Title: Factors influencing the utilisation of free-standing and alongside midwifery units in England: A Mixed Methods Research Study
Funder: Department of Health and Social Care

Abstract: Government policy for maternity care in England since the early 1990s has promoted women’s choice of place of birth. These choices are hospital obstetric units (OUs), midwifery units (MUs) and home. MUs are classified in two ways: either attached to OUs, alongside midwifery units (AMUs) or geographically separate, free standing units (FMUs). MUs are only recommended for low risk women who constitute approximately 50% of all pregnant women (Dodwell, 2012). In 2012, only 11% of women gave birth in MUs, with 87% in OUs and 2% at home (NAO, 2013). This is despite strong evidence that MUs reduce caesarean section rates by two thirds, are very safe, improve patient satisfaction and are 20% cheaper than OUs (Brocklehurst et al, 2011; Schroeder et al, 2012). The reasons why most low risk women give birth in OUs when there is no clinical indication and where care is more expensive require investigation. Place of birth choices are affected by the lack of MUs across England, where a third of all maternity services have no MU of any kind. Even in maternity services with MUs, they are underused. In some maternity services, 20% or more women deliver in MUs whereas in other services the figure is 10% or less (NAO, 2013). In addition, some services have opened MUs that have subsequently closed. Identifying the barriers and facilitators to high percentage MU births and developing guidance for developing and sustaining MUs, would improve women’s clinical and psychological outcomes and be more cost effective for the NHS. Based on the Birthplace study (Brocklehurst et al, 2011), we estimate that by increasing provision so that an additional 10% of all women give birth in MUs, (to 20% overall), the caesarean section rate for these women should reduce by approximately 7% and normal birth rates increase by nearly 20%, resulting in a significant cost saving (approx. 3% of total maternity care budget) with no reduction in standard of care. The research therefore aims to investigate the barriers and facilitators to provision of MUs across England, to identify interventions to increase MU provision and uptake and to develop service guidance for commissioners and providers. The project will adopt a mixed method design, incorporating a Comparative Case design. This will draw on Damschroder et al’s (2009) Consolidated Framework for Implementation Research (CFIR) to identify constructs which help explain cross case variations in the degree of implementation, combined with consideration of salient institutional factors shaping the broader context of change (Currie et al, 2012). Stage 1 will map the existing national configuration, organisation and operation of MUs. Stage 2 will purposively sample 6 case study sites, and investigate the complex interrelation of variables of potential importance in understanding the provision of MUs in England (Anderson 2005). Using documentary analysis, focus groups, interviews and analysis of local media coverage of local maternity care provision, these in-depth case study data will provide not only detailed context dependent knowledge but also identify what can be transferred to other NHS sites (Payne & Williams 2005). There will be extensive user involvement throughout. The final phase will include a multidisciplinary stakeholder workshop to collaboratively generate interventions and to develop service guidance to support future maternity service commissioning and provision and commence the dissemination process (Minkler, 2005).

Lay abstract: Women in England have three choices for where to have their baby: in traditional labour wards in a maternity hospital, in midwifery units (MUs) or at home. MUs are run by midwives and are suitable for women having a normal pregnancy and expecting a normal birth. There are two types of MUs: alongside midwifery units (AMUs) attached to a maternity hospital and freestanding midwifery units (FMUs) geographically separate from a maternity hospital. Only 11% of women in England have their baby in a MU. This is despite very good evidence that having a baby in a MU results in better outcomes than having a baby on a traditional labour ward and is cheaper. For example, the risk of caesarean section is reduced by two thirds and mothers’ satisfaction with care is significantly improved. Not all maternity services have MUs and of those that do, some are not being fully utilised. We want to explore why usage varies so much and why many maternity services have never developed MUs. We will address this by examining two areas of England where 20% or more of women are having their babies in MUs, two areas where 10% or less of women give birth in MUs, two areas where there are no MUs and other maternity services that have opened a MU and then closed it. We estimate that by increasing provision so that 20% of all women give birth in MUs, the caesarean section rate for these women would reduce and the normal birth rate increase. Care would also be cheaper and mothers’ satisfaction with childbirth would improve. The reasons why changes in service provision occur are complex. In order to properly understand this process and provide guidance for improving policy and practice, we need a research method which is of proven worth in investigating such issues. We have thus chosen a case study approach. Comparative case studies are a good way of exploring large, complex organisations like maternity services and they will enable us to understand the differences between services that have led to the variations in MU provision. Following a mapping of the organisation of maternity services nationally, we will choose 6 areas to study in depth. In each place we will gather information from women who have used maternity services, midwives, and NHS managers and commissioners using interviews and focus groups, and will analyse the policies of each organisation. We will also look at how the local press and television have covered maternity provision issues. We will compare the results of the individual case studies with each other and explore how what we learn can be transferred to other NHS hospitals and services. These methods will help us identify why some services are successful in opening and promoting MUs and others are not. In collaboration with service users and other key people, we will develop guidance for local maternity services in England to help increase the provision and uptake of MUs. We are fully involving many kinds of people in the study, including service users, health professionals, commissioners and academics who will advise the research team and help with dissemination. The team is multi-disciplinary including service users and is highly experienced in undertaking this kind of research. We believe the project represents good value for money. The research has the potential to significantly improve the experience of maternity care for thousands of women and make considerable cost savings (3% of maternity care budget) for the NHS.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH