Independent midwives

An NCT position statement

 
It is important for women and families that independent midwives are available as one of the range of choices available for maternity care. Independent midwives provide holistic care; they provide for the physical, emotional and spiritual needs of the women, babies and families on their caseload. They recognise the importance of birth as the beginning of the baby’s life, a potentially life enhancing or traumatic experience for women, and a family event of significance for the father, siblings, grandparents and others.

 
Often midwives working for the NHS are too pressured and rushed to be able to work in a woman-centred and family-focused way. This needs to be addressed so that all women get high quality maternity care. The NCT lobbies at all levels for improvements in maternity services.

 
Independent midwives are needed to:

• demonstrate positive models of high quality, woman-centre, family focused care,
• provide an alternative when the local NHS cannot deliver what women need.

 
The next sections explain these points in more detail

 
Positive models of maternity care

 
There are many ways in which independent midwives provide positive models of care which have been taken up by the NHS as part of service development, and used to inform midwifery training, practice and leadership.  These include:

·        caseload midwifery (the way midwives are organised and the number of women they care for); and

·        provision of truly woman-centred care including:

o       access to home birth,

o       extended postnatal care,

o       needs-led, one-to-one support for breastfeeding,

o       use of water for comfort during labour and birth in water,

o       holistic, woman-centred assessment of the progress of labour,

o       physiological third stage,

o       vaginal birth after a caesarean (VBAC)

o       physiological breech birth,

o       vaginal birth of twins.

 
For women who want to have continuing care from the same midwife or to make these kinds of choices booking an independent midwife is the only realistic option.  Without independent midwives, choices for women would be diminished. This would deny women their basic human right to autonomy during childbirth.

 
Background

Caseload midwifery

Many women value the opportunity to be cared for by the same midwife and a small number of her colleagues throughout their pregnancy, birth and the postnatal period. Opportunities to have ‘continuity of carer’ can be few and far between in the NHS, as midwives often work shifts and staff clinics and hospital wards rather than following a caseload of women and providing care for them. Women sometimes see a different face at every appointment and are cared for by someone unknown to them when they go into hospital in labour. Caseload midwifery is a model of care in which each full-time midwife provides the majority of care for up to 36 women from early in pregnancy to the end of postnatal care, including being there for the birth. Independent midwives working full-time limit their caseload currently to around 26 women to limit restrictions on contact time with families. Caseload carrying midwives work closely with one or more colleagues to provide back-up for each other when the named midwife is unavailable.  This model has been pioneered and promoted by independent midwives and is now practiced, or a modified version of it, in several areas within the NHS, where it is prioritised for most disadvantaged women, those with particular needs and families in Sure Start areas.

Truly woman-centred care

Pregnancy, birth and the transition to motherhood make unique demands and provide special opportunities for women. The pregnancy can be straightforward or more complex, the situation can change from one week to the next; the women’s life-style may be stable, stressful or chaotic. Some women want a lot of information and control, others relatively little. Yet despite all the possible differences, care that is respectful and kind, which involves the midwife listening to what the woman values and needs, and responding to her wishes, empowering her to be fully involved and rising to the challenges in a way that is right for her, can be a life transforming experience.  In contrast, care that is rushed, dogmatic, prescriptive, impersonal or uncaring can be traumatic and damaging, affecting the woman and how she responds to her children, her partner and life events for years to come.

In some areas and for some women, NHS care is of high quality and meets their needs, yet in other areas and for women with particular preferences or needs it leaves a lot to be desired. Many midwives who work independently have previously enjoyed the relative security of working within the NHS, where they are paid regularly and had insurance cover.  They left employment because they were unable to provide holistic, high quality care for women within the constraints of the NHS system. Women from all kinds of backgrounds are willing to pay for an independent midwife, particularly if they have heard from friends about what a difference it makes, or if they have been damaged previously by uncaring staff, a lack of control or unnecessary interventions.

Independent midwives provide an alternative to what the NHS has to offer locally. In addition, many independent midwives are opinion leaders in their profession, interpreting research, writing articles on good practice and helping to change attitudes about care for women.

Home birth

In 1970 the Peel Report recommended that all women have their baby in hospital without any evidence to show the benefits and risks compared with birth at home for women with a straightforward pregnancy. Home birth became more and more difficult to obtain for those women who wanted one. For women giving birth in hospital the caesarean section rate has risen dramatically, so that now in the UK around one in four women have a caesarean birth, twice the rate in 1990.

Independent midwives have helped to keep the option of a home birth alive as a real choice for women, not only by providing direct care for those who employ an independent midwife, but by talking to midwives employed in the NHS, teaching and lobbying. 

In the early 1990s government policy changed in England, Wales and Scotland. The principle was established that services should to respond to what women want and offer them choices, including access to home birth. Yet still fewer than 3% of UK babies are home births.  In some local authorities the home birth rate is over 10%, demonstrating a demand for home birth where it is offered.

