Women's Views on Partnership Working with Midwives During Pregnancy and Childbirth
United Kingdom (UK) health policy over the past thirty years has been predicated on a partnership model focusing on empowering service users to be fully involved in their care. Within maternity care partnership relationships have been conceptualised as empowering women to have continuity, choice and control (Department of Health (DoH), 1993), within a relationship of personal autonomy between the woman and her carers. In this study I sought to identify the extent to which the Government agenda for partnership working and choice is realised or desired by women during pregnancy and childbirth. In addition, I wanted to examine the level of alignment between the views of midwives with that of women accessing the maternity services. This study took a qualitative approach, drawing on the principles of grounded theory. In the first phase of the study a purposive sample of sixteen pregnant women were recruited and invited to complete a diary and to take part in two interviews. Women maintained diary entries following appointments with the midwife during pregnancy and childbirth. Semi–structured interviews were undertaken at 36 weeks of pregnancy and four weeks after the birth, based on the diary entries. In the second phase, four focus groups were undertaken with two groups of community midwives and birth centre midwives from two National Health Service (NHS) Trusts. Quotes from the diary-interviews from phase one were utilised to develop three vignettes which acted as a prompt during the focus group interviews. Following a thematic analysis of the data, I analysed women’s views on partnership working and choice. Most women in this study did not feel that they developed a partnership relationship with the midwife. This was associated with a lack of continuity of care and insufficient time to engage in meaningful discussion in an environment which was not conducive to shared decision making. Women described wide variations on the midwives role in supporting decision making. This ranged from decisions being dictated to midwives guiding choices and for some women, being facilitated to make informed choices. Many women described input of family and friends and widespread use of the internet as an information source. Women depicted their antenatal midwifery care as medicalised and felt that whilst their bio-medical needs were met their psycho-social and emotional needs were not. Women described the visits frequently as ‘in and out’ or ‘ticking the boxes’ to describe this approach to care. A small number of women (n=5) did experience a partnership relationship. Three of these women knew the midwife from a previous pregnancy; the remaining two women attended a midwifery led unit for all of their care. In relation to the choice agenda, most of the women who participated in this study were not aware that they had a choice about who provided their care or where they would have their care. The midwife focus groups concurred with the women’s findings and suggested that a lack of time was a significant factor hindering the formation of a partnership relationship. Midwives felt that this was exacerbated by the paperwork they were required to complete in order to audit care and meet the ‘payment by results’ agenda (DoH, 2003b). During the focus groups midwives identified strategies which could be implemented to enhance midwifery led care, including offering antenatal care to small groups of women and undertaking an antenatal home visit towards the end of pregnancy, to provide women with the time to discuss any issues that they wanted to explore in more depth. The findings from this study contribute to the current body of knowledge on midwifery led care particularly in providing the women’s perspective on partnership working. Women want to experience midwifery care that meets their psycho-social needs as well as bio-medical needs through a model of care that provides continuity. In contrast to previous research findings, the women in this study described community based care as mechanistic, clinically focused and time bound, more in line with an obstetric model of care than a midwifery model. However, midwifery led care offered within a birth centre was perceived by women as providing a more holistic, social model of care. Whilst continuity of care is not a new concept, what this study contributes is that despite successive administrations supporting partnership working and informed choice over the past twenty years, most of the women in this study did not experience this level of care. The findings from this study resulted in the development of a midwifery partnership model as a theoretical framework that could be utilised in future research studies to evaluate the extent to which a partnership relationship exists within a range of midwifery care settings.