the birth depending on a variety of factors. It must be acknowledged that it was dependent upon the viewpoint of the GP concerned as to whether or not primigravidae were 'allowed' to birth at the small unit. Some doctors had a policy that first time mothers had to birth at a large hospital. This probably arose from a directive from Bonham2 (1982), that high­ risk women should not be confined in a small maternity unit. According to Bonham, high risk women included, "All primigravidae, women aged 30 or over, those with a medical complication, a history of obstetric complications or of stillbirth or of neonatal death, any complication developing in the current pregnancy" (p. 2) . He regretted that most confinements were supervised by family doctors within "smaller maternity facilities some of which merely provided 2 Professor Bonham was the Chair of the University of Auckland postgraduate School of Obstetrics and Gynaecology, based at National Womens hospital from 1964-1988. He also headed the Maternity Services committee of the Health Department which over two decades monopolised maternity policy and favoured channelling births into a few high-tech base hospitals (Coney, 1988). 12 aggregated domiciliary confinement" (p. 1). Bonham's memorandum undoubtedly discouraged the use of small maternity units and Rosenblatt and Reinken (1984) reported that during 1982, approximately one third of all women who lived closest to a small unit had their babies in large obstetric hospitals . In general, midwives working in the small unit supported primigravidae and women without complications to birth in that setting. There was one occasion, however when I recall having been afraid of the potential outcome. The woman was having her second baby and the shoulders were impacted. I later discovered that the woman had had shoulder dystocia with her first baby, but that this had not been documented. I asked the other midwife to ensure that the GP had responded to my earlier call as I anticipated needing additional assistance with resuscitation of the baby. After several manoeuvrers the baby was born much to the relief of all in attendance. The GP arrived around fifteen minutes after the birth, and by that time the baby had been resuscitated and had recovered well. Midwives were expected to manage problems competently, and most of the GPs generally had a respectful attitude towards midwives' abilities . While midwives did manage several emergency situations each year, this work was generally unnoticed. Patterson (2000) described rural midwifery as requiring skilled and experienced practitioners, yet the work of these midwives is often invisible. Patterson noted that while some maternity units are so called general practitioner maternity units, it is the midwife who makes the majority of decisions and manages the labour, or initiates transfer. In many instances it is the midwife, who had to manage a haemorrhage or neonatal asphyxia with perhaps only a nurse on duty to assist her, My experience of practising in a small maternity unit has increased my midwifery wisdom, yet until undertaking this research, I had not articulated why this is so. On reflection, the small maternity unit was often considered quiet in contrast to the large obstetric hospital. Yet in the quietness, I learnt to spend time with women and to care for women throughout their childbirth experience. Hunt (Hunt & Symonds, 1995) similarly explained that she learnt the art of midwifery doing night duty in a small maternity unit, unsupported by medical staff. There she 13 learnt about physiological birth and discovered the skill of being a midwife 'with' women. Research and Midwifery Practice Extensive searching of the literature was undertaken to establish if research existed concerning intrapartum care provided by independent midwives in different settings . The majority of studies reported outcomes between different settings, and incidentally included data concerning midwifery practice. Outcomes with respect to safety in different contexts are discussed in chapter two. Studies that explore midwifery practice in Australia, Britain and New Zealand are discussed to provide a background for this present study. Research conducted within New Zealand has provided information concernmg independent midwifery practice. Moloney (1992) used critical social science methodology and interviewed five midwives employed in a large hospital. Moloney described conflict internally between hospital-employed midwives and externally between independent and hospital-employed midwives . Moloney stated, "Overt aggression is displayed toward independent midwives who are viewed by the policy of the institution to be inferior for not possessing the technical knowledge and skills to be on a.n epidural register" (p. 113). She surmised that technology fosters technical knowledge and creates elitism as opposed to liberating midwives. Critique of Moloney's (1992) thesis raises some issues that could be further explored. Independent midwifery was in its infancy so to speak when Moloney conducted her study, and Auckland hospital policies deterred independent midwives from caring for particular women. Independent midwives needed time to gain access to the epidural register and to meet the requirements of local policy. Hospital employed midwives were expected to enforce the various policies, and as a result tension between hospital and independent midwives was rife. Moloney's five participants had been qualified for only eighteen months and were working in the culture of a tertiary obstetric hospital. They felt that their philosophy of 14 midwifery from their training was not supported and this also resulted in conflict between them and senior midwives in the hospital. Fleming ( 1995) used feminist methodology to explore the concept of partnership, power and politics between independent midwives and their clients. As part of her study, Fleming deliberately sought opinions concerning the relationship between independent and hospital midwives after hearing derogatory comments throughout New Zealand and after reading Moloney's (1992) study. She found that the independent midwives acted as advocates for their clients. However often this advocacy resulted in a polarisation of ideologies held by the independent midwife and the hospital midwives. Lesley, an independent midwife participant in Fleming's study commented: A hospital system is a very hierarchical system It has a trickle down effect and regardless of what we have to say practice is still limited by the fact that there are endless power structures and you have to survive within that power structure (p. 142). Power structures emerged as an important theme in Fleming's (1995) and Moloney's (1992) study. Hotchin (1996) who also used feminist methodology, explored independent midwives ' use of unorthodox therapies . Unorthodox therapies were used mostly in homebirths,· as homebirth was also viewed as unorthodox. In contrast, the hospital was perceived as being orthodox, hence midwives working there restricted or restrained in the use of unorthodox therapies . Griffith's (1996) study supports Fleming's (1995) and Hotchin's (1996) findings that the setting influences midwifery practice. Griffith (1996) used (feminist) standpoint theory to consider the beliefs, practices, conditions and constraints that construct midwifery practice in Australia. Griffith argued that while there is awareness that midwifery is practised differently in different contexts, there is not awareness of the extent to which birth and midwifery practice is a social construction. She commented that in Australia, "this balance of power rests with the medical discourse and the ideologies of technology and patriarchy" (p. 366). Griffith categorised different maternity contexts according to the degree of medicalisation. Large teaching hospitals were 15 classified as overtly medicalised and the way of practising appropriately was defined by protocols. The midwifery discourse was at least as influential as the medical discourse in birth centres where there was sufficient flexibility to negotiate medically defined parameters of safety and protocols. According to Griffith ( 1996), midwives practising in large teaching hospitals were restricted by the overtly medicalised context with a scientific and mechanically orientated medical text. She was unsure however, where to categorise independent