Maternity care provision in Australia has undergone many changes in recent years, and over time a variety of models of care provision have been developed and implemented. This is particularly the case in the public maternity care setting, in which around two thirds of Australian women receive care [1
]. The impetus to introduce these new models is likely to be multifactorial, and ‘driven’ by different stakeholders, i.e. consumers, policy makers and care providers. It is also likely that the ‘outcomes’ of various models of care may be viewed differently by different groups; that is, an outcome of care highly valued by one group may not be valued by another. For example, for some, ‘safety’ (e.g. intervention rates, maternal and neonatal morbidity and mortality, and longer term health outcomes) might be of most value, whereas others might value consumer satisfaction, cost, staff satisfaction and recruitment/retention more highly.
There is evidence that in addition to safe maternity care, women want choice, control and continuity, and that increasingly, consumers of maternity services want greater access to midwifery led models of care and the opportunity to know their caregiver [3
]. Although successive state-wide reviews of new mothers in Victoria have found that the model rated most highly by women is private obstetric-led maternity care, midwife-led models are also rated favourably [7
]. When thinking about these findings, it is important to describe the Australian context. Two largely separate options for maternity care exist in Australia – public and private, with around two thirds of women accessing public care [1
]. The private sector is characterised by obstetric-led care, whereas standard (or conventional) public maternity care incorporates a range of different approaches to care. In Australia, as in many developed countries, public maternity care has traditionally been fragmented, with different groups of caregivers providing care at different stages. In a typical example, a woman may have her antenatal care provided by one or a number of medical practitioners or midwives, and the care may be hospital or community based. In standard care models, labour and birth care is often provided by a midwife unknown to the woman and in more than 95% of cases takes place in hospital [6
]. Following birth, women are usually cared for by another group of midwives in the postnatal ward, then after discharge yet another midwife/s may visit the woman’s home to provide care [8
]. It may be that the private obstetric models have been successful in offering continuity of carer to women thus increasing satisfaction, while midwifery-led models of care have been challenged by barriers in providing primary carer models.
From a policy perspective, continuity of care has been strongly recommended throughout Australia [6
] . In June 2004 the Victorian Department of Human Services (DHS) released a policy document “Future directions for Victoria’s maternity services” [5
] which endorsed and promoted the expansion of public models of maternity care that offer continuity of carer
. While the distinction between continuity of care and continuity of carer is not always clear [10
], in general it is considered that continuity of care
refers to a continuity of philosophy among a group of care providers, with a shared view of how care should be provided, or adherence to set guidelines and protocols [11
], whereas continuity of carer
implies care provision by a known provider [9
] or fewer care providers [10
]. Recently there has been an emphasis on continuity of carer
as opposed to continuity of care
], despite the supportive evidence (increased satisfaction, decreased interventions) for models of care such as team midwifery, that offer continuity of care rather than carer [13
A number of studies report that midwives want to work in models that offer the opportunity to work autonomously and to provide continuity to women across the continuum of maternity care [16
], and that this opportunity may be an effective retention strategy for such midwives [9
]. However, not all midwives want to work in this way [9
], particularly where the model involves working on call [9
]. It is therefore critical that new models are properly evaluated with regard to midwife job satisfaction, recruitment and retention, [22
] both for midwives providing continuity of care/r and those working in standard care [9
]. Brodie reflects on the lack of research on the experiences of midwives and a lack of ‘sociological analysis of the implementation or maintenance of this innovation from their perspective’ [23
] (p132), and suggests this is crucial, given that the main reason cited in the literature for the discontinuation of new models is midwife dissatisfaction [24
There are complex factors involved in the introduction of new models of maternity care; organisations are complex, and new models may be impacted by internal and external factors. New models of care are likely to involve not just a single change, but multiple changes within both care provision and organisational structures. In light of this complexity, new models of maternity care fit the UK Medical Research Council (MRC) definition of complex interventions, in that they comprise multiple and inter-linking strategies that attempt to take a ‘whole of problem’ approach to health issues [25
Complex interventions in health are those that are not limited to a single dose or activity, but comprise many potentially ‘active ingredients’ [27
]. It is therefore critical that the impact of new models of care are rigorously evaluated, considering outcomes for women and infants as well as outcomes for midwives and other maternity care providers [9
]. The capacity and willingness of organisations to implement and support a new model of care must also be considered. Thus, when researching new models of care, the ‘success’ of a randomised controlled trial (RCT) is only one factor involved in whether a new model of care will be implemented at the conclusion of the study or in other settings. We propose that there may be a number of other barriers and enablers to the successful implementation of new models of care which may account for the success or dissolution of such models, even when in the context of trials with positive clinical findings.
The aim of this paper is to discuss how theory can be used to explore, understand and interpret implementation strategies and the impact of organisational context when evaluating new models of health service delivery. We propose that consideration of these issues is crucial to considering sustainability for interventions that are shown to have beneficial outcomes. We use two case studies to illustrate the discussion, a retrospective reflection on an RCT which, despite positive findings, was not implemented; and a recent RCT that has used a theoretical framework to reflect on implementation of a new model within the trial context. The conceptualisation and rationale leading to the use of the Normalisation Process Model in exploring the implementation and organisational context of the second case study is discussed.