IMA Submission To Choice, Responsiveness & Equity Task Group
A Solution to the problem
For twenty years midwives practising independently, in a self-employed capacity, outside the NHS have provided women with a unique model of midwifery care that is truly women centred.
The fundamental and pivotal difference, between this model and that provided within the NHS is that the woman chooses her midwife. From here flows the all important relationship of partnership between the woman and midwife in which individualised, responsive care is provided. This includes:
- 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.
As each woman and her needs are unique, this model works for each individual woman. The current NHS system is inherently flawed in that despite superhuman efforts by the staff, a woman’s care is determined by what enables the institution to function. A fundamental change in structure is required.
Statistical Evidence
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 many studies such as Hodnett ED Caregiver support for women during childbirth (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software show that ‘The continuous presence of a support person reduced the likelihood of medication for pain relief, operative vaginal delivery, caesarean delivery, and a 5-minute Apgar score less than 7.’ Women expressed greater satisfaction and level of personal control during childbirth having received continuous support.
From January 2001, the IMA began to collect ongoing, basic, quantitative, prospective data about the practice and outcomes of UK independent midwives (IMA members). 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)
*** One 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.
The IMA 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. The difficulty is that to access this individualised service at the present time a woman must fund it herself.
Equity of Access
The NHS currently funds 99.9% of midwifery care in the UK but it is the constraints of models offered within the system that deny true choice and control for the women using the service.
The IMA has believed for many years that all women should be able to access the model of care outlined above, if they so choose. If all women are to benefit from the better outcomes resulting from this type of care, equity of access needs to be urgently addressed.
The challenge is to set in place a structure within the NHS that would provide this choice. The IMA has worked hard at developing a framework for such a structure and sets out below its proposed way forward.
NHS Community Midwifery Model
The model of NHS community midwifery care would enable any woman to have the option to choose one-to-one care throughout her pregnancy, labour and the postnatal period from a midwife of her choice. This model would sit alongside the current midwifery service and it would be up to each woman which model she would choose. Within the current system, some Trusts do offer schemes to some women that provide one to one care with a known midwife but not one of the woman’s choice. These are valued and should continue as an option.
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For those midwives who wish to practise as self-employed independent midwives and provide services to the NHS, a national midwifery contract that pays a midwife a set fee per woman for providing midwifery care. 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. It must be a national contract to ensure consistent terms and conditions to avoid the waste of resources from negotiating locally.
National standards of care would be based on the NMC Midwives Rules and all midwives involved would undergo regular peer review. Midwifery is one of the most tightly regulated professions in the country and no change in this strong regulatory system would be needed. It has been in place for over 100 years and includes statutory supervision.
The national contract would include access to all NHS birth facilities, laboratory services, obstetric and neonatal services, ultrasound and antenatal screening services. Women could therefore choose where they would plan to give birth, be it an obstetric unit, midwife led unit/birth centre or at home.
If care involves specialist obstetric services, it would be expected that the midwife would continue to provide ongoing midwifery support.
Additional supplements would be paid for midwives caring for women in special situations such as VBAC (women planning vaginal birth after C/S), women with drug and alcohol problems, mental health problems, teenage mothers, women with special learning needs and disabilities to reflect the increased workload. These women in particular would benefit from this model of one to one, individualised care.
A set amount for the care provided by self-employed midwives, would be paid by the DOH to the NHSLA (or the New Body proposed to replace it) to provide professional indemnity cover. As no Professional Indemnity Insurance is available for self-employed midwives to purchase on the open market, then the DOH contributing in this way would overcome this problem. The new General Medical Services Contract sets a precedent where the NHS funds independent practitioners, contracting into the NHS, (GP’s), professional indemnity insurance.
Trusts employing midwives providing one-to-one care and holding their own caseloads, could also claim the set fee per woman encouraging more diversity of service provision. The fees paid to the self-employed midwife and the Trust could be administered by the current PCT structure.
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Recruitment and Retention
The major problem facing the provision of maternity services is the shortage of midwives. Despite many initiatives to curtail the recruitment and retention crisis within the midwifery profession, the problem continues to escalate. Over the last decade constant change within the existing structure has been imposed upon midwives working in the NHS. Most of these were well intentioned initiatives to provide a more flexible workforce or to provide more choice for women however it has left midwives feeling disillusioned, stressed and demoralised.
Research shows that midwives are leaving because they are dissatisfied with midwifery but over two thirds said they would return if the conditions were right. (Ball et al, 2002 Why do Midwives Leave? RCM, London.). 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.). To make a difference a radical solution is required to the structure of the service. Midwives need choice and control of their professional lives if the haemorrhage from the profession and the miserable consequences for childbearing women is to be stopped. The current 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. Yet 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.
To achieve a dramatic improvement in the provision of maternity services for women that will grow and develop for future generations, a national structure in which midwives can choose to work must be put in place. It is within this structure that sound one-to-one, woman centred midwifery can flourish at a local level. It is only when care can be truly individualised for women and the system stops trying to attempt to make women fit the system, that a framework is sustainable - ‘Fair for all, personal to you’.
A new structure within the NHS, sitting alongside the current provision would enable the service to grow from the practitioner up, rather than impose change from the top down.
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.
Many other benefits would flow from care provided within the new structure.
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. 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 postnatal depression.
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.
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.
The IMA is very interested in working together with the Department of Health to explore and develop a way of providing this model through the NHS and would welcome the opportunity to contribute further.