Using a Clinical Pathway to Support Normal Birth: Impact on Practitioner Roles and Working Practices

Abstract

The Normal Labour Pathway is a complex intervention with complex outcomes. It has had intended and unintended consequences, for maternity care in general and for the roles and relationships of maternity care practitioners. The study raises questions about the appropriateness of clinical pathways and other standardized decision-making tools for the complexity of childbirth.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

“…” [40:p.45] Where intervention content imitated existing practices some health professionals welcomed them as legitimising and supportive of their clinical judgement, [50,52–54] while other staff in the same studies, particularly more experienced staff, experienced them as constraining of clinical judgement suggesting they encouraged “robotic care” through a “tick-box-approach . ” [53:p.232] The burden of tools to audit and record standardised processes, and the time this took away from direct hands on care was also noted in one cross-country study. [58]…”

“…[61] In 11 studies, reported in 13 papers [42,46,47,49,50,52–54,57,58,60–62] interventions, including initiatives to promote physiological birth in Iran [57], hospital primary vaginal birth in the US [61], normal labour and birth in the UK [50,52–54] and the humanization of birth in Japan [46] and Chile, [49,62] challenged the structural balance of power between stakeholders. In UK organisations where a more equal balance of power did exist between women, midwives, family doctors, and obstetrician, there was some evidence that midwifery-led staffing interventions to keep birth normal and reduce caesarean section empowered midwives to work more autonomously [50,52–54] by “…sort of put[ting] a little tag on that woman as a way of saying ‘leave her alone’ , which I think some doctors respect , and some don’t ” ([53]:p.232). A further perspective on power, roles and relationships between stakeholders was offered by a nurse in the US who said; “My job is to empower them [women] .…”

“…[46,47] For example, the interdependency of the British National Health Service’s internal structures and workforce (midwives, obstetricians, junior doctors), and “the hugely complex series of events” , contributing to high rates of intervention in pregnancy and childbirth, meant many participants reported that achieving higher rates of normal birth and lower rates of caesarean section was unlikely to be effectively addressed by the apparently simple solution of a clinical pathway . ( [53]:p231) In Nicaragua, healthcare providers spoke of high CS rates as a way of compensating for the multi-dimensional weaknesses in their health system (including insufficient human resource, material resource, or coverage). [55] This was evident in other middle- and low-income countries where antenatal care was absent, communication between all levels of the system, and between the system, staff, and women, was deficient, and infrastructural and geographic challenges of reaching skilled labour care existed.…”

“…In the UK (Wales), doctors expressed concerns that they no longer had an overview of the overall maternity unit workload. Their new role, “placed in a much more technical position” , meaning they were confined to “coming in like the fire brigade .” [53:p.233;54:p732] Other doctors opposition to midwife led care was interpreted by study authors as fear of a shift in medical authority, loss of financial benefits, for both individuals and facilities, and the convenience of scheduled caesarean section, which made workloads more manageable (with less time on the wards, or on-call).…”

“…targeting home birth) as potential confounders, nevertheless caesarean section and instrumental delivery rates continued to rise, with the culture of individual units a significant factor. [53] There was recognition of the need for local tailoring of interventions, and for acknowledgment of how local culture must be actively and continuously negotiated as part of a wider system.…”