Policy and practice concerning women with an RhD negative blood type: a midwifery perspective
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Date
05/07/2014Author
Harkness, Mairi
Metadata
Abstract
In May 2002 the National Institute for Clinical Excellence (NICE) made the
recommendation that all pregnant women with an RhD negative blood type should
be offered routine antenatal anti-D immunoglobulin (Ig) prophylaxis (RAADP).
Midwives were the key professional group who would be involved in administration
of anti-D Ig and yet they had little input to formation of policy and contributed little
to the evidence base that informs policy and practice. A midwifery perspective is
however important and relevant, and forms the basis of this work.
The thesis comprises three distinct, but related, pieces of research: a survey
conducted in 2005 to determine implementation of RAADP at UK maternity units;
secondary analysis of anti-D Ig errors involving midwives that were reported to the
Serious Hazards of Transfusion (SHOT) scheme in 2007/8; and focus group
interviews conducted in 2010 to explore midwives’ views on issues that impact the
care provided for women with an RhD negative blood type.
The aim of the RAADP survey was to establish current {2005} policy in the United
Kingdom in relation to the NICE recommendation for RAADP (NICE, 2002).
The
survey formed the foundation on which to build the thesis by determining that by
2005 RAADP had become an integral aspect of maternity care within the UK.
However it also found that there were significant variations within local policies and
among the information that was provided to pregnant women and healthcare
professionals. The aim of the survey was to determine implementation of policy and
not to explain findings, raising important questions which were used to inform the
subsequent research.
The second piece of research was secondary analysis of existing anti-D Ig error
reports collated by SHOT. The analysis was unique in that it included only those
errors involving midwives. The findings highlight both individual and organisational
impact on errors, building on the findings of the RAADP survey. The research
identified proximal errors, trigger events and fallible practices providing a
framework within which the common pathways to error involving anti-D Ig can be
understood. This will allow midwives to better understand and improve the care they
provide. This piece of research also raised further questions about midwifery practice
and those questions informed the focus group research.
The focus group research aimed to consolidate the findings of the previous research
by gaining direct input from midwives. Two focus group interviews were held, with
clinical midwives as participants. The research found that the midwives and the
organisations within which they worked provided care in line with policy and
procedure at the apparent expense of a woman centred approach. This appeared to be
linked to the midwives’ understanding of their responsibility, accountability and the
education and information that underpinned the care they provided. The other
important finding from the focus group research was that the midwives regarded
RAADP as a less important intervention than they did anti-D Ig given following a
potentially sensitising event (PSE) during pregnancy or given following delivery.
When considered as a whole body of work, this research provides unique and
valuable insight to midwifery involvement in the care of women with an RhD
negative blood type. The research highlights the challenge of achieving government
objectives for individualised, woman centred care within the present framework of
clinical governance and evidence based care. In doing so it also raises questions
about how individual midwives and the midwifery profession have engaged with
medical colleagues and policy makers to maintain a midwifery context to the care
they provide. Although the research findings relate to care provided for women with
an RhD negative blood type the findings are pertinent to other aspects midwifery
practice, particularly those originating within the medical profession that are now a
routine part of midwifery care.