Adaptive performance of midwives as a resilience mechanism to improve safety in maternity services.

Background

Despite efforts to improve safety in maternity services, progress so far has been unsatisfactory and remains a high-profile public concern (Health and Social Care Committee, 2021a; Ockenden, 2025). Traditionally improvement efforts have focused on standardisation, compliance with policies and procedures, and learning from incidents to prevent recurrence (Reason, 2000). However, this approach may be inadequate to improve outcomes in healthcare settings such as maternity services which are complex adaptive systems (Patriarca et al, 2017). Resilience Engineering may offer a more useful theoretical foundation, by considering how midwives adapt to adverse or unexpected conditions to enable the system to function, providing effective care to women and babies.

Methodology

A multiple-case embedded design case study, utilising sequential observation and semi-structured interviews was conducted at two tertiary level maternity units in the English midlands. The aim was to explore adaptive performance by midwives as a resilience mechanism to contribute to safety in maternity services.

Findings

Four themes were identified which pertain to specific tensions within the work system which midwives must navigate to succeed in everyday work. These were: Individualising Standardised Care Guidelines, Prioritising Competing Demands of Individuals within a Multiple-Patient Ward, Autonomous Midwifery Practice Within a Multidisciplinary Team, and Maintaining Safety Despite Finite Resources.

Discussion

A new theoretical model has been produced, adapted from Anderson et al (2016), which demonstrates that midwives’ adaptive performance is the pivot point, balancing the needs of the woman and the organisation. In this context, the ability to provide individualised care to women may be compromised by the requirement for efficient patient flow and the safety of other women. Meanwhile, a perception that safe care, which is legally defendable, is achieved by adherence to policy or procedure, means that adaptive practice may not be organisationally supported.

Conclusion & Recommendations

Stakeholder engagement is required to build consensus on the priorities in maternity care, and to innovate longer term strategies to support both patient safety, and efficiency and productivity. Such strategies must consider the impact upon women’s experience such as delays in care, alongside the benefits for organisational resilience. An ideological disparity may exist where organisational, structural adaptations are permissible, but individual, in-situ adaptations are not, despite often being unavoidable. However, in-situ adaptations to overcome work system deficiencies may mask issues with the potential to inadvertently decrease organisational resilience in the longer term. Thus, upward communication must be supported if midwives are to safeguard the continued functioning of the system during expected and unexpected conditions, in a way which is conducive to organisational monitoring and learning. To this end, a fundamental shift is required towards a Safety-II perspective which learns from everyday work and values adaptive performance of midwives which is vital to organisational resilience and the safety of women and babies.