midwifery practice that takes place within an institution. She recognised the expectation by the institution that independent midwives work within the protocols, however whether they did or did not follow protocols was not open to public scrutiny. Hunt and Symonds (1995) conducted an ethnographic study to explore the social meaning of midwifery and birth as it happens in many British maternity hospitals in 1989. Findings include the notion that the masculine profession of medicine dominates the hospital practice of midwifery. "This is an everyday lived expenence for midwives . Independence and autonomy may have a strong ideological influence on midwifery, but in everyday practice they have to be constantly redefined" (p. 37) . According to the authors, the antagonisms present between midwives and others stem from the ·contradictions of the ideological and the work context. Hunt and Symonds found that midwives enjoyed the freedom of night duty where they were undisturbed by doctors, and the pressure to use medical interventions. The midwives who participated in their study were all hospital-employed midwives and this might have limited their ability to work autonomously of medical staff and protocols. Pairman (1998b) used feminist methodology to research the midwife/woman relationship in New Zealand and found that there are commonalties in what each brings to the partnership relationship. Taking time and sharing power and control were important to the development of the relationship where the midwife develops a "professional friendship" as part of the partnership (p. 193). One of Pairman's participants called 'Heather' described the difference between being an independent practitioner and previously working in a base hospital. Heather 16 described the restrictive 'one hour second stage' of labour in a base hospital. If this timeframe was exceeded "you would get a hard time from doctors and often other more, so called senior midwives" (p. 73). Further to comments about restricted timeframes, Pairman ( 1998b) surmised from another participant's narrative that, "even as an independent practitioner making use of the hospital facilities, she is conscious of the influence of hospital protocols on practice and the strength it takes to reject these" (p. 71) . One might ask how does the culture of a hospital exert so much influence upon the way independent midwives practise? Pairman described a positive outcome of midwives "relearning the normal" (p. 71) through questioning routines and imposed protocols within the hospital setting. Participants in Pairman's study also favoured their "freedom to practise" (p. 72) as autonomous independent midwives. Challenges for Independent Midwives As Pairman (1998b) indicated, independent midwives reflect a different way of working with women and practising normal childbirth. None the less, the history of independent midwifery in New Zealand has been fraught with opposition from sectors of society. Change often involves gains and losses and inevitably some bitterness remains. Baird, an Obstetrician,_ (McLoughlin, 1993) expressed his personal view that independent midwives were not independent as they relied on hospital staff, hospital facilities, and were totally dependent upon the state for their income. Their heavy dependence was said to be causing division and stress at the hospital. In Baird's opinion, independent midwives used hospital midwives to cover for them when they got out of their depth, which he thought was often. Donley (1989) commented that Baird had warned fellow obstetricians that the three greatest threats to modem obstetrics were: consumerism, feminism and midwives. It would be fair to suggest that some obstetricians resented midwifery autonomy and were deliberately outspoken against independent midwives . On the contrary, other obstetricians such as Enkin (Stuart, 1994) commented that New Zealand was ahead of the world in recognising the value of midwifery as an autonomous profession, and that midwives were the best-trained professionals to 17 deal with 85% of women who experience normal childbirth. Enkin commented, "One hopes the tension between midwifery and obstetricians will settle down" (p. 13) as primary care midwifery is reliant upon obstetric backup. Dissent around issues such as maternity payment and changes to the way midwives practised created tension between self-employed and hospital-employed midwives. Tensions between 'Know your midwife' or team scheme midwives and hospital-employed shift midwives occurred in other countries, long before independent midwifery was established in New Zealand. Flint, Poulengaris and Grant (1989) reported favourable outcome statistics from a study in England of four midwives who provided continuity of care. The authors remarked that while these four midwives were very supportive of one another, their independence created problems in working relationships with other personnel. The authors advised that such difficulties should be taken into account when other schemes were planned, indicating that the relationship difficulties must have been significant. Returning to the New Zealand context, O'Connor (1994) reported that some hospitals allowed employed midwives to also work independently, while Health Waikato had forbidden midwives to practise independently. If hospital employed midwives were found to be practising independently (self employed) they could expect to be disciplined. Midwives from Kenepuru hospital had also reported that they had been advised to stop independent practice. O'Connor was concerned that such threats from hospital managers would escalate conflict between self­ employed midwives and hospital-employed midwives to the detriment of the women. Butler (1994) acknowledged that although midwifery autonomy had received accolades, the changes had brought confusion about the interface between hospital and independent midwives in the practice arena, as well as causing retention and recruitment difficulties for hospitals. Experienced midwives were opting for independent practice as opposed to remaining in hospital employment. From my personal observation, the loss of experienced midwives from busy labour wards results in increased tension between hospital and independent midwives. 18 Structure Of Thesis Chapter 2: Literature Review This chapter provides a critical overview of the literature in order to place the research study within a context of existing knowledge. Chapter 3 : Research Design and Method In this chapter a description of the study using Van Manen's (1990) method of hermeneutic interpretation is provided. The design and conduct of the study are discussed with particular attention to ethics, data collection, data analysis and ngour. Chapter 4: Real midwifery Data within the context of this chapter relate to what midwives describe as practising 'real midwifery'. Sub-themes include the notion of practising more autonomously, having time, giving time, and managing options. Chapter 5: Carrying the Can Carrying the can is the other theme from the data where midwives describe the sole responsibility of providing care in a small maternity unit. Sub-themes include the notions of being solely responsible, making risky or reasoned decisions and being judged. Chapter 6: Discussion of the data, Conclusion and Implications for practice This chapter pulls together the meaning from the two data chapters and addresses the research question and its aims by showing the differences between providing intrapartum care in small maternity units compared with a large hospital. Implications for practice, education and research are presented in relation to the findings from this study. 19 Summary The orientation to this study has introduced the research question and the aims of the study, and overviewed the method. The study is designed to uncover the differences between providing intrapartum care in a small unit compared with a large hospital. The serious under-utilisation of small maternity units was used as a justification for the study. The context of the study was explained, and the number of small maternity facilities available within the greater Auckland area, separate to the facilities oflarge obstetric hospitals was recognised. Terminology relating to maternity facilities was explained. An historical overview was given of midwifery in New Zealand and of independent midwifery practice. My background experience was discussed, and any biases arising as a result are further acknowledged during discussion of the research method in Chapter three. Pertinent studies that might assist the reader to orientate to this study were discussed, as were some of the challenges for independent midwives. Challenges in the relationships between independent and hospital-employed midwives were described as this provides background understanding to lingering tensions between midwives. Finally an overview of the structure of the thesis was provided. 