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Society Guardian - Marvis Kirkham - Cutting the Cord 24th May 07 |
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Comment
A system of freelance midwives could help retain some of the profession's disillusioned staff and improve care for new mothers, argues Mavis Kirkham
It seems that midwifery has hardly been out of the press in the last few months, with the media talking about a crisis in the profession, government reports saying that every woman should be able to choose their birth experience, and exposés about a system that is seen to be on the verge of crumbling.
One reason commonly cited for the perceived crisis is a shortage of experienced midwives, with many midwives leaving the profession. Why?
All of my research and experience shows that, despite popular opinion, midwives aren't leaving due to low salaries, although this does become a sore point once midwives become disenfranchised. They are leaving because changes to the way services are run mean that many feel unable to deliver the care that mothers and babies need.
Midwives enter the profession wanting to support women and babies through the whole of their birth experience - pregnancy, birth and postnatal care. Unfortunately, overstretched services mean that many midwives are only seeing women for one-off appointments or are caring for more than one woman in labour, affecting continuity of care and short-changing both women and their midwives.
In some areas midwifery has become a production line system, aimed at ensuring that babies are safely delivered and then moving on to the next delivery. This squeezes both ante and postnatal care, as midwives are moved from these areas to ensure that the delivery area always has adequate staffing.
This not only drastically reduces job satisfaction for midwives themselves, but also makes the experience of birth a lot harder for women. All of the evidence shows that women who have time to build up a trusting, one-to-one relationship with their midwife have a far better experience than those who haven't had this opportunity. This means less chance of surgical intervention and a more natural delivery, making the experience as stress-free as possible for mother and baby.
The problem is that the system currently is not set up to encourage one-to-one care for pregnant women. NHS money isn't being directed into the preventive care that midwives routinely offer during pregnancy, and pregnant women and midwives are finding themselves trying to fit in with a system that doesn't meet their needs.
It is getting to the point where pregnant women are seeing the strain their midwives are under, and are trying not to "bother" them with their problems. This obviously has repercussions for the care women receive, as well as suggesting that there is a huge amount of goodwill between women and midwives, and that all they need is a better way of managing the service.
The Independent Midwives Association (IMA) has suggested a new system that I think will resolve many of the problems inherent in the current system.
Under the new proposals, women would choose their own midwife, with the NHS then paying the midwife directly for her services. The midwife would act as a contact to allow the mother to access other NHS services, and would remain the woman's main carer from pregnancy through to postnatal care, wherever that care is given.
This would allow midwives to offer women one-to-one support and would place the focus back onto providing long-term care for mothers and babies, rather than just seeing women through a delivery.
It would also mean that midwives have a greater degree of flexibility in terms of when they work, how many women they choose to work with and the geographical boundaries in which they operate.
This system would mean that women could have true choice, allowing them to find the midwife that practises in a way that best suits their own individual needs. It recognises that midwifery is a craft as well as being a science, and allows women to choose a midwife with whom they feel completely comfortable.
In areas where one-to-one midwifery schemes are already running, the evidence shows that mothers tend to have far better experiences of birth and are less likely to require surgical intervention.
Set up alongside the existing service, this model would provide real choice and meet government objectives. Such arrangements will not suit all midwives; not all can manage the on-call requirements involved. Nor will it suit all women, as many would opt to stay with the present system. But it would provide an alternative to the present conveyor-belt model of care, and the contrast would lead to changes within the existing system.
The current system doesn't use midwives to their full advantage and I hope the government looks closely at the IMA's proposals and commissions a pilot project. I think the improvements for women would be enormous, and the benefits of keeping our experienced midwives in the profession cannot be overstated.
· Mavis Kirkham is professor of midwifery at Sheffield Hallam University's centre for health and social care research.
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