Using a Clinical Pathway to Support Normal Birth: Impact on Practitioner Roles and Working Practices Billie Hunter, PhD, BNurs, RM, and Jeremy Segrott, BA (Hons), MA, PhD ABSTRACT: Background: Widespread concerns are being voiced in the Western world about rising rates of childbirth intervention. In Wales, United Kingdom, a Clinical Pathway for Normal Labour (Normal Labour Pathway) was devised to support normal childbirth and reduce unnecessary interventions. This study investigated the implementation of the pathway, from the perspective of midwives, doctors, and midwifery managers. Methods: An ethno- graphic approach was used to observe use of the Normal Labour Pathway in real life settings and evaluate its implementation. Data were collected by means of semiparticipant observation, focus groups, and interviews. Participants (n = 56) included senior practitioners involved in creating the pathway (n = 4), midwives (n = 41), managers (n = 5), and doctors (n = 6). Data were analyzed thematically. Results: Key themes related to the effect of the Normal Labour Pathway on Welsh maternity care, and midwives’ and doctors’ experiences. Midwives’ views focused on the pathway as a decision-making protocol and record of care. Recently qualified midwives were more likely to view the pathway positively than those with more experience. Doctors were critical of the pathway, experiencing it as exclusionary. Midwives and doctors considered that the Normal Labour Pathway had increased interprofessional tensions. There was no evidence that it had increased the normal birth rate. Conclusions: The Normal Labour Pathway is a complex intervention with complex outcomes. It has had intended and unintended consequences, for maternity care in general and for the roles and relationships of maternity care practitioners. The study raises questions about the appropriateness of clinical pathways and other standardized decision-making tools for the complexity of childbirth. (BIRTH 37:3 September 2010) Key words: clinical pathway, ethnography, interprofessional relationships, midwifery care, normal birth The United Kingdom, in line with much of the Western world, has seen a decrease in the normal birth rate and a rise in childbirth interventions (1). In Wales, one of the four United Kingdom countries, the cesarean section rate has increased from 20 percent in 1997 to 1998 to 26 percent in 2007 to 2008 (2). A corresponding decrease has occurred in ‘‘unassisted deliveries’’ (defined as babies born by maternal effort), from 69 percent in 1997 to 1998 to 62 percent in 2007 to 2008 (2). The reasons for these changes are complex and multifaceted (1,3). As noted in the recent consensus statement of the UK Department of Health, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, and the National Childbirth Trust (1), rising intervention Billie Hunter is Professor of Midwifery in the Institute for Health Research, School of Human and Health Sciences, Swansea University, Swansea; and Jeremy Segrott is Research Fellow in Public Health, DECIPHer, Cardiff Institute of Society, Health and Ethics, Cardiff School of Social Sciences, Cardiff University, Cardiff, UK. This research was funded by the Health Foundation, London, United Kingdom; Leading Practice through Research Project no.: LPTR 1084 ⁄ 2869. Address correspondence to Billie Hunter, PhD, Professor of Mid- wifery, Institute for Health Research, School of Human and Health Sci- ences, Floor 2, Vivian Tower, Singleton Park, Swansea University, Swansea SA2 8PP, Wales, UK. Accepted February 10, 2010 Ó 2010, Copyright the Authors Journal compilation Ó 2010, Wiley Periodicals, Inc. BIRTH 37:3 September 2010 227