20 Chapter 2: Literature Review Introduction The literature review serves to place the research study within a context of existing knowledge that has relevance to this particular study (Rountree and Laing, 1996). In this instance the present study concerns the experience of midwives providing intrapartum care within small and large hospitals. During preparation of the research proposal, literature was searched to provide background information and to find out if such a study had been undertaken before. Justification for the study included the fact that few studies addressed the experience of midwives providing intrapartum care, and the significant under­ utilisation of small maternity units and over-crowding of large obstetric hospitals . Most of the literature located focussed on the outcomes of childbirth in various maternity facilities , as opposed to the midwifery care during the intrapartum process. In keeping with the underpinnings of hermeneutics, Van Manen ( 1990) advised that it is sound practice to attempt to address the meaning of one 's own data first , before turning to the literature. According_ to Van Manen, "If one examines existing human science texts at the outset then it may be more difficult to suspend one 's interpretive understanding" (p. 76) . In line with this, narratives from participants in this study were analysed for themes and meaning prior to the reading of literature related to themes that emerged from the data. This is to ensure that my interpretation comes from the data of participants, as opposed to what other authors have written on the topic. Once data analysis was completed, literature was searched by electronic searching, manual searching from reference lists and through access to Joan Donley's (author of Save the Midwife/Birthrites, 1986/1998) personal library. Electronic searching was employed using numerous different key words and phrases for different purposes. For example small maternity unit was searched under a variety of key words including birthing centre, rural maternity hospital, 21 cottage hospital, general practitioner unit, and level one hospital. Databases were accessed through CINAHL, Ebsco, Medline, Proquest Medical Library, Psyclnfo, Webspirs, and Wilson Social Sciences. During the course of this study, on-line resources have become increasingly sophisticated and more readily available. Searches ranged from 10-50 years back, depending on whether historical material was being located or whether current aspects of midwifery practice were being sought. As stated in chapter one, Griffith ( 1996) showed that the context or setting has an influence upon practice. Of relevance to this study are the contexts of small maternity units and large obstetric hospitals, hence themes concerning the maternity context, practitioners and models of care are critiqued. Firstly, the history of small maternity units in New Zealand is described followed by studies concerning the safety of small maternity units . The influences upon midwives' and women 's use of small maternity units are outlined, and the trend toward large obstetric hospitals is detailed. The midwifery and medical models of care are discussed including use of technology and interventions in childbirth. History Of Small Maternity Units Small maternity hospitals where available, provide a 'half way house' between the options of homebirth and giving birth in a large obstetric hospital equipped with caesarean section facilities . Mein Smith (1986) asserted that most New Zealand women in 1920 gave birth at home, while "approximately 35% of deliveries had occurred in hospitals" (p. 62). She commented that the transition from midwife care to doctor care had definitely taken place in New Zealand by 1924, abetted by insurance to cover the medical fee for birth. "This change to the doctor preceded the transition from domiciliary midwifery to hospitalised childbirth, which occurred between 1920 and 1930" (p. 16). By 1930, 68% ofNew Zealand women who gave birth did so in hospital. Mein Smith commented that New Zealand women experienced medical care during childbirth many years before this became common in other countries. 22 The change from midwife care to doctor preceded the change from home to hospital birth, and one might assume that the increase in hospital births was promoted by doctors. Opposition to small maternity hospitals can be traced back to the 1920s when Jellett, a former obstetrician of Ireland's Rotunda hospital, favoured the abolition of New Zealand's 200 private maternity hospitals. Some of these private hospitals, including the prestigious Kelvin hospital in Auckland, had been plagued by puerperal sepsis (Mein Smith, 1986). Jellett believed that these hospitals should be replaced by large teaching hospitals in order to improve the training of medical students and midwives, and to provide a more economical and efficient maternity service. On the other hand, Paget (employed by the Department of Health) opposed Jellett and advocated that small maternity units were the most sensible option for the small and scattered nature of the New Zealand population. Paget favoured homebirth for low risk women as this was cost effective, and he envisaged that small hospitals could manage women with complications (Mein Smith, 1986). Despite differences in opinion, Paget and Jellett united to eliminate the threat of puerperal sepsis that had given New Zealand the second highest maternal mortality rate in the developed world in 1920. Through Health Department initiatives, the mixing of obstetric women and general cases was discontinued and the Department introduced antisepsis through the use of Dettol. By 1932 New Zealand had earned worldwide acclaim for producing the lowest death rate from puerperal sepsis among eight countries which used identical methods for compiling maternal mortality statistics. However, the New Zealand statistics did not include Maori women, as only 17% of Maori women had their babies in hospitals in 193 8 (Mein Smith, 1986). The popularity of hospital birth (in small maternity facilities) arose through women being fearful of puerperal sepsis, persuasion by doctors, and the Health Department initiatives toward promoting hospital births with the aim of reducing infection. It is a sad irony that attending a hospital, such as the Kelvin hospital, increased the risk of death from sepsis for some women. Small maternity units further increased in popularity as a result of the passage of the New Zealand 23 Social Security Act 1937, that provided 14 days of free hospital care following childbirth. Fleming ( 1996) deduced that a further reduction in home births occurred as a result of free hospital confinement, which pleased the medical profession. She wrote, "Small cottage hospitals sprang up throughout the country, providing relatively homelike environments for birthing women, thereby reducing the perceived need for homebirths" (p. 348) . From the success of the Health Department's drive to eliminate puerperal sepsis, the state had established its right to manage and investigate maternity services. The Maternity Services Committee (1976) was one of the many committees to review the provision of maternity care. While small maternity hospitals were described as having "incomplete facilities" (p. 38), advantages were described as a homely atmosphere that fostered good emotional relationships and high rates of breastfeeding. The Maternity Services Committee reported that 27 maternity hospitals existed where a "single handed doctor" (one general practitioner) provided care. The committee opposed single-handed maternity units and recommended that they serve only as maternity aftercare units. The report also recommended the closure of an additional 15 small maternity hospitals that existed with general patient beds, in view of the risk of infection. The Maternity Services Committee ( 197 6) also