APPENDIX 50
Memorandum by the Independent Midwives
Association (MS 64)
Maternity care is so important to get right
for women and their families and for the long term well being
of society. However women are losing confidence in the system
of maternity care which is in place in this country at the present
time: a system operating similarly in both the NHS and the private
hospital sector.
THE PROBLEM
The maternity services are in crisis as a result
of a combination of factors. There is enormous difficulty in retaining
midwives throughout their training and after qualification. A
recent survey from the Royal College of Midwives identifies the
highest number of vacant midwifery posts ever recorded (RCM, 2002).
This is set to get worse with many Trusts expecting 20% of their
midwives to retire in the next five years (McKenzie, 2002). Midwives
train to become practitioners of normal birth. However, this is
now the exception rather than the norm in many hospitals, mainly
due to lack of staff and the increasingly rigid obstetric policies
and protocols, not always supported by evidence from research,
but intended to reduce litigation. Ironically, it is often this
rigid care provision framework that triggers dissatisfaction for
women and leads them to consider litigation. Morale within the
midwifery profession is at an all time low. Midwives leave, creating
additional strain on those remaining, and as a result, women receive
less and less midwifery care. Some areas are now only able to
provide four or five antenatal appointments, with a midwife, of
five to ten minutes each, throughout pregnancy. Most women do
not even see a midwife, apart from the booking visit, until two
thirds through their pregnancy. The chances are small that during
her pregnancy a woman will meet the midwife who will care for
her in labour, let alone that she will be able to form a relationship
of trust with her: a factor well known to contribute towards a
safer outcome of labour (Hodnett, 1989, page 1,999). This minimal,
fragmented care dramatically affects the woman's confidence in
her ability to give birth. Postnatal care, either in the hospital
or the community, is almost non-existent. New parents are unable
to receive the care they need in many areas due to shortages of
staff, and are thus deprived of the skills and professional midwifery
input that supports and guides them in the first weeks of parenting.
In order to overcome these problems some women
are able to employ an independent midwife, but for most women
this is not an option, due to the limited number of independent
midwives and the cost to the individual client.
Over the last decade many attempts have been
made to improve the provision of maternity services in the NHS
yet most have failed to make sustainable improvements or be expanded
beyond the initial scheme.
Midwives are predominately women, who all have
changing commitments and pressures throughout their working lives.
True flexibility in working practises must become a priority to
enable midwives to work in different ways at different stages
of their lives. Currently many midwives leave the profession when
changes occur in their lives, and the current system is unable
to offer them sufficient flexibility in working patterns to continue
to practise. It is proving extremely difficult to try to encourage
midwives who have left the profession to return to practise within
the existing structure and none of the hoped for signs of a resolution
to the staffing crisis have yet become apparent.
A BETTER WAY
FORWARD
The Independent Midwives Association believes
that there is a realistic, sustainable solution.
The answer is a change in the structure of maternity
care provision: creating the option for women and midwives to
choose the independent model of midwifery care, paid for by the
state. Dentists, opticians and pharmacists currently work in
this system so it is not new. Each woman would have the option
to choose her midwife, who would be paid a set fee by the government
for providing maternity care. The model works well for women and
babies in maternity care in Canada and New Zealand. The World
Health Organisation recommends the one to one model as the safest
and most cost effective provision of maternity care in the developed
world (WHO 1999). The current maternity service would also continue,
and it would be up to individual women and midwives as to which
system they preferred to opt into. Research shows that midwives
are leaving the profession because they can no longer bear the
system in which they work which amongst other things, results
in lack of fulfilment in their work, not because they want to
leave midwifery (Ball, et al 2002). Figures suggest that
many would return to practice if able to work in the way outlined
above (RCM, 1999). The insurance issue, and the financial insecurity
of practising as an independent midwife, currently discourages
them from doing so.
The IMA was set up in 1985 to disseminate information
about and to support midwives who have chosen to practise outside
the NHS, in a self employed capacity. We support the aims and
ideals of the NHS. Independent midwives are able to provide truly
individualised care and continuity of carer throughout pregnancy,
birth and up to a month after the baby is born. Research has demonstrated
that caseload midwifery practice provides care which is seen both
by women consumers of the service and by midwives as more satisfactory
than current norms.
In January 2002 we began an ongoing project
to collect basic quantitative prospective data about the practise
and outcomes of IMA members. The aim was to assess the safety
and efficacy of this type of caseload midwifery practise and to
be able to discuss and publicise analysis of the data. Initial
examination of last year's figures is already providing a rich
source of factual including information relating to a significantly
reduced recourse by women to technological interventions, two
obvious results of which are lower costs to the government and
less morbidity for women.
We would very much like to have the opportunity
to provide oral evidence to the Sub-Committee, and be able to
answer questions directly on the way forward for maternity provision
as we have outlined in this paper.
March 2003
REFERENCES
RCM October 2002 RCM Evidence to the Pay Review
Body Midwives Vol 5 No 10 p 346
McKenzie C. Return to Midwifery. Presentation
London LSA Conference For Supervisors of Midwives. November 2002.—Unpublished.
Hodnett ED, Osborn RW. October 1989. Effects
of Continuous Intra partum Support on Childbirth Outcomes. Research
in Nursing and Health Vol 12, Issue 5, p 289-297.
Page L, McCourt, Beake S, Vall A, Hewison J.
September 1999 Clinical Interventions and Outcomes of One—to
One Midwifery Practice. Journal of Public Health Medicine Vol
21, Issue 3, p 243-248.
WHO Care in Normal Birth: a Practical Guide
1999. WHO FRH/MSM/96.24
Ball L, Curtis P, Kirkham M. 2002 Why Do Midwives
Leave? Royal College of Midwives, London.
RCM 1999 Personal communication.
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