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) is a structured framework aimed at guiding quality and continuous improvement of midwifery units across the United Kingdom and Europe. As a team, we are passionate about providing holistic, person-centred care and enhancing the safety of maternity services.

The MUSA Framework was developed from the MidwiferyUnit Standards, in collaboration with City St George's, University of London, Midwifery Unit Network, international expert stakeholders and service users. 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, servicer users, stakeholders and the 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 St George's, 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 United Kingdom 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 United Kingdom 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 United Kingdom and Europe. The framework is used alongside a self-assessment tool and with bespoke support from a local facilitator and the MUNet/MUSA team. There are eight steps to the framework: Prepare, Assess, Engage, Plan, Implement, Support, Reassess and Celebrate, which are completed over one year.

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 MUSA 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 consists of questions about your midiwfery unit and indicators focusing on philosophy and organisation of care, performance, governance and environment. The tool indicators enable midwifery units to benchmark their care provision and practice against the Midwifery Unit Standards and to identify areas of improvement and good practice.

The self-assessment tool supports existing midwifery units to undertake a gap analysis, identifying areas of improvement that can be actioned during the MUSA Framework process. Those undertaking MUSA regionally can also link with other midwifery units and collaborate with them on actions that feed into the development of regional documents. For units that are under development or planning to open, the self-assessment tool can aid in identifying objectives for implementation plans.

The tool can support midiwifery units to undertake a prospective risk assessment and provides the foundation for continuous improvement. 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.

A short version of the MUSA Framework is available on our website here. It provides an introduction to MUSA and an outline of the Prepare and Assess steps of the framework. If you are interested in using the full MUSA Framework in your midwifery unit, region or country, please contact us at musa@city.ac.uk.

An PDF version of the self-assessment tool is also free to download from this site under the Publications section. The Excel version of the MUSA self-assessment tool is available by request.