recorded concern about the standards of care. The report stated, "Some doctors were frankly hopelessly inexperienced, some being straight from medical school and others from alien cultures abroad" (p. 52). With regard to the role of the midwife the committee stated: The responsibilities of the midwife, particularly in a small hospital without resident medical staff can be very considerable, either when she feels that she has a patient with an abnormality or in terms of deciding how far she can allow matters to proceed without seeking consultation with the doctor, who may be very busy in his surgery or on his rounds (p. 54). In acknowledging the considerable responsibilities of a midwife, the Maternity Services Committee (1976) authors indicated subservience from midwives with 24 reluctance to call a doctor who might be busy elsewhere. When analysing this report, admittedly a quarter of a century after it was published, judgements are apparent concerning the ethnicity of general practitioners and regarding the age of the midwives who worked in small maternity units . A discourse analysis might find that the language used in the report was congruent with values held by the members of the committee at that time in history. Ten of the fourteen board members were medical doctors and four were midwives. From their investigation, the Maternity Services Committee (1976) recommended closure of 42 or half of the smaller obstetric units in New Zealand, partly on the assumption that hospitals with fewer than a hundred deliveries annually were unsafe. Rosenblatt, Reinken and Shoemack ( 1985) estimated that approximately a quarter of births in New Zealand occurred in small general practitioner maternity hospitals at that time. However 33 rural maternity units, most being the only hospital in that rural community, were closed between 1970-1984. Donley ( 1986) commented that by 1984 in the greater Auckland area, "only five small hospitals remained" (p. 111 ). Rosenblatt et al. added that The Maternity Services Committee Board of Health report was responsible for regionalisation of maternity services, with a belief that availability of technology meant greater safety in childbirth. Large hospitals were necessary also for the future training of doctors . Regionalisation of maternity sefVlces began in the 1970s, and by 1980 most maternity units were part of a formal regionalised perinatal care system (Rosenblatt, Reinken & Shoemark, 1985). That is to say that small cottage hospitals in rural and urban areas were closed and centralisation of maternity care was organised into large hospitals. The Health Funding Authority ( 1999) published the number of births in 'primary maternity hospitals' during 1997. These ranged from only three births in Ranfurly and the Chatham Islands maternity units, to the highest rate of 418 births at Kenepuru maternity unit. The authors indicated that from the time of data collection to publication of the Health Funding Authority report, two more of the small maternity units had been closed. 25 New Zealand is not umque concernmg closure of small maternity facilities. Campbell ( 1997) recalled that small units were similarly closed in the United Kingdom on the grounds that they were less cost effective than large centralised consultant obstetric hospitals . However the little evidence available, mostly from the 1970s, tends to point to the opposite conclusion. Despite this evidence, the United Kingdom along with countries throughout the developed world have moved toward increasing the concentration of births into consultant-led hospitals over the past 50 years . Walsh (2000a) reported that midwives and consumers lamented the closure of the many isolated general practitioner units in England during the 1980s. Walsh said these units were closed under the smokescreen of safety and economics, whereas the real reason was control of childbirth by obstetricians. Curtin ( 1999) reported a small increase in births occurring in freestanding birthing centres in the United States of America, possibly due to the lower cost of confinement compared with large hospital care. Returning to the New Zealand context, Larkin ( 1985) wrote of action taken by Auckland consumers and midwives to save small maternity units from closure. Midwives initiated new ways of working in these units in an effort to avert closures. O'Leary and Bilton (1993) commenced a hospital based midwifery team scheme at the Papakura maternity unit aimed at increasing births there. They commented, "While the three level 0 units in South Auckland have survived 'round one', there is still considerable anxiety about their continued existence" (p. 20) . Hendry (1995) established a 'Continuity of Care Midwives' scheme at the Burwood birthing unit at Burwood hospital, Christchurch. This resulted in an increased number of women choosing to birth at the unit and an increase in Maori women using the unit. Transfer rates to the base hospital remained at around 8- 12%. 26 Safety of Small Maternity Units Small maternity units have been closed throughout New Zealand and in the United Kingdom on the grounds that they are unsafe for labour and birth, and/or that small maternity units are not economically viable. In discussing the safety of small maternity units, Rosenblatt et al. (1985) undertook a landmark study within the New Zealand context. Additional studies are presented later in this section concerning maternal and neonatal outcomes and the economics of small maternity units . Sociological studies have also contributed to the literature concerning safety of childbirth, and as such, are discussed. Findings from the Rosenblatt et al. ( 1985) study are particularly significant in showing the safety of small maternity units in New Zealand. Data were obtained from the National Health Statistics Centre of New Zealand concerning all births, birth weight, perinatal deaths, and the location of births, over a three-year period. These authors found that babies of normal birth weight born in small maternity hospitals had a lower perinatal mortality rate than normal birth weight infants born in larger obstetric hospitals . Rosenblatt et al. ( 1985) concluded that "The significantly lower perinatal mortality rates of normal-weight infants in level 1 hospitals by comparison with level 2 and 3 facilities may indicate that low-risk mothers fare better in low technology environments" (p. 431 ). The favourable statistics in New Zealand's small maternity units were further explained by Rosenblatt et al. (1985) who commented that New Zealand's maternity care is more tightly organised and uniform. High-risk patients are identified and sent to referral centres before delivery. "General practitioners and midwives are responsible for most normal deliveries, and most maternity hospitals have no specialist coverage" (p. 431). In this context, Rosenblatt et al. confirmed that obstetrics is safe in small hospitals. The authors did not support plans to close small maternity units on the assumption that those with less than 100 deliveries annually were unsafe. Fleming (1996) noted that the Rosenblatt et al. (1994) report was never put into general circulation as it contradicted the intentions of the New Zealand 27 Postgraduate School of Obstetrics and Gynaecology. Donley ( 1986) also objected to the report being embargoed by the Health Department and wrote, "This is monstrous, as the report's findings challenge many of the assumptions behind the strategic plan" (p. 114). The report did not support centralisation of maternity services into large hospitals, hence the government did not release it. A number of other studies internationally, supported the continuation of small maternity units. Taylor, Edgar, Taylor and Neal (1980) conducted a comparative study in West Berkshire, England concerning safety between general practitioner units and a consultant unit. The authors found no difference in maternal or infant morbidity or mortality in the different settings. The authors noted that the cost of services in general practitioner maternity units was half that in the consultant unit, and restricting confinements to a consultant unit could not be supported. At a similar time Ashford (1978) examined regional statistics from England and Wales concerning perinatal mortality for selected years between 1963-1973. He compared the outcome in consultant units, general practitioner units, and in home