Midwife-Led Units: A Place to Work, A Place to Give

Midwife-Led Units: A Place to Work, A Place to Give Birth Claire de Labrusse and Alice Kiger

BACKGROUND: With an estimated 120 midwife-led units (MLUs) and 15 years’ experience, the United Kingdom displays expertise in what ways women and professionals might benefit from MLUs. This study explored midwives’ satisfaction and skills for working in an MLU and a consultant unit (CU) and how these compared. METHODS: In this exploratory study, both quantitative and qualitative data were collected by anonymous questionnaire from 45 midwives in 2 Scottish maternity units (July 2007). RESULTS: Midwives working in the MLUs reported a higher level of job satisfaction than midwives working in the CU. Demographic characteristics of the 2 groups differed: MLU midwives were older, had been in practice longer, and had higher grade posts. Qualitative findings revealed some reasons midwives preferred working in the MLU with the emotional support they could give to women, and highlighted some negative predictors of midwives’ satisfaction. The questionnaire also explored the midwives’ practice: most agreed that the ability to avert and manage problems, work in a low-technology setting, and let labor be are necessary to work in these units. CONCLUSION: Our findings revealed midwives’ greater satisfaction from working in MLU compared to CU. We identified midwives’ opinions of specific skills to work in MLU, highlighting areas of importance for midwifery. KEYWORDS: midwife-led units; midwifery; satisfaction; birth; maternity services

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INTRODUCTION

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Having midwifery experience both in France and in the United Kingdom prompted the first author to look at the differences in practice, especially in terms of options for childbirth. Midwife-led units (MLUs) were of particular interest because France has been recently challenging the status quo in relation to where childbirth takes place (College National des Gynecologues et Obstetriciens Francais, 2003; Agence de Presse Médicale [APM], 2011). It was interesting to see from the experience of the United Kingdom, which has an estimated 120 MLUs (freestanding and co-located alongside an obstetrics unit), the ways in which women and professionals might benefit from MLUs, some of which have been in place for about 15 years now (M. Dodwell, personal communication, 2008).

The MLU extends the choice for women who meet the acceptance criteria for birth without active intervention in a home-from-home setting. In these units, midwives seek to facilitate informed choice and foster a nonintrusive, nonintervention approach to birth. LITERATURE REVIEW Because the literature about MLUs is large, this article will present a review of four main themes in relation to the research topic. 1. Comparison of epidemiological data Several randomized controlled trials have evaluated and compared midwifery-led care to obstetric-led care.

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 3, Issue 2, 2013 © 2013 Springer Publishing Company, LLC www.springerpub.com http://dx.doi.org/10.1891/2156-5287.3.2.1

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2 Midwife-Led Units Labrusse and Kiger

The Stockholm Birth Centre Trial assessed the outcome of care at an in-hospital birth centre in Sweden. A lower intervention rate was found and no statistically significant differences in perinatal mortality were discovered between the midwifery model and the obstetric care model (Hatem, Sandall, Devane, Soltani, & Gates, 2009). Hundley et al. (1994), in a large randomized controlled trial recruiting about 3,000 women, compared intrapartum care and birth of low-risk women in the MLU and the consultant unit (CU) in one of the tertiary units in the North of Scotland. The morbidity results confirmed that low-risk women allocated to the MLU had a lower rate of intervention than similar women allocated to the CU. This alternative model of midwifery care was associated with less use during labor of obstetric interventions such as induction, augmentation of labor, electronic fetal monitoring, obstetric analgesia, instrumental vaginal birth, and episiotomy. Gottvall, Grunewald, and Waldenström (2004) compared the infant morbidity rates between infants born in standard care and infants born in an in-hospital birth center, and found that severe infant morbidity was not more common in the in-hospital birth center group compared to the standard care group. Finally, recent research in Australia comparing perinatal death in a hospital-based birth center and an obstetric unit found a significantly lower rate of perinatal death in the birth center. Along with the lower rate of perinatal death, this study showed that this result was irrespective of the women’s parity (Hatem et al., 2009). International studies have consistently shown perinatal morbidity rates in MLUs to be equal to or lower than those attained by more traditional care of similar low-risk women (Hatem et al., 2009; Hodnett, Downe, & Walsh, 2012). If we look at the results of perinatal mortality in the United Kingdom and abroad, we can see that the advent of MLUs has had no detrimental effect on perinatal mortality rates (Birthplace in England Collaborative Group, 2011; Hodnett et al., 2012).

