Organisational strategies and midwives' readiness to provide care for out of hospital births: an analysis from the birthplace organisational case studies.

Objective: the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies.

Design: organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review.

Setting: a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring 'best' or 'better' performing in the Health Care Commission survey of maternity services (HCC 2008).

Participants: professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents.

Findings: each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a 'hub and spoke' model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence.

Key Conclusions And Implications For Practice: maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.