Home birth and the English NHS: exploring the dynamics of institutional change in the context of health care

Research aims and objectives This study explored factors that shaped the institutional work of a non-dominant professional group in a mature institutional field that sought to maintain or transform existing institutional practices. It aimed to understand and explain the work involved in creating, maintaining and disrupting divergent models of health service organisation and delivery, with a specific focus on maternity care provided to healthy women who chose to give birth at home. This study investigated questions about the priorities that frame the allocation and management of health service resources and sought to understand how opportunities to advance new institutional practices were recognised, created or resisted by different stakeholders. Particular consideration was directed towards legitimacy contests associated with advancing or preventing change in strategic action fields . It explored how practitioners captured attempts at reform to maintain or extend their influence or counter the interests of others. The degree to which intra- and inter-organisational relationships are developed, established and maintained to influence institutional change were explored in this study. Further, the mechanisms by which service user experiences were sought, articulated and integrated into scripts that either promoted or delegitimised new institutional practices at both the micro- and macro-levels were examined. Research gaps Critiques of existing approaches to institutional change have questioned the relative neglect of bottom-up change and the improvisations initiated at practitioner level (Smets, Morris, & Greenwood, 2012). This study had added to understandings of the micro-level origins of institutional change through the actions of “individuals at the front line”, while at the same time sought to extend understandings of the micro-level processes that maintain the status quo and prevent change (Reay, Golden-Biddle, & Germann, 2006:979). This study examined the degrees by which change emerges from the innovations enacted by the everyday work of non-dominant professional groups; whether this led to these innovations consolidating at an organisational level; and the potential there was for new innovations to radiate up to the institutional field level (Smets et al., 2012) and become ‘taken for granted’. This study drew upon concepts of deinstitutionalisation to examine why the disappearance of older institutional practices [in this instance, home birth] were not always inevitable when a newer practice [such as an obstetric unit birth] became prevalent or dominant. Work examining mature institutional fields exposed to modernising influences has suggested that non-dominant professional groups appear to engage in countervailing activities that maintain the persistence of older institutional practices while making efforts towards reinstitutionalisation. To date, studies have tended to focus attention at the top of organisations or on embedded or dominant occupational groups. This study has expanded and developed understandings of the agentic activity undertaken by non-dominant professional groups that sit largely outside governance, management and funding structures that sought to re-legitimise institutional practices which had been eroded or threatened with extinction. Methodology and methods This was a multiple case site study that employed a social constructivist approach to use a variety of qualitative research methods to explicate particular phenomena. This was compatible with institutional theory which has sought to examine how enduring social patterns and arrangements are constructed, become taken for granted and treated as inevitable. This study engaged with three separate organisations providing maternity services and a range of organisations and individuals associated with, or affected by this activity. The case sites were selected to represent a range of settings, conditions and relationships that are recognisable across the English National Health Service (NHS). Intended contribution The theoretical contribution of this study is to organisational and medical sociology questions about occupational relationships and the priorities that frame the allocation and management of health service resources. This was achieved by identifying institutional work both seeking to reinforce or resist existing medicalised and acute-focused maternity services. Practically, this study engaged with the socio-cultural and political complexities of maternity services’ organisation and delivery. It provides information for policy-makers, service leaders and innovators who are contemplating implementing changes in contexts where home birth services are under-developed or under-performing