Debate Around “Normality in Childbirth” or the Normal and the Usual The MLU aims to maximize normality and support women who choose to labor and give birth with minimal or no interventions. Normal birth has been defined in the United Kingdom by the National Institute for Health and Clinical Excellence [NICE] guidelines (2006) as without S — surgical intervention, use of instruments, induction, epiE— dural, or general anesthetic. But in 2002–2003, only 47% L—

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of births in England were described as “normal,” and 41.5% in 2001 in Scotland (Information and Statistics Division [ISD], 2004). In Gould (2000) “normal labour” is defined as a “purely normal physiological event with no intervention” (p. 419). But midwives have expressed the view that some interventions don’t systematically put a woman into “abnormal labor,” and they suggest that the word “normal” is usually mistakenly taken to mean “natural.” Professionals need to be clear with the words and concepts they use. There have been several reports on the subject of normal birth from official organizations over the past few years, and their definitions can differ considerably (Clinical Standard Advisory Group [CSAG], 1995). The World Health Organization (WHO) Department of Reproductive Health and Research (1997, p. 3) gave its definition:

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Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 weeks completed pregnancy. After birth, mother and infant are in good condition.

Another concept in the debate is that normal labor cannot be limited by these measurable criteria, with a woman in labor being witness to, or victim of, these changes. Cassidy (1999) described normal birth in a holistic way, taking into account the feelings of the woman, because there is evidence that a laboring woman who is in a setting she likes and feels comfortable has a greater chance to experience a normal labor (Boulton, Chapple, & Saunders, 2003). Taylor (2001) exposed an interesting view of “normal but not the usual” aspects of midwifery care. Taylor explores the idea that to describe a clinical assessment, there is not just normal and abnormal, but some situations can be just unusual. For instance, a home birth compared to hospital birth, a water birth compared to a bed birth, and a physiological third stage and an active third stage are all examples of not the usual (but not abnormal). As we have seen, there is a wide variation of practice within the United Kingdom (CSAG, 1995); in addition, the Dr. Foster’s survey in 2001 (see Downe, 2003) noted that: In some hospitals (a baby) is 25 times more likely to be delivered by forceps than others; in some, almost twice as likely to be born by caesarean. Why?

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Midwife-Led Units Labrusse and Kiger 3

The norm for one maternity unit can be different from another, making the norm for one not the usual in the other one. With a national rate of 11.7% of instrumental birth and 24.9% of cesarean section in 2004, Aberdeen Maternity Hospital with a higher rate in both is probably seen as normal but not the usual (ISD, 2004). Page (2000) also believes that normality in childbirth has roots in personal belief, local customs, and may vary between society, practitioner, maternity units, and trusts (health care regions). The lack of normality means that in a woman’s mind, this is abnormal and needs medical intervention. 2. Comparison of midwives’ job satisfaction between MLU and CU There is a limited body of knowledge about job satisfaction of midwives working in MLU compared to what can be found about maternal satisfaction. Hundley et al. (1994) compared the job satisfaction of midwives working in the MLU with that of midwives working in the CU. In that study, autonomy and continuity of career were the best indicators of midwives’ satisfaction. Because, in the MLU, midwives found that there was a greater chance of autonomy and continuity of career, their satisfaction there was higher compared to the CU. Lavender and Chapple (2005) distinguished the views of midwives working in different settings. A key finding was that all participants shared a common vision of ideal practice, which emphasized midwife autonomy, equity of care for woman and job satisfaction. However, participants experienced different degrees of success according to their job location. Small birthing units such as MLUs were generally described as more supportive and satisfying work environments. In contrast, consultant-led units were described negatively, because of the dominance of a medical model, and the pressure to conform. Hunter’s (2000) qualitative study of the experience of midwives working in small units explains some elements of what midwives find attractive in these settings. Often, MLUs provide a focus for midwives, a place where it’s safe to practice what can be unacceptable in a labor ward, a place to practice “real midwifery.” “Real midwifery” can be seen as doing normal midwifery and attending to women as opposed to attending to the “machine.” Davies, McDonald, Austin, and McGregor (2003) specified that in such units, midwives have a common shared vision and are valued for their individual skills. Having the opportunity to develop their midwifery skills, midwives become confident and transfer their