confinements. "The overall perinatal mortality rate was substantially higher in the consultant units than in the general practitioner units, which in tum was the same as for home deliveries" (p. 29) . Even when allowance was made for low birth weight infants, mortality remained higher · for infants above one and a half kilograms born in the consultant units . However the author did state that this might be representative of the case-mix attending consultant units . Ashford noted a paradox with general practitioner units providing a less intensive form of institutional care, but they cost almost twice as much per delivery compared to a large hospital. From an economic perspective, Ashford recommended closing general practitioner units and expanding domiciliary services. In response to Ashford's viewpoint, Huntingford (1978) reviewed trends in obstetrics, and recalled that the Cranbrook committee (United Kingdom) had recommended in 1959 that small units be established to reduce domiciliary confinement. The committee had also recommended that general practitioner maternity beds were "best situated within, or very close to, consultant maternity hospitals" (p. 232). By 1970, the majority of women in England were delivered in 28 consultant beds, indicating that obstetricians had gained control over where women birthed. Huntingford concluded that the closure of small units due to cost, instigates other costs, including the loss of a personal local service, and resentment caused by the removal of choice. American authors have also been active in researching the safety and cost of birthing units compared with large obstetric hospitals . Feldman and Hurst (1987) matched two groups of low risk women in New York. One group birthed in a freestanding birth centre while the other gave birth in a tertiary care teaching hospital. Women in the birth centre tended to have longer first and second stages of labour, yet there was no difference in neonatal outcomes. Women in the tertiary hospital were significantly more likely to have amniotomy, use of intravenous infusion, anaesthesia and analgesia, episiotomy and forceps. Feldman and Hurst concluded that evidence is mounting, that out-of-hospital birth centres offer an alternative as safe as large hospital settings. Secondly, the birth centre alternative or small unit provides safety with less intervention, and possibly less cost. Sangala, Dunster, Bohin and Osborne ( 1990) undertook a large prospective study in England, where 14,415 births occurring in a consultant unit, isolated general practitioner units and integrated general practitioner units were analysed. The authors found that perinatal mortality rates due to asphyxia were more common in the isolated general practitioner units ( 1. 511000) than in the consultant unit (0.611000). However, the authors collated statistics according to the initial booking venue, as opposed to the actual birth venue. Women who had an intra uterine death prior to labour, were deemed to be part of the statistics of the isolated unit, if that had been their original booking. The findings showed that "there was an excess of fetal deaths during labour among babies delivered in the isolated general practitioner units, suggesting that intrapartum care in these units was partly at fault" (p. 301). The authors concluded, "As skilled anaesthetic and paediatric services can be quickly available only in the consultant unit it could be said that all deliveries should take place in that unit, with transfer back to the isolated units for care shortly after delivery" (p. 301). The authors also recommended that all women were seen by an obstetrician during pregnancy to conduct risk scoring. 29 These statistics are m contrast to the Rosenblatt et al. ( 1985) findings, and Campbell ( 1997) issued a cautionary note advising readers to question the statistical analysis from the Sangala et al. (1990) study. Campbell did not elaborate on faults within the statistical analysis. However as mentioned previously, fetal deaths that occurred antenatally were attributed to the small units' statistics if that had been the venue chosen at booking. Pertaining to statistical analysis, Tew ( 1990), a medical researcher, revealed that published statistical data had been deliberately misinterpreted in the United Kingdom from 1958-1970. Data were collected concerning every birth, live and still, that occurred in Britain in one single week of each year. The 1958 study collected information for the following three months about every stillbirth and neonatal death. Tew stated that an impartial observer could clearly see that the perinatal mortality rate was higher in hospitals, yet this fact was distorted in the report. The experts claimed, "The family home is the most dangerous place for birth" (p. 29). Obstetricians throughout the world used the false interpretation of these statistics to influence the future development of the maternity service. A study conducted by Hundley et al. ( 1994) compared outcomes between women who birthed in a midwife led unit with no doctor involvement and women who birthed in a consultant unit. Women considered low risk at booking were randomised to birth in each facility and 2,844 women agreed to participate. Women allocated to the midwife unit were less likely to have continuous electronic fetal monitoring, and tended to use natural methods for pain relief. There was no significant difference in outcomes between the groups except that women in the consultant unit had more interventions. The authors surmised that the lower rate of intervention in the midwife unit points to this being the most effective option for women at low risk. However, the authors cautioned that the high rate of transfer for primigravidae indicated that antenatal risk scoring is unable to determine who will remain at low risk during labour. A number of obstetricians have favoured 'risk scoring' of women with a belief that an obstetrician should advise the most appropriate venue for labour and birth (Morrison, Carter, McNamara & Cheang, 1980; Knox, Sadler, Pattison, Mantell & 30 Mullins, 1993; Walker, 1995). O' Driscoll and Meagher (1986) similarly believed that the obstetric consultant should involve himself with the "larger number of perfectly normal women who had hitherto been overlooked at consultant level because they suffered from no organic disease" (p. 3). He believed that ironically, most of the problems arise in the women who are considered to be 'normal' . Despite such claims, Tucker et al. ( 1996), in a multi-centre randomised controlled trial, showed that routine specialist visits for women initially at low risk of pregnancy complications offer little or no benefit concerning safety. A further large study on birth centre outcomes was undertaken in Stockholm. Waldenstrom and Nilsson (1997) reported that 1860 women were randomised to either birth centre care or to standard care. All care took place on the same prerruses of a major hospital, although electronic fetal monitoring, pharmacological pain relief, induction and augmentation of labour were not available in the birth centre ward. Midwives attended women in the birth centre and they made their own decisions about transfer according to established guidelines. Within the standard care ward, midwives provided labour care, but an obstetrician was usually on hand. Women at the birth centre had slightly longer labours and less medical intervention than the women in standard care. There was no statistical difference in infant health and maternal health between the two groups. Rooks, Weatherby and Ernst ( 1992) conducted a prospective study of 11,814 women admitted for labour and delivery to 84 freestanding birth centres in the United States of America. The transfer rate of women, usually for prolonged labour was 12%. Birth centres used few invasive, uncomfortable or restrictive procedures and had fewer caesarean sections. The authors concluded that birth centres offer a safe and acceptable confinement for selected pregnant women. This study has reviewed the largest number of women who have given birth in units away from consultant hospitals and found that outcomes are satisfactory. Goer (1995) concurred with the previous two studies and stated, "Birth centre studies uniformly report outcomes equivalent or superior to those of comparable women giving birth in the hospital" (p. 320). Campbell, Macfarlane, Hempsall 31 and Hatchard (1999) conducted a prospective cohort study of low-risk women who booked at Bournemouth, a midwife led unit, and the consultant led unit at Poole. Women who booked at Bournemouth were more likely to use a water bath during labour, whereas women booked to deliver at Poole had higher rates of induction, augmentation, pethidine and epidurals. The authors concluded, along with other studies, that there were no differences in outcomes between the two units, however there were significant differences in practice. Differences in practice appear to be related to the different maternity settings . Campbell et al. (1999) stated, "It is not so much who provides the care during labour but the philosophy underpinning that care and the context in which it is provided" (p. 190). In other words, if the philosophy of the unit supports natural childbirth, general practitioners and midwives working there are more likely to practise normal childbirth. Alternatively, if the context is highly medicalised, practitioners tend to adopt a philosophy of medicalised practice and use interventions during labour. Tew (1986) analysed outcomes between home, unattached general practitioner units and consultant hospital obstetric units, and found that obstetric interventions intrapartum, did not reduce the perinatal mortality rate. Tew commented that it was extremely unfortunate that the improvement in perinatal mortality rate, that was bound to follow the improvement in health status, should have coincided with the expansion of obstetric intervention. Too many doctors incorrectly assumed a cause and effect, and the assumption has remained. Wagner ( 1994) lamented the demise of small maternity hospitals and noted, "The trend to hospital birth has been accompanied by a trend to close maternity units in small hospitals with the justification that larger hospitals, where obstetricians and technology are in place, are safer" (p. 14). Wagner stated that numerous studies, as shown by this literature review, do not support this claim. Some sociologists have paid particular attention to childbirth and shown concern regarding interpretations of safety. Annandale (1988) conducted a study using both quantitative and qualitative methods to study the structure of birth in a birthing centre in America. Her study included 18 months of observation, repeated 32 focus group interviews and content analysis of 900 women's records over a five­ year period. Obstetricians did not see women unless a risk factor arose, however Annandale commented that midwives and obstetricians disagreed about what constituted a risk factor. Midwives tended to disagree with post-term inductions and also the use of interventions after twelve hours of rupture of membranes. Annandale found that birth centre midwives adopted strategies to maintain the 'normal' such as encouraging women to stay at home until active labour was well established. This strategy reduced the likelihood of transfer to a large hospital for perceived prolonged labour. This section has provided findings for and against births occurrmg m small maternity units . Some of the units studied were 'free-standing' units while others were attached to large obstetric hospitals. Rooks et al. (1992) and Waldenstrom and Nilsson ( 1997) conducted large trials and concluded that birth is safe in small maternity facilities . This confirms the findings from Rosenblatt et al. (1985) that New Zealand women fare better in low technology birth environments. The purpose of the following discussion of the literature is to analyse why small maternity units are or are not utilised. Use of Small Maternity Units Midwives seem to be free to choose whether or not to practise in the setting of the small maternity unit. The literature suggests that midwives frequently determine the place of birth and that there is an inverse relationship between years of experience and willingness to practise in a small unit. Women's use of small maternity units is influenced by attitudes to childbirth and a preference for homelike surroundings. Influences upon midwives' and women's use of small maternity units are discussed. Midwives' Use of Small Maternity Units Since the amendment to the New Zealand Nurses Act (1990) midwives have been able to offer women a number of options during the birthing process. Hedwig and Fleming ( 1995) stated, "Autonomous midwifery practice permits midwives to attend births at home, in birthing units or in hospitals" (p. 217). Gulbransen, 33 Hilton, McKay and Cox ( 1997) similarly commented, "The optimal maternity system will include home, birthing centre, and hospital, with those responsible working in partnership and cooperation for the prime benefit of mother and child" (p. 89) . Hendry (1996) noted that midwives who work in small community hospitals are able to offer women continuity of care, and have been doing so for many years . Continuity of care is possible with fewer births occurring in small units, in comparison with large obstetric hospitals . Independent midwives are able to provide intrapartum care to women in small maternity units, provided that a unit exists in their district. However, a number of authors found that a midwife frequently determines the place of birth according to her own beliefs. Levy ( 1999) found that the personal opinions and attitudes of the midwife influenced the facilitating of informed choice for women. Information is provided within the context of the midwife's bias. Jabaaij and Meijer ( 1996) confirmed that midwives in favour of women birthing at home, did indeed attend more home births; or if they were comfortable with 'low tech environments ' they were likely to use small maternity units . The midwives had a strong influence upon the place where birth occurred. Woodley (2000) wrote about her concern that Papakura (South Auckland) maternity unit was under-used for intraparium care. Woodley questioned, "the social, economic and emotional costs of directing. women to an inappropriate place of birth based on so called women's-choice" (p. 3) . She implied that midwives influence women as to where they should give birth, and all too frequently the recommendation is for women to go to a large obstetric hospital. Axe (2000) and Stuart (2000) have suggested that interventions commonly used in large obstetric hospitals might contribute adversely to the woman's emotional well-being. Woodley's comments also remind midwives to consider the effect of the environment of birth on women's health. A high technology, medicalised birth environment is frequently a less satisfying environment for women than the setting of a small maternity unit. This alone should be an incentive for midwives to offer women the choice of giving birth in a small maternity unit. 34 Page (1995a) referred to the 1993 report 'Changing Childbirth' published in Britain that gave women the right to make choices about their care, including the place of birth. Choice over the location of birth is an important issue for many women, and may affect women's subsequent psychological well-being (Creasy, 1997; Walker, Hall & Thomas, 1995) . These authors suggest that women want the choice to birth in small maternity units, and it is important for women's physical and psychological well-being that an opportunity is given for those without obstetric problems, to labour and birth in this setting. With further regard to choice, Steele ( 1995) noted that midwives should provide women with researched evidence to assist decision-making concerning the place of birth, while Guilliland and Pairman (1994) emphasised the need for the midwife to follow the woman wherever she chose to give birth. Griffith ( 1996) commented that it is not for midwives to tell women how and where they should birth, and midwives need to support women to make an informed choice. Symon ( 1998) surveyed midwives through a questionnaire as part of his doctorate study. Midwives who were not already working in a midwifery run unit, were asked if they would be happy to do so, taking full responsibility for a woman's care. Replies were received from 1,522 midwives. The majority of midwives (76%) stated they would happily do so, and -24% said they would not. Midwives with more than 20 years of experience, and those working in units with 2000-2999 deliveries per year were least likely to say 'yes'. Reasons for not wanting to work in a midwifery run unit included, preference for consultant cover and full facilities, not having enough experience (although most of these midwives had 20 or more years experience!), not having enough confidence, fear of complications, and fear of litigation. Symon reported the following comments from a midwife participant: I strongly believe that these units are an excellent means by which midwives (particularly junior ones) can develop their true midwifery skills and practice - working in an obstetric or consultant unit should be seen as a different type of practice altogether. Many of today's midwives do not seem to know the difference or care for that matter (p. 45) . 