Maternity care service is a well-established service in Norway. Even though Norway has a high standard of maternity care, improvements are still needed when it comes to make the service more continuous throughout primary and secondary care level. The implementation of a planed change, i.e. the Coordination Reform, into a well-established system like maternity care in Norway, can trigger various forces, which can either enhance or constrain the realization of policy guidelines.
The newly introduced Coordination Reform in Norway receives a lot of attention in media and among researchers. One of the goals of the reform is to transfer duties from secondary health care to primary health care. This in order to achieve treatment on the lowest effective care level, while freeing up specialized resources on secondary care level to those who need them most.
One measure to achieve this goal are legal contracts, which shall be signed within various areas between local health trust and the municipalities. Agreements between the hospitals and municipalities within municipal midwifery care represent one of these contracts in the Coordination Reform. The content of this contract shall be led by the white paper on continuous pregnancy-, birth- and post-natal care. The design of the contract shall facilitate the implementation of new policy guidelines within maternity care.
The objective of this report is to explore how municipalities realize policy guidelines within midwifery care through the legal contract. The research is conducted by semi-structured interviews carried out with three informant groups in three municipalities in one county in Norway. The forces behind organization change represent the theoretical framework of the study and will be investigated.
The results show that various degrees of professional conflict between midwives and general practitioners were found in each municipality. It seems to be the case that none of the midwifery services in the municipalities have changed much. This is a surprising result given that the intent of the Coordination Reform within midwifery services instigates changes.
Nevertheless, municipal midwifery care is being developed, though not on the premises of the new policy guidelines within maternity care. One municipality has initiated a project in order to facilitate the implementation of the new policy guidelines, but this happened independent from the contract about midwifery care.
The analysis has shown that theories within organizational change are supported by the findings in the three municipalities. In the following this can be summarized by:
• Resistance determinants from organizational change theory are shown to be valid:
It has been found that some general practitioners seem to show reservation for plans of enhancing midwifery services by giving them a more coordinating role in antenatal and post-natal care. Through the theory, it is argued that such a change can threatened their identity/position within maternity care and maybe lead to a shift in the power balance. In addition, necessary new investments and the seemingly establishment of double work, i.e. maternity care services on primary and secondary level, can lead to resistance against change on an administrative level.
• Success factors are proven to be necessary for successful implementation:
Success determinants like to convey the need for change, provision of resources, support from top-management, and a clear strategy have been proven to be important for the implementation of planed change. The two municipalities that did not fulfill these four criteria where also the ones, which did not seem to have implemented changes within midwifery care in connection to the Coordination Reform and the new policy guidelines within maternity care.
• Conflict groups can enhance change:
It can be argued that the conflicting interests between professions in one of the municipalities has led to early initiation of the implementation of changes within midwifery care.
• Leadership plays an important role in facilitating planed change:
The findings show that the leader in one municipality, which showed most of the characteristics of a charismatic leadership, has come furthest in the initiation of projects within midwifery care services.