APPENDIX 7
Memorandum by the Independent Midwives
Association
THE MODEL
OF CARE
INDEPENDENT MIDWIVES
PROVIDE
1. The Independent Midwives Association
(IMA) represents registered midwives who have chosen to practise
outside the NHS, in a self-employed capacity. This enables us
to offer a unique model of care that is truly women centred.
— The woman chooses the midwife.
— The care is individualised for the
woman and her family.
— The relationship between the woman
and midwife is one of partnership.
— Unhurried antenatal care, which is
a crucial and integral part of the childbearing experience, enables
the woman to explore issues through full and thorough discussion
which leads to her making genuinely informed choices about her
care. This process of decision making enables the woman to gain
confidence in her ability to birth and parent positively and effectively.
— Labour care with the midwife with
whom a relationship of trust has developed throughout the pregnancy.
— Postnatal care and support for up
to a month following the birth.
2. By choosing this model of care, women
exercise control over the external factors around their childbearing
experience. This enables them to surrender control of the birthing
process to their bodies, a crucial factor in a woman's ability
to birth optimally. Many of us believe, taking the evidence of
our own caseloads, that the woman who is able to exercise real
control in her birth experience has a safer birth, than she otherwise
would have.
STATISTICAL EVIDENCE
3. Since it began in 1985, the IMA believed
that the outcomes of the care members provided were good but had
not been able to collect data in a manner that could enable these
outcomes to be critically evaluated. However studies show that
"The continuous presence of a support person reduced the
likelihood of medication for pain relief, operative vaginal delivery,
caesarean delivery, and a five-minute Apgar score less than seven.'
Women expressed greater satisfaction and level of personal control
during childbirth having received continuous support. Hodnett
ED Caregiver support for women during childbirth (Cochrane Review).
In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
4. From January 2001, we began to collect
ongoing, basic, quantitative, prospective data about the practice
and outcomes of UK independent midwives (IMA members). Appendix
1. This is now beginning to provide a rich source of valuable
data. Below are a set of preliminary, but incomplete, statistics
from the project.
|
| Total Births Analysed 1.1.02—1.3.03 |
340 | |
|
| Planned to have Home Birth | 87%
| |
| Achieved Home Birth | |
75% |
| Hospital Transfer | | 25%
|
| Normal Birth * | 70%
| |
| Induction | 2% (over 21% )
| |
| High Risk ** | 56%
| |
| Planned Vaginal Birth after C/S/s | 15.5%
| |
| Achieved Normal Birth | |
70% |
| Caesarean Section | 16% (over 22%)
| |
| Planned (decision made before onset of spont labour)
| | 9% |
| Emergency (decision made after onset of spont labour)
| | 91% |
| Instrumental Deliveries | 4% (11%)
| |
| Ventouse | | 86%
|
| Forceps | | 14%
|
| Episiotomies *** | 5% (13%)
| |
| Fully Breastfeeding at 6 weeks | 78%
| |
|
| * | Spontaneous onset of labour, no artificial rupture of membranes, no pharmacological drugs (for analgesia or augmentation), no episiotomy, and no instrumental delivery.
|
| ** | Aged over 40, multiple birth, breech birth, >3 miscarriages, previous stillbirth, previous C/S, previous PPH, chronic medical condition, assisted conception, malpresentation, previous obstetric complication (eg pre-eclampsia, 3rd degree tear etc).
|
| *** | 1 by midwife at home, others by hospital staff following transfer.
|
Bracketed figures in italics are national rates
from the Department of Health—NHS Maternity Statistics,
England 2001-02.
5. We believe that the model of care practised by independent
midwives provides a woman with real choice. She is able to make
informed decisions about her care throughout her antenatal, labour
and postnatal period, secure in the knowledge that she will be
supported in these decisions by a professional she has come to
trust.
Equality of Access
6. Women across the country are disadvantaged by their
current lack of choice in maternity services. For all women to
benefit from the better outcomes resulting from this type of care,
equality of access needs to be urgently addressed.
7. Putting this model into place could be quite straightforward
by implementing it as a parallel model to sit along side the current
structure.
8. No change in the regulation of the midwifery profession
would be needed. A strong midwifery regulatory system already
exists to protect the public and statutory supervision for midwives
has been in place for 100 years.