35 Graham ( 1997) indicated that it might be a certain type of midwife who prefers to work in settings away from the dominance of obstetricians: It is intuitively obvious that systems of care which give the practitioner more independence in decision making, a homely environment in which to work, continuity of involvement with women, and a focus on nonnality and natural childbirth will attract particular individuals (p. 396). The statements above suggest that 'true' midwifery skills develop when a midwife practises in small maternity units, whereas a different type of practice is apparent in a consultant obstetric unit. Graham concluded that more independence and a focus on nonnality might be more enjoyable for some midwives. As stated previously, independent midwifery enables midwives to provide intrapartum care in a variety of settings . It seems likely that the midwives' personal beliefs and length of time practising in a large hospital, (the more years of experience in a large hospital were inversely related to a desire to practise in a small maternity unit), might influence their choice of venue for provision of intrapartum care. Women's Use Of Small Maternity Units This sub-theme explores the factors that influence women's use of small maternity units . Lazarus (1997) suggested that the feminist movement has urged women to make choices and to control their own lives, including the childbirth experience. Lazarus said, "Women's decisions are influenced by their acceptance of or ambivalence toward ever-increasing use of advanced technology" (p. 150). Rejection of interventions during childbirth will encourage women to birth in alternative settings, whereas a desire for epidural analgesia or caesarean birth will influence women to utilise large obstetric hospitals. The following discussion includes reasons for women selecting to use low-technology small maternity units and reasons for women rejecting them The following studies have examined the environment of birth, and women's experiences of birth in particular settings. Walker et al. (1995) used in-depth 36 focussed interviews to elucidate the experience of women receiving care m a midwife led unit, anonymously located in Britain. These authors found that having choice over the location of birth emerged as such an important issue that they recommended this be examined further in the future . The relaxed atmosphere and friendliness of midwives drew much comment from clients in this study. Proctor ( 1998) conducted focus group interviews with women and midwives in Yorkshire, England. She discovered that women want locally provided maternity care, and homelike surroundings that conveyed that their experience was normal and that they were not ill. While homelike surroundings are valued, the hospital environment is perceived as being safe and as having less risk than a home birth, therefore women frequently submit to a hospital environment for intrapartum care (Berg, Lundgren, Hermansson & Wahlberg, 1996; Bluff & Holloway, 1994; Machin and Scamell, 1997; Ogden, Shaw & Zander, 1998). Daly-Peoples (1977) commented on the use of small maternity units at a time when a number of these faced closure. She agreed that many New Zealand women feel safer in a hospital and that in some circumstances homebirth might not be a viable option. She said, "For these women, smaller local hospitals can offer safe, convenient and comfortable maternity services without the impersonal routine of large institutions" (p. 24) . She regretted the fact that small hospitals have been closed on economic grounds. Yet it is not the women who refuse to use these small hospitals, it is the doctors who will not attend birth unless they have the elaborate 'back-up' services provided by base hospitals. One may ask if this complaint could also be directed against some midwives, who currently do not offer women the choice of giving birth in a small maternity unit. Use of birth centres and small maternity units is frequently associated with natural birth. Waldenstrom, Nilsson and Winbladh (1997) claimed that the very nature of birth centres encourages natural childbirth, limiting the use of medication and technology during labour. Waldenstrom (1998) concluded from a descriptive study undertaken in Stockholin that women enjoyed "parental participation in decisions, responsibility, freedom and individualised care" (p. 212) in small maternity units. Annandale (1988) revealed that from her study in the United States of America, a third of the women initially chose a birth centre, as they had 37 no msurance. However, as pregnancy progressed the commitment to a natural ideology grew, and the commitment to birthing in a birth centre was cemented. Bennetts and Lubic ( 1982) described a freestanding birth centre in the United States of America as a 'maxi-home' and admitted that these were established in response to discontent with hospital birth. However they had not been supported by the American College of Obstetricians or paediatricians. Women and midwives using low technology birthing settings may endure opposition from the medical fraternity. Women from England and Australia also wanted the opportunity to use a birth centre as opposed to a large hospital. Campbell et al. ( 1999) when reporting on the Bournemouth study, (previously referred to with regard to positive outcomes for women who gave birth in the midwife led unit) acknowledged that widespread public consultation rejected the centralising of all births into a consultant hospital and that hence the Bournemouth midwifery led unit was built and established. Rowley, Hensley, Brinsmead and Wlodarczyk ( 1995) cited two Australian ministerial reviews that recommended increasing the number of birth centres in each state. The homelike surrounds of small maternity units combined with the safety of a hospital, appeal to a certain number of women. The previous authors emphasised the importance of women's choice regarding the venue for birth, women's expectations of safety, and some women's desire for natural childbirth in a small maternity unit. In contrast, Lo Cicero ( 1993) reviewed reports on the interactions between obstetricians and women in labour, and found that women are more likely to submit to authority. She found that gender and psychosocial development contributed to women's acceptance of interventions during labour, that women have a tendency to trust the experts and that epidural analgesia enables a woman to maintain feminine stereotypes such as quietness. LoCicero argued that birth in high technology hospitals is perpetuated by gender and psychosocial factors . 