In some areas where demand outstrips supply the only way to be sure of getting a home birth is by booking an independent midwife.

Use of water and water birth

These days it is widely recognised that water is an effective means of coping with pain during labour (NICE, forthcoming) yet it has taken well over a decade for this to become widely recognised and provided for. Independent midwives have gained experience in using water for labour and birth and offered this expertise to women as a matter of course. 

They, alongside pioneering midwives working in the NHS, have worked to change attitudes and opportunities for women to use a birth pool during labour.

Woman-centred assessment of progress

Women in labour usually prefer to have as few vaginal examinations (VEs) as possible because the procedure is intrusive and can be painful.  Independent midwives, who care for many women at home, are less constrained by rules and protocols laid down by the NHS, and tend to carry out fewer VEs than midwives working in hospital. They assess progress in labour using a range of observations and reflecting on their experience of what is within the range of normal, what might be a barrier to progress, what might facilitate progress, and which circumstances need intervention. 

Now a more flexible, holistic approach is being used in NHS birth centres and on some hospital delivery suites. 

Physiological third stage

 
The time from when the baby is born to the placenta emerging is called the third stage of labour. Like the rest of labour, this can happen without interventions unless there are complications or there have been earlier interventions in labour that might affect the normal physiological process. However, it has become the norm in UK hospitals to use drugs to make the woman’s womb contract and the placenta come away. This is called and ‘actively managed’ third stage. There can be risks as well as benefits to this approach and some women would prefer not to have the drugs with early clamping of the umbilical cord.  

Independent midwives always offer women a choice and advice about the balance of risks and benefits of the alternative approaches, based on their circumstances.  In many areas, particularly in midwife-led birth centres, women can now make this choice with NHS care, but in some places NHS midwives still have limited experience of a physiological third stage.

Vaginal birth after a caesarean

 
It matters a lot to some women who have had a caesarean birth to have the best possible chance of a vaginal birth in another pregnancy, particularly if they feel that the earlier surgery may not have been necessary if their care had been managed differently. For these women, it is essential that they find a midwife who understands their obstetric history and respects their wishes. Continuity of carer is therefore vital, including the knowledge that they will be cared for in labour by a midwife with suitable experience and confidence.

Often the only way to be sure that a supportive and familiar midwife will be available is to book an independent midwife. In the NHS, while support for VBAC is growing, the availability of experienced and supportive staff can be hit and miss. For a woman who really cares about having a vaginal birth if possible, the uncertainty of this lottery in care is unacceptable. Booking an independent, caseload-carrying midwife provides peace of mind.

Physiological breech birth

Many obstetricians and midwives no longer have experience in assisting a mother to give birth to her breech baby as caesarean section is routinely recommended in most areas. This change of practice was accelerated when results of a large multi-centre international medical trial of breech births was published. For women who want a vaginal birth for their breech baby, often the only dependable option is to book an independent midwife as independent midwives respect a woman’s right to choose the mode of birth they prefer, and as a group have maintained skills and knowledge in vaginal breech birth.  Since publication of ‘The Term Breech Trail’, several papers have been published criticising the methodology and conclusions of the study and there is growing acknowledgement that obstetricians and midwives need to maintain their skills in vaginal birth for persistent breech-presenting babies. 

Leading independent midwives offer vaginal breech birth to women and provide training to health professionals on good practice when assisting at a vaginal breech birth.

Vaginal birth of twins

Increasing numbers of twins are being born by caesarean section.  Often women expecting twins would prefer a more natural birth, particularly if the babies are well positioned and everything has gone well during pregnancy.  Having a vaginal birth can be a joyful experience for the women and, enable her to have the full range of choices in a subsequent pregnancy, rather than becoming higher risk because of a scar on her womb. Having the support of an independent midwife as an advocate for her wishes, and her main carer in labour if that is what she chooses, can give a woman the confidence to ask questions and say what she wants.

Conclusion

Midwives in independent practice in the UK have usually worked for the NHS but left employment to work alongside the health service because they have felt compromised and unhappy working within the constraints of the current system.  Women’s autonomy should not be compromised by new legislation requiring all midwives to be covered by professional indemnity insurance when there is currently no company offering to provide insurance cover. 

A solution is needed that enables independent midwives to continue in practice. The NCT would welcome a solution that included a means of providing insurance cover.

Ultimately, however, a woman’s right to give birth where and how she chooses should not be compromised. Access to a supportive and experienced midwife with no insurance is better than no access to such a midwife. The alternative for some women will be, and is already, to give birth alone at home and this poses a greater risk to both women and their babies than lack of insurance cover. 

Reference:

National Institute for Health and Clinical Excellence (2007 forthcoming) Intrapartum Care Guideline. NICE, London.