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Table 4 Overview of different strategies used to implement the MUs

From: What are the strategies for implementing primary care models in maternity? A systematic review on midwifery units

N Country Year Who initiated/led the implementation Drivers to open the MU
1A China
2009 Researchers Promote more humanised care to reduce intrapartum interventions and medicalisation Engagement with leadership and training for midwives.
A five-stage action research project was used to: define the plans, assess midwives’ confidence and ability, outline policies, procedures and standards of practice, review and tackle the obstacles found in the previous steps.
1B China
2009 Researchers (See 1A) A follow up from study 1A with the same strategies and adding the involvement of a wider range of stakeholders (including midwifery staff managers and researchers) to assess feasibility of the MU.
2 US 1991 Nurse-midwives in four different institutions Negotiating a middle-ground service between homebirths and the medicalised OU Eight strategies were used, described as: going it alone, compromising, getting others involved, capitalising on consumer pressure, promoting the idea of “it’s not different”, playing the waiting game and overcoming government regulation.
3 Iran 2013 UNFPA and the Health Centre of Sistan and Balochestan Province Increasing accessibility to perinatal care in areas with poor access to care Response to a local situation in which vulnerable women lacked access to appropriate care and a high birth rate to increase accessibility of facilities and reduce perinatal mortality.
UNFPA supervised the first three years of operation.
4A Brazil 2009 Brazilian Ministry of Health Promoting more humanised care to reduce intrapartum interventions and medicalisation Normal Childbirth Centers or Childbirth Houses were implemented as consequence of a strategic governmental initiative to reduce medicalization in childbirth in Brazil.
4B Brazil 2013 Brazilian Ministry of Health (MoH) (see 4A) The MoH invested in nurse-midwives’ professional profile by sending them for an international exchange in a country where MUs were established. This was considered to give them greater symbolic power to fight for the implementation of the MU.
5 Canada 2018 The Ontario Ministry of Health and Long Term Care Implementing evidence into practice The availability of evidence was the reason why the MoH decided to invest in this model of care. They used interprofessional approach for planning the change, develop appropriate policies, protocols and to enhance teamwork. They also gave attention to the midwives’ admission privileges at the moment of transfer and to the continuous service evaluation.
6 England 2005 Consultant midwife Opportunistic or pragmatic reasons such as reconfiguration of the service, including centralisation The refurbishment of the maternity setting became the opportunity to promote the inclusion of a MU. Consultant midwife doing a postgraduate thesis initiated an action research study, which included different stakeholders (including managers midwives and medical staff) and established a group to promote normal birth.
7 England 2018 Local managers (not specified) Implementing evidence into practice After the publication of the Birthplace study in 2011 the NICE Intrapartum guidelines published in 2014 recommended all 4 options of birthplace. This guideline had a significant impact and was used by stakeholders as main facilitator to make the case and open new MUs nationally.
8 England 2020 Midwifery managers Implementing evidence into practice Key factors for successful implementation were: leadership (and continuity of it), active promotion of the MU as part of the local policy, clear clinical pathway from the beginning of pregnancy until the onset of labour and appropriate information for women.
9A 9B England 2014 and 2018 Midwifery managers Opportunistic or pragmatic reasons such as reconfiguration of the service, including centralisation Key drivers for development of AMUs in all the services studied had been a combination of pragmatic, even opportunistic, decisions. Lead midwives had often seized an incidental chance to develop the service responding also to financial constraints or existing plans for service redesign or improvement, including merging of different OUs within a single service organisation.