9. Women in the UK are already entitled to free maternity
care but it is the constraints of models offered within the system
that deny true choice and control. A national structure that pays
a midwife a set fee per woman for providing midwifery care would
enable equal access to this model of care for all women. Opticians,
pharmacists and general practitioners currently work on a similar
basis so it is not new in this country. Similar systems currently
work in New Zealand and parts of Canada, based in the community,
ensuring equity of access for all women and are recognised as
being at the forefront of international maternity provision.
10. National standards for access agreements to hospital
facilities, birth centres, specialist services, diagnostic testing,
and prescribing would be required for midwives.
11. Vicarious liability provision for all midwives would
be required. The NHS already provides this for more than 99.5%
of practising midwives in the UK.
Benefits of this Model
12. Targets for increasing normal birth and breast feeding
rates, and reducing caesarean section rates would be met leading
to major cost benefits in the medium to long term.
13. Public health benefits could be achieved including
all the benefits of increased breastfeeding rates for both the
baby and mother. The comprehensive postnatal support that this
model offers has significant impact on post natal depression.
14. Models of care that provide one to one support, such
as the Edgware Birth Centre, Albany Practice, etc. have proven
to reduce the rate of obstetric intervention in labour whilst
providing excellent outcomes for mothers and babies. Since every
obstetric intervention carries some degree of risk as well as
benefit, lower rates of intervention are likely to lower the risks
of litigation through an adverse outcome.
15. The escalating recruitment and retention problem
within the midwifery profession could be addressed by implementing
this model of care along side the current system. The IMA is constantly
receiving enquiries from midwives leaving the NHS frustrated by
being unable to practise the full role of an autonomous practitioner
and provide holistic care. Figures suggest that many would return
to practice if able to work in the way outlined above (RCM, 1999
Personal comm.). Historically this was available in the first
few decades of the NHS in the form of the domiciliary midwifery
service which gave midwives the opportunity to practise with professional
independence and social flexibility. Allison, J. 1996 Delivered
at Home, Chapman Hall, London. The present structure of maternity
provision struggles to offer genuinely flexible ways of working
to midwives trying to balance the demands of work with family
and other commitments. Many would like the opportunity to practise
within the independent model but are currently discouraged from
doing so by the financial insecurity and insurance issues and
so are choosing to leave midwifery altogether. Independent practice
enables a midwife to determine the number of women she books and
when they are due to give birth, whether she works singly, in
a partnership or within a group, the type of care she feels experienced
to offer (home and/or hospital) and the geographical area she
wishes to cover. She is able to balance her work and personal
life in a dynamic way as her circumstances change throughout her
working life.
16. The model could resolve the crisis in midwifery education
by providing opportunities for students to work along side experienced
midwives practising the whole range of normal midwifery skills.
17. This model of midwifery care provision, if made available
to those women who want it no matter where they live or what socio-economic
class they come from, and provided by those midwives who wish
to work in this way, would be good for mothers and babies and
good for midwives.
18. The World Health Organisation acknowledges that midwives
are "the most appropriate and cost effective type of health
care provider to be assigned to the care of women in normal pregnancy
and birth including risk assessment and the recognition of complications."
(WHO 1999 Care in Normal Birth).
19. At the height of twentieth century domiciliary maternity
provision, it was acknowledged that "the status of midwives
should be safeguarded...." "They should be regarded
as colleagues of doctors and not merely as maternity nurses working
under the orders of a doctor." Cater, GB and Dodds GH 1953,
Dictionary of midwifery and Public Health Faber and Faber, London.
20. Implementing a parallel structure to sit alongside
the current provision would enable women and midwives maximum
choice. Experience in New Zealand showed that since this model
was introduced in the early 1990's, 50% of women now choose a
midwife practising independently as their lead maternity carer
for their pregnancy, birth and the postnatal period. A further
21% chose an employed midwife who holds her own caseload. MIDIRS
Midwifery Digest13:2 2003 p222.
Recommendations for Action
21. A recommendation from the Sub-Committee for this
model of midwifery care to be available nationally sitting parallel
with the current provision of maternity services to offer real
choice and control to women and choice and flexibility for midwives.
22. A working party set up to plan its implementation
which should include significant user group representation. IMA
would be very willing to involved.
June 2003
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