A qualitative study identifying the key components of independent midwifery practice in mainland UK

Independent Midwives provide relational continuity of care whilst promoting women's autonomy. They report associated high levels of physiological birth and positive outcomes for women and babies and low levels of interventions (Milan 2004). Since the publication of the Changing Childbirth Report (Department of Health 1993) it has been government policy for these components of care to be incorporated into national maternity services to facilitate higher quality of care, although this policy has as yet to be widely implemented in the United Kingdom (UK). The Better Births report (National Maternity Review 2016) has most recently reiterated the need for the inclusion of these components into maternity care in England as a measure to improve care. In Scotland, The Best Start: five-year plan for maternity and neonatal care (Scottish Government 2017) sets out their strategy for improving maternity care based on a commitment to provide individualised continuity of care to mothers and babies. The Welsh strategic vision for maternity services (Welsh Government 2011) is less specific, broadly describing respectful care in which the mother and family are the focus. Whilst continuity of care and supporting women's choices are commonly known attributes of independent midwifery care there is little knowledge about the full gamut of this type of practice. Aims and objectives: The overall aim of this study was to advance knowledge about the practice of Independent Midwives working in Mainland UK. The objective was to explore Independent Midwives' perceptions and experiences of independent midwifery, through in-depth interviews, and to gain an overarching understanding of what is involved in working independently and providing care for clients. Through this exploration the intention was to identify and understand the essential components of a way of practising midwifery which reportedly work well for both mothers and midwives. Research design: This study took a qualitative approach, drawing on the principles of constructivist grounded theory methodology and used semi-structured, in-depth interviews to generate the data. With the participants' consent each interview was digitally recorded, transcribed and then analysed using a constant comparative method. Participants: Eight Independent Midwives were recruited from across Mainland UK using purposive and then theoretical sampling techniques. Ethical approval was gained from the Bournemouth University Human Ethics Committee. Findings: Five categories were identified as being key components of the independent midwifery model of care: professional autonomy, time, mother-centred care, knowledge, evidence and practice, and midwifery philosophy. Conclusions and key recommendations: Professional autonomy is a vital component of independent midwifery practice, enabling Independent Midwives to practise in ways which best serve their clients. They are free to choose how they can best practice in particular circumstances, and importantly, how they apportion their time. Providing continuity of care through caseloading facilitates the establishment of mother-midwife relationships and results in a sustainable work-life balance for the midwives. Time is a critical factor in providing high-quality care. Independent Midwives allot substantial amounts of time to working with their clients and developing their practice, both of which are associated with safer care and better outcomes. The development of mother-midwife relationships results in individualised care and consequently safer care and better outcomes. Independent Midwives' use of a continuum of evidence enables them to incorporate a range of information into the care they provide which caters to the individual needs of the client, resulting in safer care. The midwives' philosophy of normality guides their practice, enabling them to promote health and physiological processes and avoid interventions. The Independent Midwives' model of care provides mother-centred relational continuity of care in the context of the woman's choices, through a caseloading scheme, as recommended by current government policy for maternity services. This exemplar can be used to assist service providers implement government policy recommendations for maternity care. A systems-level change is required to enable all midwives to move from providing fragmented care, to providing individualised, relational continuity of care. Midwives need to have greater professional autonomy and more time, in order to effectively provide this type of care. Maternity services need to focus on normality throughout the pregnancy continuum because it promotes health and physiological processes and reduces the use of interventions.