This thesis explores what ‘woman centred care’ means to both women and midwives and how this care is offered by midwives and perceived by women. It is set within the context of current health care policy and the way in which this impacts on both the organisation and implementation of maternity care. A flexible qualitative design was used to explore both women’s and midwives’ experiences of current maternity care over the full trajectory of maternity provision. A modified grounded theory approach was used framed within a feminist perspective. The fieldwork was undertaken in two phases. In phase one and interviews were undertaken with twelve women in early pregnancy, later pregnancy and after the birth; a total of twenty-five interviews with women were completed. Nine midwives were also interviewed in phase one. Preliminary and tentative categories were identified from both sets of interviews and were used to inform phase two of the study. Five women participated in the second phase of data collection. This included both informal, telephone contact and in-depth interviews spanning from early pregnancy until after the birth and included observation of their care in labour. The community midwives and delivery suite midwives specifically involved in their care were also interviewed. The data demonstrated a continued mismatch between the women’s and the midwives’ perspectives and it was evident that despite the policy drivers and consumerist rhetoric of ‘woman centred care’ and its original underpinning principles of continuity, choice and control, that this was not the overriding experience for the women who participated in the study. Data analysis highlighted some opportunities for negotiation but these were not explicitly recognised or realised by the women or midwives and there was little time or flexibility in the system to accommodate such opportunities. The increasing bureaucracy of the maternity care system also constrains continuity of carer over the full spectrum of the childbearing trajectory and reduces the potential for women to know the midwife who provided care. Thus for many midwives being ‘with the institution’ was more likely than ‘being ‘with woman’.

Since the late 1990s there has been an increasing focus on parenting ability, support and education which is reflected in policy, practice and research in the UK. This research analyses how nurses might intervene to provide this support, specifically in relation to crying baby and the role of nurses at NHS direct. It involves collection and analysis of data from NHS Direct call data in 2002, and solo focus group data in 2006. Within the wider tradition of grounded theory, the methodology includes use of discourse and thematic analytical approaches. The research analyses the means by which NHS Direct nurses make different use of the algorithms and organisational protocols to make decisions and give advice to parents with crying babies, how their clinical knowledge and experience influences these decisions, and how nurses explore parents’ ability to cope. This is seen within the organisational context of NHS Direct, a 24 hour government funded telephone service described as both a triage service and an advice/helpline service. Findings from the study indicate a degree of tension between the essentially humanistic nursing culture and the highly scripted, protocol driven rules based system that underpins NHS Direct. Despite this tension, nurses will sometimes combine their knowledge with that of the algorithm where the call is involved with eliminating emergencies. The same synthesis of knowledge is not apparent with the knowledge contained in the algorithm regarding non-medical, nonemergency, value-sensitive issues relating to parental coping with excessive infant crying. Findings suggest that NHS Direct nurses use the ‘crying baby’ algorithm differently and this variance is influenced by experience and familiarity with the algorithm. Adherence to the algorithm is perceived by nurses as safe in relation to the medical questions which exclude emergencies. The non-medical elements of the algorithm, which include prompting the nurse to ask about parent coping ability and the possibility of shaking their child, are treated differently and it is considered safe to not ask, or ask around the question and to not offer the advice prompted by the decision aid software. The algorithm prompt to assess parental coping ability is rarely successful in encouraging the nurse to do so overtly. From these findings, consideration might be given to enhancing nurses’ knowledge, skills and confidence, supported with appropriate supervision, to provide effective intervention in relation to value sensitive, non-medical issues such as parental coping ability and in handling the uncertainty such issues may yield. Allied to this would be establishing clarity and recognition of the inherently different, but not opposing functions of providing a triage service and an advice/ helpline service.