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confidence to women. Although retention of midwives is a crucial problem in the United Kingdom, small birthing units like MLU have not tended to experience job shortage; on the contrary, in 2003, Kirkham (2003a) reported that they had waiting lists of midwives wanting jobs. What Makes a Midwife Working in a Midwifery-Led Units? A philosophy of care behind the MLU has been proposed in the literature as to provide a safe, home-from-home environment, where women can retain choice and control in the management of their labor (Hundley et al., 1995). This concept has evolved into a concept of family-centered care, where the midwife seeks to facilitate a nonintrusive, no-intervention approach to birth. The aim is to provide a positive experience of childbirth so the family can have a good start into parenthood (Tinsley, 2003). However, Persad, Hiscock, and Mitchell (1996) have suggested that “not all midwives have the competencies to provide all elements of maternity care for low-risk women” (p. 20). To provide care in a small unit, free from technology and elective work, midwives need to develop different skills. Hunter (2000, p. 15) describes eight additional skills that a midwife should have to work in an MLU:

• Being confident in providing intrapartum care in a low-technology setting

• Being comfortable using embodied knowledge and skills to assess a woman and her baby as opposed to using technology • Being able to let labor “be” and not interfere unnecessarily • Being confident to avert and manage problems that might arise • Being willing to employ other options to manage pain without access to epidurals • Being responsible for outcomes without access to on-site specialist assistance • Being confident to trust the process of labor and to be flexible with respect to time • Being a midwife who enjoys practicing what the participants call “real midwifery.” This list is quite different from the usual clinical competencies seen for midwifery, although one competency related to emergency skills is included; this is important especially for an isolated unit. On this list are found competencies other than those that are manual and intellectual. These skills are for relationships and tasks that are not narrowly defined.

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The study reported in this article set out to explore the idea that job satisfaction could be related to the level of “medicalization.” Therefore, the research aim was: What Are Midwives’ Views About the Satisfaction They Gain From Working in a Midwifery-Led Unit and a Consultant Unit, and How Do These Compare? The study had the following research objectives:

• To describe the personal and professional background of midwives working in the MLU.

• To define what is seen as “normal childbirth” in both types of maternity unit.

• To examine the concept from Hunter (2000) that special skills are necessary to work in an MLU.

• To explore the level of job satisfaction of the midwives working in the MLU.

• To explore the elements which can be related to job satisfaction. METHODS Because this was an exploratory study, a questionnaire survey was selected as the most appropriate means for eliciting data on the topic of interest. Information gleaned from the literature review was used to develop the questionnaire. The questionnaire included 25 quantitative items divided into three sections:

• Background of the midwives working in the maternity units • Midwifery skills in the MLU • Satisfaction in the MLU and in the CU It also included nine open-ended questions designed to elicit qualitative data. The target population for the study consisted of all midwives working within the delivery suites of two large tertiary maternity units in northern Scotland during the period of the study. These will be referred to as Unit A and Unit B. The 60 midwives working in Unit A were the most easily accessible for the principal investigator because she was working there as a bank midwife at the time. This accessible population provided a convenience sample. To increase the number of participants and to broaden the scope of the study, the questionnaire was S — also distributed in the maternity unit at Unit B, located E— in a different northern Scottish city, which employs L—

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30 midwives in the labor ward. Between these two units, 45 questionnaires were returned and analyzed. This represents 50% of the potentially available population (the actually available population is unknown because the numbers of midwives on holiday, maternity, or sick leave could not be identified). Before the questionnaire was administered, a pilot study was conducted with five midwives who had extensive experience working in labor ward but who were not working at that time in these units and would therefore not be part of the main study. Examination of their data enabled the principal investigator to test the procedure and several changes were made according to the respondents’ comments. Four envelopes containing the relevant documents were then made available in the labor wards (MLU and CU) in Units A and B. Prior to this, the local NHS Ethics Committee had approved the conduct of the research project on both sites. The questionnaire was available at both sites for 3 weeks in July 2007. The documents completed by the participants at Unit A were returned via internal mail, and for Unit B via the normal post. A reminder letter was distributed to the midwives working at Unit B. In addition, flyers publicizing the study were displayed at both sites to raise awareness about this ongoing research. To analyze the quantitative data, SPSS was the tool of choice. The qualitative data from the open questions were analyzed using a thematic framework. Descriptive statistics were then used to compare the types of comments made and their incidence in both groups. RESULTS In this section, the results of the study are described. In several places, where it appeared pertinent to a specific point, some elements of discussion have been included. 1. Background of the midwives a. General findings Forty-five questionnaires were returned by the deadline. This provided a total response of 50%, which is considered a good response. All the midwives involved in the research were female and 88% were registered as both general nurses and midwives, the other 12% being registered only as midwives. During the period of the research, 45 midwives agreed to complete the questionnaire. From the findings, 27 of these midwives (60%) were working in the CU,

