Management – visible, accountable, connected

For a maternity system to function well, it needs to be managed well.

Managers play a key role at every level. Their ability and willingness to provide resources and support makes a considerable difference to the care midwives are able to provide. Where midwives are satisfied in their work, they will often praise support they have from a ‘good manager’. In comparison, midwives who feel stressed and unable to provide good care often feel let down and unsupported by their manager.

What about managers?

Managers of maternity services need support to do a good job too. When asked about how effective they can be in their roles, some midwives in middle management roles (for example, those managing a birth suite) describe limitations in what they can do because their own managers do not support or understand them. However, others in middle management roles say they were attracted to working for the organisation by:

• supportive leadership at the organisational level
• shared values and commitment to woman-centred care
• support received from managers to enable them to do their job.

What is clear is that support and commitment to resourcing midwives and others to provide woman-centred care is needed across every level of management in the maternity care system. Everyone within the facility – midwives, doctors, and other staff – need to be supported and resourced by their manager to ensure they are able to do their job well.

At the heart of supporting others, and feeling supported, are relationships.

How can relationships help?

Effective relationships based on mutual respect and trust between care providers and management provide a framework where positive change can occur. Too often, we see the effect of unsupportive management when individuals who want to innovate and change the way care is provided are met with resistance from their manager. On the other hand, we see situations where the manager wants to create change and re-orientate a service – but clinicians resist because they worry they will be disadvantaged in the process or by the outcome.

At the most basic level, respect is required to create effective collaborative working relationships. Respecting the secretaries and ambulance officers as much as the doctors and midwives is vital, and effective management is key to ensuring this happens. If anyone involved in providing the maternity care service feels disempowered or experiences a lack of trust then the chain breaks, placing the the entire structure at risk of dysfunction.

It seems straightforward, doesn’t it? Most organisations providing maternity care would state their goal is to provide excellent maternity care, and individuals within the organisation would claim that to be their goal too, so it should be easy to create this environment of collaboration. And yet, so many barriers emerge in this picture of working together with respect and trust.

What’s stopping us?

One of the most powerful barriers to improving maternity care is funding. In the face of tight budgets, attempts to make change may be met with very real constraints – and those managing the budgets may be under a lot of pressure to keep costs low. To the professionals that see the need for change to occur, the budget constraints may translate into poorer service, worse outcomes, and more work for them. Tensions run high when different parties within an institution feel like they’re on different teams, with different needs and divergent goals.

Another factor lies with the often hierarchical health system, which tends to foster a ‘blame culture’. In a ‘blame culture’, health professionals may be reluctant to challenge institutional norms – even if those norms are built around provision of care that is not based on evidence. It can be risky to confront other practitioners if they are denying women’s choices: practitioners need to feel safe and supported by their managers if they are to openly challenge unsafe practices.

Instead people find their own way of coping with a ‘blame culture’. Some maternity care providers stop trying, and conform to the organisational norms. Others become skilled at working covertly: doing what they can to help women achieve the birth they want, despite routine policies outside the woman’s best interests. A midwife may know the institution’s policies are not evidence-based, yet be unwilling or fearful to directly confront the policy makers.

The way forward

Most people don’t realise that many midwives are suffering negative experiences – and the ‘blame culture’ further isolates midwives and limits opportunities to join together to create change within institutions and maternity care systems.

It takes excellent communication and a deep level of understanding between the different parties to forge relationships where everyone is clear that at the core they have the same goal: the health and wellbeing of women, their babies, and their families. The relationship between the overall structure of a system – its management systems in particular – and those who work in it and use its services, are what makes the wheels run smoothly.

Over to you

What are your ideas about how to improve and build relationships within management structures?