Inequalities in health care provision: the relationship between contemporary policy and contemporary practice in maternity services in England
Aim. The project Addressing Inequalities in Health: new directions in midwifery education and practice (Hart et al. 2001) was commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB). Here, we draw on those research findings to consider current midwifery policy and practice in England.
Background. Little guidance on providing equality of care exists for midwives. The Code of Conduct [United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992] makes no specific requirement for midwives to address issues of inequalities of health in their practice. Recent policy documents emphasize the need to work towards reducing inequalities and to target practice to `disadvantaged clients' without giving guidelines on how to identify and care for target groups.
Methods. In-depth studies of midwifery education and service provision were conducted in three very different parts of England. Three months of fieldwork were undertaken at each site, comprising a series of interviews with midwifery educators, managers, students, midwives and service users. Focus groups were also held and observation of classroom sessions and midwifery practice undertaken.
Findings. A lack of clear and specific strategies concerning inequalities in health was evident at managerial level. Patchy knowledge of current policy was also evident amongst practising midwives. Specific projects with disadvantaged clients usually resulted from a particular midwife's personal interest or evident local need. All midwives emphasized the importance of `equality of care'. How this was operationalized varied, and `individualized' or `woman-centred' care was assumed to encompass the concept. In the few examples where care was systematically targeted in accordance with policy directives, the midwife's public health role was increased.
Conclusion. In the absence of a co-ordinated strategic vision driven by managers, practitioners find difficulty in prioritizing care and targeting resources to disadvantaged clients in line with policy directives. Tensions between policy and practice in the care of `disadvantaged' women clearly exist. Successful implementation of policy at practice level needs: commitment from managers; clarity of purpose in documentation; and provision of specific targets for practitioners. However, the latter should remain flexible enough for the delivery of care to be appropriate and sensitive to individual needs.