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9 (20%) were working in the MLU, and 9 (20%) were in charge of the labor ward; in the latter case, they were managing both sides of the labor ward and not clinically caring for specific women. Three of the 45 midwives, all from the CU, had an extra qualification in nursing counselling. Midwives working in the MLU were more likely to have been practicing as a midwife for longer than the midwives looking after women in the CU side: about 3 years more. This accords with the higher grades in MLU. Finally, one-third of the midwives preferred to work in the MLU, whereas only 20% actually worked there at the time of the survey. Although eight midwives indicated that they were happy to work in the CU, six stated they would rather work in the MLU. The six midwives who worked on the MLU side were happy to do so, and none would choose to work in another department. b. “Normal birth” and interventions To understand the perceptions of the midwives about expert skills in the MLU, it was important to explore their views on “normal birth” and interventions. In this research, according to the thematic analysis, 52% of the midwives recognized that a normal birth should involve either no interventions or minimal interventions, but further on they describe their practice as incorporating routine interventions. The binary cross tabulation between place of work and regular interventions shows clearly that more midwives in the CU met this situation than in the MLU, which is understandable as women are admitted or transferred to consultant care to undergo treatments or investigations that cannot be done in the MLU. But still 50% of the midwives working in the MLU indicated that they intervene regularly with the process of labor. It is clear that the blurring around the definition of normality explains that midwives could not give a common definition but instead referred to seven different themes. Although the NICE (2006) guidelines stipulate that normal birth should not entail epidural anesthesia or induction of labor, this study suggests that about 22% of practicing midwives think epidural anesthesia is part of normal birth and 13% think induction of labor can be part of normal birth. Table 1 gives the rank order of the midwives’ estimations of interventions being part of normal birth; the four most common being transcutaneous electrical nerve stimulation (TENS), Entonox, morphine injection, and episiotomy, in that order. Routine interventions such as TENS, morphine injection, and Entonox are accepted by policy makers, but statistically, practicing artificial rupture of membranes (ARM) or an episiotomy, or providing epidural

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TABLE 1 List of Interventions Seen as Being Part of Normal Birth

TENS Morphine Entonox Episiotomy ARM Epidural Induction

YES

NO

DON’T KNOW

45 36 44 25 20 10 6

0 7 1 17 22 33 38

0 2 0 2 3 1 1

Note. TENS ⫽ transcutaneous electrical nerve stimulation; ARM ⫽ artificial rupture of membranes.

anesthesia, are also seen as routine by these midwifery staff. Indeed, if the midwives are really supposed to be the guardians of and the specialists in normality, the current findings suggest that there is a problem. The findings of this study show clearly that interventions are reported as being part of the daily practice of most of the midwives because among these midwives, 90% reported intervening regularly during the childbirth process. But still, 42% of the same midwives indicated that they believe that normal birth does not require these procedures, or 33% think just a few are required. Perhaps these midwives don’t value the limitation of the procedures to the same extent that they value giving appropriate emotional support and meeting the family’s expectations. For 22% of the midwives, this target of meeting family’s expectations is part of describing normal birth. In this research, five points summarize what the midwives would see as normal birth: (a) a spontaneous onset of labor, leading to (b) a vaginal birth with (c) no or minimal interventions, with (d) the woman emotionally well supported and (e) the family’s expectations met. This interesting finding may also help explain why midwives are so accustomed to intervening. From the thematic analysis, it became clear that a large number of the midwives expressed their liking for highrisk complicated cases. This opinion was expressed by 41.0% of the midwives when asked what they like the most in the CU; also, 20.5% gave the support they get when working in the CU as an explanation. Hundley, Milne, Glazener, and Mollison (1997) explored the emotional work of hospital midwives and described junior midwives who were happy to work in this environment feeling safe with peers. It is interesting to see that these midwives related a higher job satisfaction in a low-intervention setting, happy to promote normality

