Primary maternity units hold an important place in contemporary Aotearoa-New Zealand and other high-income countries. Despite research evidence revealing that low-risk women have a greater chance of normal birth with fewer interventions and equal or improved outcomes for the woman and baby, the number of births in primary units in Aotearoa-New Zealand has declined. This study seeks to uncover what enables, safeguards and sustains midwives to provide labour care in stand-alone primary maternity units in Aotearoa-New Zealand; ‘what works’. Eleven midwives (hospital employed and self-employed) along with three obstetricians who provided a consultancy clinic at primary units were interviewed in this hermeneutic phenomenological study.

Findings show that midwives who provide labour care have an embedded mode of confidence grown from a firm belief in primary units as the space/place for low-risk women to labour and birth. The midwife’s confidence is regenerated through seeing normal labour and birth unfold in this space and by trusting the whole team. Paradoxically, midwives working in the primary unit need to uphold protection of normal birth while ensuring the woman and baby’s wellbeing is never compromised. Midwives are tasked with constantly thinking ahead, not to discourage the unfolding of normal, but to shed light on the things that might be problematic. There is a sense, by midwives, of ‘everyone’ in the primary unit being responsible; midwives speak out, guiding and protecting, supporting normal and recognising the not normal.

Good relatedness occurs with obstetric colleagues who consult in the primary unit. Support from colleagues in the secondary/tertiary region is essential to maintaining a midwife’s confidence in working in the primary unit. The work of the midwife promoting normal labour and birth in the primary unit needs to be upheld; what ‘works’ requires more than a midwife practising named technical skills. Midwives in primary units acquire an all-encompassing mode of confidence-as-conviction sustained by practising in this space. Having confidence and trust overrides fear and is reinforced by excellent relating within the primary unit team and the secondary/tertiary region in a manner that holds understanding and respect.