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By Cassandra Yuill
In recent years, choice of birthplace has been at the forefront of the conversation about improving maternity care in England. Better Births (NHS England, 2016) again emphasised the importance of choice of birth options, stressing the value of personalised care and advocated continuity of midwifery carer. Freestanding birth centres (named freestanding because they are not co-located with an obstetric unit), within a well-organised Local Maternity System, have the ability to provide women with straightforward pregnancies with safe and effective maternity care. In fact such centres have been found to have lower rates of intervention than both alongside birth centres and obstetric units (Birthplace in England Collaborative Group, 2011).
In May 2018, the Barkantine Birth Centre, located in the borough of Tower Hamlets in east London, celebrated ten years of operation. The centre has become a beacon for a social model of midwifery care, in which midwives understand and embrace women’s autonomy and their role as the key decision-maker in their care. As more areas of England are looking to develop such free-standing birth centres, this article offers my reflections on our local successes and challenges.
The centre was planned and opened in response to the increasing population and growing demand for maternity care in Tower Hamlets, which is home to one of the most ethnically and linguistically diverse populations in England. A steering group, the Birth Centre Network, was established to plan the freestanding birth centre, subsequently applying for a grant to build the centre on an available floor of a GP health centre that was under construction. The plans were approved by the Trust Chief Executive, and the centre was opened in January 2008.
As the one of the first inner city freestanding birth centres in the UK, several groups of researchers have conducted studies on the centre. This article draws from the current birth centre research and The Barkantine Birth Centre: Celebrating 10 Years as a Community Hub, a recent report released reflecting on a decade of operation, to look at how the application of the Better Births policies is working on the ground in maternity services.
A social model of care
The development of the Barkantine was guided by two core principles; the founding team wanted a birth centre where the social model of midwifery care could flourish and where midwives could provide woman-centred care. This social model of care recognises that the arrival of a baby is a socially and culturally significant occasion for women and their families. The philosophy of care at the Barkantine is to promote woman-centred birth by helping mothers to feel empowered and supported to give birth on their own terms, using their own resources. The centre offers women and their families a calm environment in which to birth, where they are disturbed as little as possible, combined with skilled and compassionate social and emotional support to help women cope with labour and birth.
Partnership in decision-making between midwives and service users is essential to determining a woman’s care plan. Observational research of the centre found that there is a process that midwives use to build this partnership, so that it becomes a key aspect of creating a woman-centred plan of care (Rocca-Ihenacho, 2017). For example, to develop this partnership midwives work hard to establish rapport with women in their care and to build a sense of trust and emotional commitment. The midwife provides information to the woman, including the pros and cons of different possibilities, and then discusses care options. This partnership element means that midwives can offer targeted support in order to facilitate a personalised plan of care.
This model of social midwifery care is woven into the very environment of the Barkantine, which was purpose built. Midwives aim to promote co-ownership of the centre with women and their families by allowing mothers to have as many visitors as they choose and sharing the common areas (e.g. the kitchen and reception) with them, while providing a calm, home-like space. A study found that freestanding birth centres often act as a “protected space,” in which features, such as nature-themed wallpaper, rocking chairs and comforting colour schemes, are used to evoke a feeling of home and a sense of wellbeing (McCourt, et al., 2016). The built environment is often constructed and organised in a way that supports physiological birth, and research suggests that there is an interaction between the physical environment and the work culture. At the Barkantine, this interaction has fostered positive collaboration between staff members (Rocca-Ihenacho, 2017).
Outcomes from the Barkantine
Over the last decade, 8,341 women have booked for their maternity care at the Barkantine, and 4,726 women have started their care during labour at the centre. Women who arrange their maternity care at the Barkantine, whether they plan to birth there or not, can receive antenatal and intrapartum care at the centre. At present, the staff do not provide these women with care during labour and birth if they choose to birth in a setting other than the Barkantine, which is an issue we need to address, in light of the continuity of carer agenda. In terms of mode of birth, of the women who started their care during labour at the centre, 81% had a spontaneous vaginal birth at the Barkantine, and 7% were able to achieve an unassisted vaginal birth after they were transferred to the nearby obstetric unit. Of those women who transferred in labour, 5% gave birth via caesarean section and 7% gave birth with the assistance of instruments (e.g. forceps or ventouse).