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TABLE 2 Midwives’ Perception of Expert Midwifery Skills

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NOT IMPORTANT

IMPORTANT

VERY IMPORTANT

0 0 0 0

7 16 17 17

38 29 28 27

1 0 1

17 19 21

26 25 23

“Being confident to avert and manage problems Being confident to provide intrapartum care in a low-technology setting Being able to let labor be and not interfere unnecessarily Being comfortable to use embodied knowledge and skills to assess a woman and her baby Being solely responsible for outcomes without access to onsite specialist assistance Being confident to trust the process of labor and be flexible with respect to time Being willing to employ other options to manage pain without access to epidurals” (Hunter, 2000)

in both MLU and CU, but on the other hand found that working with complicated clinical cases, even if they are less likely to assist the birth of this woman, was satisfying for them and a positive challenge they like to take. 2. Midwifery skills in the MLU Almost all of the midwives (apart from two responses of “not important”) thought that all the eight expert skills in the given list are either important or very important to make a midwife working in an MLU (see Table 2). In rank order, the first three skills that were described as very important were the ability to 1. Avert/manage problems, 2. Work in a low-technology setting, and 3. Let labor be. Although the midwives rated their biggest challenge in the MLU as being to empower women to help them achieve their expectations, they ranked in third position the challenge of keeping interventions to a minimum (mainly Entonox, TENS, or morphine injection). This may mean that midwives not only value their freedom from technology but also value even more the positive impact they can have on a woman’s life. The list of additional skills developed by Hunter is not merely describing competency or emergency skills, but instead includes statements regarding the midwife’s relationship skills, self-confidence, and self “being” as skills midwives working there should have (Kirkham, 2003b). 3. Satisfaction in the MLU and in the CU S — In this third and last section, the midwives were asked E— to describe their job satisfaction and rate it. Of those L—

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who indicated a preference, more than five times as many (35.6%) preferred the MLU as compared with those who preferred the CU (6.7%), but most (53.3%) found the same satisfaction in both units. In looking at this area in more detail in the descriptive text, several themes emerged about the reasons for preferring the MLU:

• They could achieve women’s expectations, assist, help, and empower women (from 36% of respondents). • They had decision-making power and autonomy in practice (30% of respondents). • The MLU has a low rate of interventions (18% of respondents). • They could promote normality in the MLU (12% of respondents). The 95% confidence interval for the mean is 5.89–7.40 in the CU compared to 6.4–8.9 in the MLU. Despite the apparent differences in these results, the t test undertaken gave a p value of .112, indicating that the association between the level of satisfaction and the place of work is not statistically significant (see Table 3). The strongest theme from the descriptive text, which emerged independently from the quantitative findings, was “To achieve women’s expectations.”

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TABLE 3 Satisfaction in MLU and CU Using a 10-Point Likert Scale

MLU CU

MEAN

STANDARD DEVIATION

p VALUE

6.62 7.69

1.83 201

.112 .127

Note. MLU ⫽ midwife-led unit; CU, consultant unit.

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The comments quoted in the following texts provide evidence in this respect: #10 “Adopt what women want rather what they may need” #11 “Giving the woman confidence to cope with the pain of labor and birth herself ” #15 “Allowing women to experience the birth process as a positive experience” #29 “Encouraging and supporting women and allow them to believe in themselves and the birthing process” In the analysis of the qualitative responses, several relevant findings relating to reasons for satisfaction with working in the CU emerged from the data:

• The satisfaction of caring for women with complicated medical histories

• The support given by the senior staff or the medical staff • The satisfaction of using midwifery skills to promote as much normality as possible

• The chance to provide one-to-one care Comments that provide evidence to support this include the following: #26 “Working closely with women high risk which have additional stress than being in labor” #27 “I am getting more variety in high risks” #12 “If there is a problem, there is always someone more senior and medical staff around” #37 “Challenges knowledge as try to bring normality to abnormal situation” An open question highlighted some problems with working in the MLU: lack of staff, lack of work breaks, and interference from the medical staff, which were negative predictors of midwives’ satisfaction. The following example statements support these themes: #13 “Getting my dinner breaks!!!” #35 “Keeping medical staff out of the labor suite when they are not needed”

