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Chapter 3 ■ The transformation perspective

While the research, evidence and analysis underpinning and providing the context for
Changing Childbirth is complex and not short of controversy, for our purposes the focus
of the report for maternity practice is best summarized by quoting the report’s indica-
tors of success (within 5 years, i.e. by 1998):
■ Every woman should know one midwife who ensures continuity of her midwifery care
– the named midwife.
■ At least 30 per cent of women should have the midwife as their lead professional.
■ At least 75 per cent of women should know the person who cares for them during
their delivery.
■ At least 30 per cent of women delivered in a maternity unit should be admitted under
the management of the midwife.
Often measures designed to achieve these success indicators were being devised in the
context of another development, integrated patient care (IPC).
IPC is an example of a general rethinking of patient care brought in from the USA in
the early 1990s. It focuses on aspects of care such as continuity of care, improved doc-
umentation, physical redesign of buildings, locating facilities close to patients, staff role
reviews, etc. Sometimes known as patient-focused care (PFC), this philosophy places the
patient at the centre, seeks active involvement of the patient, continuity of care, decen-
tralization, multi-skilling of care staff and streamlined documentation. Finally a further
concept is the pathway of care, which in essence is the time sequence of events, tests,
assessments, experiences and outcomes associated with the patient’s care process. If the
objective is to seek high-quality ’seamless’ care for individual patients across the bound-
aries of department, directorate and discipline into which hospitals have been fashioned
by history, then horizontal focus is a key issue.
At Brighton Health Care NHS Trust these concepts have been implemented along
with team midwifery within the community. Three teams of six full-time equivalent mid-
wives based in different geographical locations aimed to provide 24-hour care for
250–350 women. The service encompassed all aspects of midwifery care including
home assessment of labour and care continuity. An early evaluation concluded that team
midwifery enabled Brighton to provide a more patient-centred care service at the same
high standard of care (avoiding a perceived risk of the team approach) with no evidence

of decreased satisfaction for the women involved (there has been a very high reported
satisfaction) or for midwives (again a concern which did not appear to materialize).
The early research (see Hart, 1997) indicates significant progress towards Changing
Childbirth success indicators. While some evidence of tension emerged between team
midwives and their labour-ward colleagues, it was also clear that there were many per-
ceived advantages. Moreover, many of the negative points emerging appeared to be
linked to other factors, i.e. workloads in general, problems of working conditions, prob-
lems over grading within the reward arrangements. Clearly continuity of care was seen
as linked positively to job satisfaction. The general practitioners interviewed were satis-
fied both with the service overall and with team midwifery but this was not without per-
ceived problems, some related to the adequacy of resourcing and GP involvement
(which may lessen given continuity of team-based care).
Interestingly enough, recommendations for further development place much
emphasis on developing relationships, partnerships and care protocols (which define
the parameters within which care professionals practise). Care protocols are clearly

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