One key study (Macfarlane, et al., 2014a) found that women who booked at the birth centre were more likely to rate their care as ‘good’ or ‘very good’ when compared to those who were eligible for the Barkantine but booked at the Royal London Hospital (RLH). It also indicated that women who started their care during labour at the Barkantine were more likely to be cared for by a midwife they had already met, to have one-to-one care and to have the same midwife with them throughout labour (Macfarlane, et al., 2014a). Barkantine midwives always accompany women who require a transfer to the RLH and often continue their support during labour at hospital.
Giving birth in the Royal London Hospital (RLH) v the Barkantine: continuity of carer outcomes during labour
Women cared for by a midwife they had already met
Women had one-to-one care throughout labour
Women had same midwife throughout labour
Another study from Macfarlane et al (2014b) found that women who booked at the Barkantine also benefited from this during the antenatal period. They were more likely to attend antenatal classes and find them useful, and they were less likely to be induced than those who booked at the hospital (Macfarlane, et al., 2014b). Finally, women who planned their birth at the centre were more likely to use a birth pool and reach the stage of “established breastfeeding”, which means these women were breastfeeding beyond six weeks postpartum, when feeding has been found to become less complicated and more routine (Macfarlane, et al., 2014b).
Challenges and the future of freestanding birth centre care
While the Barkantine has much to celebrate, creating and operating the centre has not been without challenges, and keeping it open sometimes feels like a triumph itself, against the backdrop of the other freestanding birth centre closures across England. Over the past year, for instance, the Barkantine has experienced a drop in the number of births (perhaps due to the opening of an alongside birth centre in the local hospital), but there is strong collaboration between local parents, staff and the wider Local Maternity System to ensure that the centre remains in operation.
Dr. Lucia Rocca-Ihenacho, a research fellow at City, University of London and former Consultant Midwife, is clear about the importance of centres like the Barkantine, and also the difficulties that freestanding birth centres (also known as freestanding midwifery units, or FMUs) face: “At a time of industrialised maternity care, rising costs and unnecessary birth interventions, there is a need for maternity services and commissioners to truly understand the positive impact that FMUs bring to their services. FMUs are ideally placed to become the community hubs outlined in Better Births, offering a series of integrated services from maternity to social care. Many FMUs in the UK are now acting as a base for local community midwives offering continuity of carer; these midwives will increasingly need to work flexibly across boundaries between the community and the local hospital, and FMUs are an ideal local hub for these staff.”
Operating integrated services in this way can be tricky, however, and it took the Barkantine a few attempts to get it right. Luckily, there is now a wider network of support for freestanding birth centres in the form of the Midwifery Unit Network, of which Dr. Rocca-Ihenacho is a co-founder. There is an increasingly strong national drive to share the philosophy of care offered by the Barkantine and similar freestanding birth centres. For the Midwifery Unit Network, this means conceptualising freestanding birth centres as part of mainstream care models, available to all women and getting a clear message out internationally: this model does work, and it could be introduced into maternity services worldwide to ensure equity of care and positive birth experiences for women and their families.
Do you want more information and support for your local initiatives? Please visit the Midwifery Unit Network: http://www.midwiferyunitnetwork.com/.
Cassandra Yuill is a medical anthropologist and PhD candidate at the Centre for Maternal & Child Health Research, City, University of London. Cassandra's doctoral research focuses on women's decision-making around place of birth.
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. BMJ, Volume 344, pp. 1-13.
Macfarlane, A., Rocca-Ihenacho, L. & Turner, L., 2014b. Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care. 30(9), pp. 1009-1020.
Macfarlane, A., Rocca-Ihenacho, L., Turner, L. & Roth, C., 2014a. Survey of women's experiences of in a new freestanding midwifery unit in an inner city are of London, England - 1: Methods and women's overall ratings of care. 30(9), pp. 998-1008.
McCourt, C., Rayment, J., Rance, S. & Sandall, J., 2016. Place of Birth and Concepts of Wellbeing. Anthropology in Action, 25(3), pp. 17-29.
NHS England, 2016. National Maternity Review: Better Births – Improving outcomes of maternity services in England – A Five Year Forward View for maternity care, London: NHS England.
Rocca-Ihenacho, L., 2017. An ethnographic study of the philosophy, culture and practice in an urban freestanding midwifery unit. London: City, University of London.
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