DISCUSSION The aim of the study was to describe the profile of midwives working in the MLU, and more specifically, to describe their satisfaction with working in the MLU, to try

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to find some criteria of job satisfaction, and compare their level of satisfaction to that of midwives working in the CU. This study has corroborated much of what has been previously described in the literature, that midwives working in MLU tend to be older with a higher grade and longer experience. But Hundley et al’s (1995) findings that midwives who work in MLU tend to have additional qualifications is not reflected in this study. Here, midwives who had additional qualifications tended to work in CU, and only three in nine midwives who worked in MLU had additional qualifications. On the other hand, we found that six midwives working in the CU (22%) would prefer to work in MLU, which could change the findings if these midwives had extra qualifications. However, going back to the questionnaires, only two of six midwives were found to have additional qualifications. A rate of normal birth less than 50% should be a source of concern for a profession for whom normal birth should be their raison d’être. Many reasons have been brought forward to explain this decline in normal birth. Several ideas come to mind, such as the “medicalization” of childbirth (Van Teijlingen, Lowis, McCaffery, & Porter, 2004), staff shortages (Robinson, 2003), or the use of modern technologies such as monitoring (Davis-Floyd, 2004), but this exploratory research highlights as well the liking of the midwives to look after high-risk women or complicated births even if it is therefore less likely that they will be able to display their full range of skills. Hunter’s idea about the eight characteristic midwifery skills that a midwife working in an MLU should require was tested in the questionnaire. Apart from two midwives who thought that either managing pain or providing one-to-one care was not a specific competence that a midwife working in an MLU should acquire, all the other midwives overwhelmingly thought that all the skills suggested by Hunter were either important or very important. In this study, the midwives ranked the ability to “avert and manage problems,” “work in a low technology setting,” and “let labor be” as the most important skills. The list of additional skills developed by Hunter does not merely describe competency or emergency skills, but instead includes statements regarding the midwife’s relationship skills, self-confidence, and self “being” as skills midwives working in the MLU should have (Kirkham, 2003b). In order for women and families to play key roles at birth, midwives acknowledged that their role is a supporting one. Even if this does not fit with the image of the “medicalized model” geared toward action, the MLU’s role is one of prevention and vigilance, states of calmness, and readiness for activity. With strongly positive answers from the midwives to

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Hunter’s ideas, this research confirms that in the views of respondents, these skills are expert skills necessary for midwives working in MLU. The findings of this research comparing the mean job satisfaction in the MLU and the CU reveal a higher level of satisfaction in the MLU compared to the CU. Forty-five midwives expressed their job satisfaction: The mean of the midwives working in the CU was 6.62 compared to 7.69 for the midwives working in the MLU. Unfortunately, the statistical test between the level of satisfaction on the day of completing the questionnaire and the place of work indicated a nonsignificant p value. However, this could relate to the small size of the sample, and the descriptive findings correlate with what is found in the literature. Several studies describe higher satisfaction among the midwives working in the MLU (Hundley et al., 1995; Walsh, 2000). Limitations of the Study The two settings where the research was undertaken were not completely similar. The Unit A’s midwife unit is in a separate unit 20 yards from the CU. In the Unit B there is no midwife unit as such, but within the same labor suite, midwife-led care is provided alongside consultant-led care according to the medical history of the woman and her requests, case-by-case. Unit A was first chosen for the research, then to increase the number of participants, Unit B was invited to participate. The original questionnaire developed for Unit A was then changed for Unit B and the term “midwife-led unit” was changed to “midwife-led care,” and “consultant unit” was changed to “consultant-led care.” These changes did not alter the meaning of the questions. Unfortunately, with the population sample of 45 midwives, most of the statistical tests did not demonstrate significant findings. Therefore, firm conclusions can only be drawn from the descriptive findings. Recommendations for Practice The findings of the study along with the literature show that midwifery staff working in an MLU describe a higher level of job satisfaction compared to a conventional medical unit. As an implication for practice and education, countries such as France should not be reluctant to put in place more MLUs. The literature review revealed some aspects of the MLU, which added to the S— finding of this study, tend to show that these units offer E— a satisfactory option for mothers and staff. With some L—

