We need a rethink - maternity services in England

It’s the last day of July 2017, and I’m sat reflecting on a month of highs, and of lows.

The week before last, I was surrounded by more that 300 future midwives, at three different events across England, over three days.

What a privilege it is to be invited to be amongst this phenomenal group of people. When I’m with them I feel inspired, hopeful for the future of maternity services, and my children’s children.  They are intelligent, compassionate, eager, aspirational, and full of enthusiasm. Some of them told me they’d had other successful careers prior to starting midwifery; I met a student midwife who was previously a stockbroker, one who owned her own business, and one who managed a marketing company. Their personal ambitions however, link them together. They all want to work with childbearing women, to facilitate positive childbirth outcomes, where mothers and babies are both physically and emotionally well. I watched delegates soaking up the information and inspiration delivered by each speaker, at all the events….and I jotted down some of my thoughts…

‘..not a movement in the room, eyes wide...’ ‘questioning comments showing so much insight’

so much desire to improve maternity services…

Brighton student midwife conference - july 21st 

Many of the speakers at each of the three events directly and indirectly talked about the importance of positive birth, of promoting physiological, normal birth when possible, and of the midwife’s role in supporting this.

One question from a future midwife stuck me. ‘Do you think that midwives, by encouraging and supporting ‘normal birth’, make women feel disappointed if they need an operative birth?’

Just before the session where this question was asked, one of the midwifery lecturers told me she was worried that the student midwives she taught had limited exposure to normal, physiological childbirth during their clinical placements. In general, the women they cared for had limited choice in place of birth, and were frequently exposed to potentially unnecessary medical interventions.

I feel some despair that student midwives question the fundamental role of the midwife in promotion normal birth, instead of challenging maternity service provision, lack of resources, lack of continuity of carer, increasing fear and political pressure.

'The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures'. 

At the same time, on social media, the polarization of birth continues, in it’s fiercest form.  Hans Dietz, a clinician from Australia, wrote a damming ill-informed opinion piece about England’s Better Births report, entitled: 

'Women and babies need protection from the dangers of normal birth ideology'

Thankfully, Prof Lesley Page gave a counterbalance to the article, providing factual evidence that quashed any authenticity to Dietz’s opinions.

In England, the word ‘normal’ in relation to birth is being increasingly demonized. This is in spite of the fact that it is a globally recognised term, and there is an international movement, backed with robust evidence, to support normal birth processes, whilst striking a balance between over and under use of medial interventions.  Indeed, Scotland’s maternity policy document published this year said ‘Services are redesigned using the best available evidence, to ensure optimal outcomes and sustainability, and maximise the opportunity to support normal birth processes and avoid unnecessary interventions’.

In England, the Royal College of Obstetricians and Gynaecologists Every Baby Counts campaign clearly highlights that staff must be vigilant for early warnings of any 'departure from normality'. Absolutely, this is a fundamental midwifery skill.  But how is this possible if midwives are seeing normal physiology less and less, and being advised not to use the terminolgy?

Every international authority in the world is now promoting normal birth where this is possible (for the vast majority of women and babies). Most, including the Lancet, WHO and the new UN Director General, explicitly state that midwifery (i.e. the active support and promotion of normal physiological birth, as well as the recognition and action on emerging pathologies) is THE solution to the world wide need to reduce maternal and neonatal mortality and morbidity’ (Downe, 2017)

Yet midwives tell me they feel afraid to support women’s choices, and admit the press, the fear of litigation, being named as a ‘maverick’ makes them more likely to practice defensively ‘just in case’.

Also, in the midst of being immersed in the fresh, eager anticipation of student midwives, I read a blog post of from a desperate midwife, wanting to remain anonymous, saying sorry to the women she cares for. The post is heartbreaking, and after being shared thousands of times, was picked up by the Australian press.

Photo: Sorry, a midwife speaks.

Even sadder, are the responses. The affirmations that this is midwifery reality, and potentially why midwives are leaving their beloved jobs, continue to roll in on Facebook and Twitter.  One of the many depressing comments also mentions not being ‘allowed to use the word normalising birth’. I believe this is ludicrous, and creating another, damaging problem. The most chilling part of the midwife’s words are at the end - 'It is increasingly difficult to be allowed to have a heart'

‘ I think this is an accurate representation of life as a midwife today. The saddest thing is that we (midwives) will recognise almost all of the things in this letter but are so far beyond knackered we don't even know where to start to make things better. NHS Trusts can have all the staff engagement incentives they want, but the truth is we won't make the slightest bit of difference. The political and fiscal drivers of our 'service' are very far removed from us. Staff engagement serves as a tick-box exercise for managers of all levels so they can score well on leadership and engagement. For every woman-centred initiative we start (aromatherapy, caseloading, a new/extra birth pool, booking appointments at home), 2 more things are created to take away the value of that - 'paperless' so we sit talking to a computer screen not our women, more 'high risk' inclusions for IOL (is there anyone that doesn't technically fall under the need for an IOL anymore??), not allowed to use the word 'normalising' birth as it has connotations about power struggles. the list goes on. I love my women, I love birth but I no longer love my job. It is increasingly difficult to be allowed to have a heart’.  

There is enormous pressure on maternity leaders too. I’ve talked to four heads of midwifery (HoM) recently, on separate occasions. All of them articulated the increasing pressures they face, unattainable goals, undoable workloads, that I wrote about several years ago. One HoM told me ‘We have just managed to achieve safe staffing levels, so women are receiving appropriate care. Outcomes are good, and we have positive feedback. But the Trust is in financial difficulty and Ernst Young are now contracted to 'sort out' the organisation, and we are being instructed to cut midwife posts. The answer to our desperate concern is ‘there is no other way’.  

Jeremy Hunt’s recent blog post on ensuring maternity safety clearly sets out the priorities. But there is no mention of the need for adequate midwifery staffing as identified by the RCM , or the important research evidence on the benefits of continuity of midwifery care. Can Hunt's goals be achieved, with exhausted midwives, with midwives leaving, or with midwives not being allowed to care, or 'to have a heart'? 

Is this the way to make services safer? To halve the number of stillbirths?

And finally, as we strive to make maternity services safer, childbearing women, with increasing medical interventions imposed, and maternity services mainly delivered in hospital settings, are feeling unhappy too. Devastatingly so. 

Why is this happening?

I continue to highlight issues and lobby for change for the daughters of my daughters, and of my sons. I am passionate and will continue for the future midwives, as I desperately want their lights to continue to shine. Go back to the top of this post, and check out those faces.

We need a rethink and your suggestions are welcome. 

Reference

Downe, S (2017) Personal communication