Midwifery units (also known as birth centres) offer maternity care to women and people with straightforward pregnancies, supporting physiological birth through a social model of care and providing a birthing environment that is calm, welcoming, comfortable and relaxing.

In midwifery units, midwives take primary professional responsibility and carry out most of the care, alongside maternity support workers, whom they manage. Interdisciplinary working with medical colleagues, ambulance service, community colleagues and service users is based on mutual respect to provide high quality, evidence-based care and smooth transfer to obstetric units, as required.

Alongside midwifery units (AMUs) are located in a hospital that provides obstetric care, close to the labour ward or on the same site in a different building. AMUs are close to medical facilities and personnel should a woman or birthing person need them. This may include access to interventions that can be carried out by midwives, for example electronic fetal heart monitoring. To access such services, women and birthing people will need to transfer to the obstetric unit, which will normally be by walking, trolley, bed or wheelchair.

Freestanding midwifery units (FMUs) are on a separate site from obstetric services, in an independent building or on the site of a community hospital. If a woman or birthing person transfers to the obstetric unit during labour they will usually travel by car or ambulance.

The Midwifery Unit Self-Assessment (MUSA) provides a structured framework to guide the self-assessment and improvement of midwifery units (MUs).

The implementation of the MUSA Framework includes the principle of co-production with stakeholders in the creation of an advisory group which contributes to the identification of strengths and area for improvement for the midwifery unit, based on the results of the completion of a self-assessment tool.

The framework provides a step-by-step guide supporting service improvement, emphasising co-production, stakeholder engagement and interdisciplinarity, particularly through strong service user input.

The MUSA Framework involves establishing a synergic partnership between midwifery units, key stakeholders and Midwifery Unit Network. This type of stakeholder engagement is highly effective because it combines insider knowledge with the benefit of gaining the fresh eye of an external facilitator.

The MUSA Framework was developed from the Midwifery Unit Standards, in collaboration with City, University of London, Midwifery Unit Network and international expert stakeholders, between 2019 and 2021.

In 2020, we conducted a rapid appraisal with four midwifery units in the UK and Europe. We gathered the views of service providers and users on the self-assessment tool and the stakeholder engagement process to identify the degree of support needed by services in the process of self-evaluation and co-creation of an improvement plan.

In 2021, we conducted a six case studies with midwifery units located in the UK and Europe to evaluate the self-assessment tool in practice, to identify barriers and facilitators for midwifery unit implementation and improvement within maternity services across Europe and to inform the development of the framework for this self-assessment process.

Through this time period, we have worked with an advisory group of healthcare professionals, service users, policymakers and academics, who have reviewed and supported us to refine the framework.

The MUSA Framework can be used by midwifery unit teams working in the UK and Europe. We recommend one or two midwives lead on using the framework. The framework is used alongside a self-assessment tool and with bespoke support from our MUSA team. There are three different phases to the framework: Prepare, Implement and Re-assess, with different steps are completed over 52 weeks.

During Prepare, your leads will attend an introductory meeting and training sessions, conduct a situation analysis using the self-assessment tool and organise wider stakeholder engagement in order to generate an improvement plan of impact actions for the midwifery unit.

The Implement phase involves implementing these  impact actions and receiving ongoing support from the MUSA team.

Finally, during Reassess, your midwifery unit will be asked to conduct a re-evaluation using the self-assessment tool and to revise your improvement plan based on the outcomes.

You can use the MUSA Framework in the UK and European health services that either have a midwifery unit or are planning to open one soon. It can be used by both alongside and freestanding midwifery units.

The MUSA Framework is available online at musaframework.org. If you are interested in using the framework in your midwifery unit, please contact us by e-mail at musa@city.ac.uk.

In 2019, researchers from City, University of London collaborated with an international group of advisors and service user representatives to develop the self-assessment tool with the purpose of helping healthcare professionals to benchmark their midwifery unit against each the Midwifery Unit Standards.

The self-assessment tool was developed in consultation with the American Association of Birth Centres (AABC) and Euro-Peristat and peer-reviewed by European stakeholders and ten experts in midwifery unit research, implementation and management.

The development of the self-assessment tool involved:

• Review of existing self-assessment tools and the methodology behind indicators;

• Meetings with key international stakeholders and experts with experience in creating indicators and self-assessment tools for maternity care;

• Delphi survey with two rounds to achieve consensus amongst experts;

• Expert stakeholder event;

• Peer review

The self-assessment tool takes a holistic view, reflecting the bio-psycho-social model of care that is adopted and promoted by midwifery units. This model takes in account physical, psychological and social needs of women and birthing people, orienting services around these needs and centring them on those receiving labour and birth care.

The self-assessment tool questions are primarily focused on midwifery units’ setting, performance and organisation of care. The tool consists of 12 questions about your midwifery unit and 60 indicators, concerning philosophy of care, governance, environment and organisation of care. Each indicator is also connected to one of the Midwifery Unit Standards, so that users can refer to the Standards for clarification.

The self-assessment tool enables different services to self-assess their philosophy of care, service organisation and related practices, enabling them to benchmark their provision. It also supports existing midwifery units to identify areas of improvement that can be actioned during the MUSA Framework process.

For units that are under development or planning to open, the self-assessment tool can aid in identifying objectives for implementation plans.

Finally, the self-assessment tool provides continuous support for midwifery units. We recommend that units aim to complete a self-assessment yearly, in order to reflect on their areas of growth and to update their improvement plans accordingly.

The self-assessment tool can be completed online via Qualtrics, a survey platform hosted by City, University of London. If you are interested in using the framework in your midwifery unit, please contact us by e-mail at musa@city.ac.uk.