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MLUs opening in the next few years in France, staff needs to be convinced that women can give birth safely in these units (APM, 2011). Obstetricians have published their worries about perinatal mortality, but it has been concluded widely that such data were incomplete or that these deaths were not preventable (Walsh, 2004), thus perinatal mortality was not higher in an MLU compared to a CU. If obstetricians need to be convinced about the safety of these units, midwives need to be trained to support appropriately women who decide to give birth in these settings. Expert midwifery knowledge such as the eight skills developed by Hunter (2000), then make sense to educate student midwives and to reorient hospital midwives. This project seems additionally desirable with public interest getting larger, and research showing high maternal satisfaction in such units. It should be achievable given the example of other European countries that have developed MLUs, such as the Netherlands, Norway, Finland, Switzerland, and Germany (De Vries, Benoit, Van Teijlingen, & Wrede, 2001).

CONCLUSION In conclusion, the midwives in this study working in the MLU tended to be older with a higher grade and had longer experience. Open-ended questions revealed reasons for a difference in levels of satisfaction, which included the emotional support the midwives provide, being able to empower the woman to achieve her expectations or the problems with working in the MLU. It has been suggested in the literature that special skills need to be developed to work in these units. Testing Hunter’s eight midwifery skills, they were overwhelmingly agreed to be important, with respondents ranking ability to avert/manage problems, work in a low technology setting, and let labor be as the three most important skills. Finally, the job satisfaction tended to be higher for the midwives working in the MLU compared to the midwives working in the CU, but the difference did not reach statistical significance. These skills need to be further investigated to explore their relevance to midwifery education for midwives who wish to work in such units.

REFERENCES Agence de Presse Médicale. (2011). Maisons de Naissance: Une économie de 7 millions d’euros par an envisagée à terme avec 60 structures. Retrieved from http://www .apmnews.com/accueil.php

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Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with “low risk” pregnancies: The Birthplace in England national prospective cohort study. British Medical Journal, 343, d7400. Boulton, M., Chapple, J., & Saunders, D. (2003). Evaluating a new service: Clinical outcomes and women’s assessments of the Edgware Birth Centre. In M. Kirkham (Ed), Birth centres. A social model for maternity care. London, United Kingdom: Books for Midwives.

AQ5

Cassidy, P. (1999). Management of the first stage of labour. In V. R. Bennett & L. K. Brown, V. R. (Eds.), Myles textbook for midwives (13th ed., pp. 11–24). Edinburgh, Scotland: Churchill Livingstone. Clinical Standard Advisory Group. (1995). Women in labour. London, United Kingdom: HMSO. College National des Gynecologues et Obstetriciens Francais. (2003). Manifeste des sages-femmes [Midwives manifest]. College National des Gynecologues et Obstetriciens Francais. Retrieved from http://www.cngof.asso.fr/D_ PAGES/MOPI_19.HTM Davies, M., McDonald, S., Austin, D., & McGregor, S. (2003). “Home from home”: The key to success. The Practising Midwife, 6(11), 16–17. Davis-Floyd, R. (2004). Ways of knowing. Open and closed systems. Midwifery Today with International Midwife, (69), 9–13. De Vries, R., Benoit, C., Van Teijlingen, E., & Wrede, S. (2001). Birth by design. London, United Kingdom: Routledge.

PE1

Dodwell, M. (2008). Birth choice. Personal communication. United Kingdom.

Hundley, V., Cruickshank, F., Milne, J., Glazener, C., Lang, G., & Turner, M. (1995). Satisfaction and continuity of care: Staff views of care in a midwife-managed delivery unit. Midwifery, 11(4), 163–173. Hundley, V., Milne, J., Glazener, C., & Mollison, J. (1997). Satisfaction and the three C’s: Continuity, choice and control. Women’s views from a randomised controlled trial of midwife-led care. British Journal of Obstetrics and Gynaecology, 104(11), 1273–1280. Hunter, M. (2000). Autonomy, clinical freedom and responsibility: The paradoxes of providing midwifery care in a small maternity unit as compared with a large obstetric hospital. Palmerston North, New Zealand: Massey University. Information and Statistics Division, Scotland. (2004). Births in Scottish Hospitals, year ending 3 May 2004. Retrieved from http://www.isdscotland.org Kirkham, M. (2003a). Birth centres: A social model for maternity care. Oxford, United Kingdom: Books for Midwives. Kirkham, M. (2003b). A ‘cycle of empowerment’: The enabling culture of birth centres. The Practising Midwife, 6(11), 12–15. Lavender, T., & Chapple, J. (2005). How women choose where to give birth. The Practicing Midwife, 8(7), 10–15. National Institute for Health And Clinical Excellence. (2006). Intrapartum care final draft for consultation. Retrieved from http://guidance.nice.org.uk/page. aspx?o=334322

Downe, S. (2003). Birth centre in Wiltshire. The Practising Midwife, 6(5), 14–18.

