Holding up a mirror: the impact of user involvement

AIMS Journal, 2007, Vol 18 No 3

While user involvement is enshrined in government policy across the UK, its patchy practice reflects the anxiety many professionals feel about the process. But here Phyllis Winters, midwifery team leader at Montrose Community Maternity Unit, explains how real user involvement can be a transforming experience for midwives, women and birth centres.

Involving mums and user representatives in the decision making at Montrose Maternity seems such a natural process that it is easy to forget this was not always the way. In 2001, Montrose Maternity was under threat. NHS Tayside was conducting an Acute Services Review and maternity services were being scrutinised. The Keep Mum (a Maternity Unit in Montrose) campaign, founded by mums, was extremely successful, and the unit escaped closure. However, it became apparent that, whilst the campaigners wanted to keep a unit in Montrose, they also wanted the service to change.

The midwifery team at Montrose has always been very caring and supportive of women coming through the unit, and has always wanted to deliver a good service. However, over the years, the number of births in the unit had fallen dramatically, the intrapartum transfer rate was relatively high, and user confidence was low. Births (or, in those days, 'deliveries') invariably took place on the bed, with mum in a semi-recumbent position. The service appeared to be stagnating. With this in mind, a maternity services liaison committee was formed and objectives made.

As midwives, we were extremely grateful to the mums for enabling us to stay open, but really, if truth be told, probably thought that was the end of our relationship. Motivation and inspiration were really short on supply within the midwifery team. We were aware that, to survive, we would have to change the service, but we were unsure of the next steps. Suggestions from the lay members of the committee often provoked a defensive attitude or negative response. Indeed, had it not been for the sensitivity of the mums, the process may well have floundered at this point. It is only now, looking back, that we recognise that ideas were often very subtly introduced and drip fed until taken up as our own initiatives.

Many of these ideas were 'humoured', such as the purchasing of new equipment to make the unit more focused on normality. The midwives felt that some of the suggested equipment was gimmicky and would do little to improve the birth rate. With hindsight, perhaps there was a certain degree of anxiety about its use. However, birthing balls and birth mats were purchased and initially placed like ornaments throughout the unit. As midwives, we felt that we knew what women wanted, even when our user reps were saying something totally different. Our arrogance reasoned that the women on the committee were not typical of our clients. We would grumble that they were 'middle class' and had different priorities from the majority of our clients. Sometimes resentments would surface and comments such as, "When did she do her training?" would be whispered amongst the team. In our defence, the midwifery team at the time felt beleaguered and threatened. We were anxious to improve the service, but also apprehensive about the way forward.

Gradual change

However, change did gradually happen. The new equipment captured the imagination of the midwives and users, and the number of births within the unit increased. At this time the user reps also suggested that we record mum's position at time of birth and that we should encourage alternative positions to semi-recumbent. This was really taking some of the midwives out of their comfort zone, both figuratively and literally. Using birth mats and facilitating birth in different positions requires thought regarding the midwives' positioning, and initially we had a few aching backs and limbs. It is however to the credit of the midwives that we persevered until we gained confidence and optimum positions. Very quickly we realised that enabling the woman to listen to her body, and to move into whatever position she felt helped her, enriched the birth experience and appeared to reduce the incidence of failure to progress. Our intrapartum transfer rate fell from 21% in 2002 to 8% in 2005.

As confidence grew, the midwifery team became more receptive to changes. A trusting and positive relationship began to develop and barriers between professionals and non professionals dissolved. Many thought-provoking discussions on midwifery care took place and it became evident that we shared a vision for the unit's future. Once this was established, any residual resentments or defensiveness faded quickly. Since then we have worked together to introduce waterbirth at Montrose and to organise study days and open days. We have also spoken together at conferences and written articles. It is very difficult to remember the mindset of 2001 and to rationalise our trepidation. Perhaps we felt that our role as midwives was being threatened, or our 'power' challenged? It is often difficult to take criticism, even when it is at its most constructive. Although at times the process may have seemed fraught, the dividends of user involvement have had far reaching implications for the women of Montrose. From a low of 47 in 2002, births increased to 169 in 2006, and now 60% of our births are waterbirths. As midwives we have learned to not only work in partnership with our user representatives, but with the women in our care.

Enlightening and rewarding

Handing that power back to the women has been the most enlightening and rewarding experience. At Montrose we have fallen in love with midwifery and birth once again. We have been recognised nationally with the Royal College of Midwives 'Promotion of Normality' award in 2005, and the British Journal of Midwifery 'Team of the Year' award 2006. The changes at Montrose have been more than cosmetic - there has been a fundamental shift in our attitude, philosophy and our very language. This evolution may have taken place without the input of our users, but it is unlikely. They held a mirror to our service, and we did not like the reflection. Phyllis Winters is midwifery team leader at Montrose Community Maternity Unit.

Montrose community maternity unit is 'integrated out', with the 9.8 whole time equivalent midwives providing community services to around 300 women per year across an area of approximately 317 square miles. More than 50% of local women coming through the service give birth at the unit - which is 35 miles from the nearest consultant unit - and the service also attracts 'out of area' women. More information is on www.birthinangus.org.uk.

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