38 Trend Toward Large Obstetric Hospitals As stated previously, childbirth shifted in the early 1920s from home to maternity units where women hoped to avoid the peril of puerperal sepsis. Papps and Olssen ( 1997) stated, "Medical control was consolidated in 1935 when the Labour government took power and made hospitalisation under the medical profession a key plank of its welfare policies" (p. 98). This resulted in the eventual demise of small private and public maternity units that were replaced by large obstetric hospitals suitable for teaching medical students, such as National Women's hospital, built in Auckland in 1946. McLaughlin ( 1993) agreed that from the 1950s, birth was shifted out of cottage hospitals, which had replaced homebirth, into large high-tech obstetric hospitals. The cycle from homebirth to birth in small local maternity units, to birth in large obstetric hospitals, occurred within a thirty to forty year timeframe in New Zealand. A scientific systems approach was applied to the New Zealand maternity service that advocated centralisation of hospital services and streamlined organisation. Other influences also contributed to the development of large obstetric hospitals . Most middle class women's organizations supported the process of medicalisation and helped Doris Gordon lobby for a professorship in obstetrics . Doris Gordon advocated twilight sleep, an anaesthetic used during childbirth from the 1920s in New Zealand. She had personal experience of this medication with all of her four children and touted its benefits to women (Donley, 1986). Papps and Olssen ( 1997) remark that the use of drugs required a change in the scale and type of hospitals, from small to large. In the present day, epidural analgesia gives women the opportunity to be pain-free and conscious while interventions occur, and many women elect this option of childbirth (Jowitt, 2000). Of particular relevance to New Zealand's change to large hospitals, is the effect upon Maori women. Donley ( 1986) noted that hospitals were alien to Maori and that the routine performance of vaginal examinations, often by male doctors, was a particularly traumatic experience. Mikaere (2000) reflected that the state, through hospitals, assumed control over Maori childbirth alienating women from their whanau. She also noted that internal examinations were a complete 39 denigration of tapu and that "the absence of karakia must have been extremely difficult for many of the women" (p. 14). Whiteside (1982), a member of the Maori Women's Welfare League, questioned the practices at large obstetric hospitals where patients' privacy, cultural values and confidentiality were ignored. She challenged the routine use of ultrasound scanning and fetal heart monitoring that was used so liberally on women and babies. Whiteside expressed her anger at the large hospital saying, "We are treated like lifeless carcasses on a freezing works chain, then if we object we are labelled anti-hospital or Maori activists" (p. 37). Rama and Taiatini (1993) and Timutimu (1992) commented that independent midwifery has offered significant changes for Maori, with Maori midwives forming collectives and offering women choice concerning place of birth and an acknowledgement of cultural customs. Rimene, Hassan and Broughton (1999) challenged maternity services to offer an environment that is conducive to wahine Maori and their whanau. Perhaps the small maternity setting with a friendly, home like ambience might be less alienating and suit the needs of Maori women, as opposed to the busy crowded environment of large obstetric hospitals . Large obstetric hospitals and centralisation ·of maternity services occurred as a result of medical control over childbirth, modernity and the desire for painless, safe childbirth. Women were encouraged to use effective analgesia that was only available in the setting of large hospitals . The literature acknowledges that Maori women have experienced alienation of traditional customary values and trauma through been confined in large hospitals . Independent midwifery schemes that were established to offer Maori women choice concerning place of birth and a culturally safe experience were noted. The different maternity settings seem to foster different philosophies of practice. This will be reviewed in the following section through an exploration of the medical and midwifery models. 40 Medical Versus Midwifery Model of Care This section aims to describe the medical and midwifery models of care and the intersections between the two models. The models of care are important as they influence the type of care that is offered to women and their families during the childbirth experience. Discussion of models serves the purpose of "accentuating differences" (Rooks, 1999b, p. 370), whereas the reality is that differences may be relative and dependent upon context, practitioner and women. Medical Model It is not within the scope of this literature review to detail the history of obstetrics and science, but to provide an overview of how obstetrics and obstetricians have dominated the provision of facilities and practices for birth, and the model of care under which many or most practise. Griffith (1996) stated adamantly that the context of a large hospital reproduces the medicalised model and manages women giving birth, as well as managing the midwives working in this environment. Historically it would appear that with a nse in scientific methods there was a similar rise in hospitalisation and interference during childbirth (Donley, 1995; Fleming, 1995; Hewison, 1993; Katz Rothman, 1991; Papps & Olssen, 1997; Sakala, 1988). These authors informed readers that increased use of technology during childbirth is supported by the medical model and is believed to be associated with lower maternal and infant mortality. Medical technology is associated with large hospitals and in tum is associated with safety in childbirth. Timeframes of labour are redefined in the medical model and medical intervention is used to shorten labour. Obstetrics developed from within medicine for the purpose of dealing with the pathologies of pregnancy and childbirth (Bryar, 1995; Rooks, 1999b). The medical model's focus is on the pathological potential of pregnancy and birth with an underlying belief that women's bodies are imperfect and liable to require assistance during birth. Most obstetricians would see themselves as having the authority and expertise to be the key decision-maker for a woman in order to achieve the safest outcome for her baby/babies. Hunt and Symonds (1995) and 41 Fleming ( l 998a) considered that obstetrics normalised technology and childbirth, and that this became acceptable to many women and midwives. The medical model of childbirth is predominant and most women give birth in large hospitals with access to pain relief. Consequently, the majority of midwives provide care in large obstetric hospitals with a medicalised philosophy of practice. Fox and Worts (1999) and Tew (1986) concluded that the medical model defines childbirth as hazardous, and that routine interventions are imposed upon an essentially natural process . Obstetricians who work within a medical model aim to impress upon women the conviction that technology is superior to nature. Fox and Worts maintained that women choosing to access help with pain, such as epidural analgesia, "can be understood as rational in a society in which pharmaceutical and technological intervention is accessible and commonly accepted" (p. 337). Tew (I 985) observed that obstetricians believe that birth is safer if it takes place in a consultant obstetric hospital equipped with the instruments of high technology, as opposed to a place not so equipped - a general practitioner maternity unit or the home. Reiger ( 1999) similarly described the medical model as having an underlying assumption that no birth was normal except in retrospect. The body as a machine, and especially women's bodies, were liable to faulty functioning . "Hence the acute care, high-tech hospital setting was portrayed as the only environment able to cope with breakdown" (p. 395) and thus the only environment in which childbirth could safely occur (Papps and Olssen, 1997). Midwifery Model In contrast to the medical model, the midwifery model of childbirth derives from a view that childbirth is a normal part of women's lives and a belief that women's bodies are well designed for birth (Rooks, 1999b). Midwives are expected to be guardians and experts in normal childbirth or uncomplicated pregnancy, and to avoid unnecessary obstetric interventions such as electronic monitoring of the fetus and epidural analgesia. The midwifery model also acknowledges that the pregnant woman, as an active participant, has the right to make decisions about her experience (Guililland & Pairman, 1994; NZCoM, 1993). 42 Pairman ( 1998c) explained how the new professional relationship between the woman and the midwife challenges the dominant medical model of childbirth. The midwife and the woman work together in partnership which integrates the notions of 'being equal', 'involving the family', 'building trust', 'taking time' and 'sharing power and control' (p. 6) . The notion of partnership has been critiqued and challenged within midwifery. Skinner ( 1999) advised that partnership might require a homogeneous population of women who are willing and able to be partners. She described the risk to the midwife if the plan for care is outside the medical paradigm, and something 'goes wrong'. With hindsight and pressure, "The family moves paradigms often