Page, L. (2000). Keeping birth normal. In L. Page (Ed.), The new midwifery: Science and sensitivity in practice (pp. 105–106). London, United Kingdom: Churchill Livingstone.

Gottvall, K., Grunewald, C., & Waldenström, U. (2004). Safety of birth centre: Perinatal mortality over a 10-year period. British Journal of Obstetrics and Gynecology, 111(1), 71–78.

Persad, P., Hiscock, C., & Mitchell, T. (1996). Midwives and perinatology (extended role of the midwife in perinatal mortality enquiries). British Journal of Midwifery, 4(1), 220–221.

Gould, D. (2000). Normal labour: A concept analysis. Journal of Advanced Nursing, 31(2), 418–427.

Robinson, F. (2003). In Parliament. The Practising Midwife, 6(5), 19.

Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S. (2009). Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Review, (4), CD004667.

Taylor, D. (2001). What is usual? Normality in maternity care. British Journal of Midwifery, 9(6), 390–393.

Hodnett, E. D., Downe, S., & Walsh, D. (2012). Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews, (8), CD000012.

Tracy, S., Dahlen, H., Caplice, S., Laws, P., Wang, Y., & Tracy, M. (2007). Birth centers in Australia: A national population-based study of perinatal mortality associated with giving birth in a birth center. Birth-Issues in Perinatal Care, 34(3), 194–201.

Hundley, V., Cruickshank, F., Lang, G., Glazener, C., Milne, J., Turner, M., . . . Donaldson, C. (1994). Midwife managed delivery unit: A randomised controlled comparison with consultant led care. British Medical Journal, 309(6966), 1400–1404.

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Tinsley, V. (2003). Birth centres in Wiltshire. The Practicing Midwife, 6(5), 14–18.

Van Teijlingen, E., Lowis, G., McCaffery, P., & Porter, M. (2004). Midwifery and the medicalization of childbirth. New York, NY. Nova Science.

AQ6

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Walsh, D. (2000). Evidence-based care series 2: Freestanding birth centres. British Journal of Midwifery, 8(6), 351–355. Walsh, D. (2004). Birth centres unsafe for primigravida. British Journal of Midwifery, 12(4), 206.

Correspondence regarding this article should be directed to Claire de Labrusse, HESAV, University of Applied Health Sciences of Western Switzerland, 1011 Lausanne, Switzerland. E-mail: [email protected]

World Health Organisation Department of Reproductive Health and Research. (1997). Care in normal birth: A practical guide. Geneva, Switzerland: Author.

Claire de Labrusse, Lecturer, PhD Candidate, MSc (Midwifery), RM, University of Applied Health Sciences, 1011 Lausanne, Switzerland.

Acknowledgments. This study was part of a master’s degree thesis carried out at the Centre for Advanced Studies in Nursing, University of Aberdeen (Scotland) and was selffunded by the first author.

Alice Kiger, Senior Lecturer, PhD (Nursing), MSc (Nursing Education), Diploma in Nursing Education (Clinical Teaching), MA (History), BA (French), RN, Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY.

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QUERIES

AQ1: Please confirm if the assigned shortened article title is correct. AQ2: Please verify if assigned levels of heads are correct. AQ3: Please clarify what is the research aim meant in this part of the text. AQ4: The word “below” should not be used to describe the position of a material on a page; please confirm if changing it to “in the following texts” is acceptable. AQ5: Please verify if supplied additional information for this reference is correct. AQ6: Please indicate reference citation in text. AQ7: Please verify if deleting the table footnote “*Hunter, M., 2000.” and inserting the citation in the table body is acceptable.

PE1: As per APA 6th, personal communication is not included in the reference list, please verify if it is okay to remove it in the reference list. PE2: Global. Please verify if the use of contractions is okay. PE3: Global. Please confirm if quotations less than 40 words are okay to be set as extracts. PE4: Please confirm if use of abbreviations in the table title is acceptable.

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