How is quality of care conceptualised by the different constituencies involved in maternity care in the UK? An organisational ethnography

Abstract

Background: A consensus exists between different constituencies involved at all levels of maternity care that high quality care is important. The implicit assumption is that everyone defines and understands the idea of quality in maternity care identically. However, contemporary debate about where the balance between safety and personalisation in maternity care lies, raises important questions about the different definitions that might be operating when people talk about ‘Quality’ in this context.

Methods: This PhD aimed to examine how quality of maternity care is defined by the different constituencies in maternity care over time, and how its dimensions are implemented. A meta-narrative review, analysis of the Babies Born Better survey, and an in-depth organisational ethnography in two diverse maternity units within one English NHS Trust were conducted, including interviews, focus-groups, documentary analysis, and observations. Framework analysis, based on previous study phases, was applied inductively to analyse the data obtained.

Findings: Sixty-three papers were included in the meta-narrative review, thirty-seven surveys were analysed, and forty-eight participants (managers, frontline staff, women, and their birthing partners) were recruited for the organisational ethnography. Twenty-seven interviews and two focus-groups were conducted. One hundred and eighty hours of observation took place, and twenty documents were collected. Results indicate that the understanding of ‘quality’ and implementation of the ‘quality of maternity care dimensions’ was not uniform. Closely interlinked factors such as safety and personalisation were seen as separate entities, where the organisation’s definition of safety was largely prioritised over the woman’s personal or individual preferences.

Conclusions: Even though people think they are communicating a shared concept when they talk about quality of maternity care, this study suggests that their underlying definitions for the term may differ substantially. High quality maternity care goes far beyond preventing morbidity and mortality. The implementation of a clear and shared vision about what goes well, for whom, under what circumstances is necessary for a maternity service to thrive.