It’s the most important, meaningful and – for many – anxiety-provoking day of your life. You’re going to experience the rare privilege of being at the centre of the action as a new life begins. Added to this, you may well be naked and somewhat indisposed. Who would you choose to be with you? Someone you know and trust? Or a total stranger? It’s a no-brainer, isn’t it?
And yet a report published today by the National Federation of Women’s Institutes (NFWI) and childbirth charity the NCT has shown, yet again, that this most obvious of human needs is simply not being met for women. Rather than being accompanied by a familiar and trusted figure, most women (88%) surveyed did not know their midwife when they went into labour or gave birth. Of these women, 12% said this made them feel alone and vulnerable, and 6% said they felt unsafe. Comments were made comparing treatment to that of cattle, and like being on a conveyor belt.
The report also highlights that as many as 50% of women are experiencing so-called “red flag events” in their labour – situations which are seen as warning signs of understaffing, such as women having to wait more than 30 minutes for pain relief, or more than an hour to receive the stitches they need.
Midwife shortages have long been highlighted; the last estimate by the Royal College of Midwives in 2016 suggested that 3,500 more were needed to meet the rising birth rate. And the impact of shortages reaches far beyond red flag events. The effect of not being able to establish a relationship with your midwife begins long before you are in stirrups waiting for stitches: research has shown, for example, that women who know their midwife are 24% less likely to experience pre-term birth, and are 16% less likely to lose their baby during the pregnancy.
Knowing your midwife also means you are more likely to have a vaginal birth, and less likely to experience interventions such as forceps or episiotomy. And women who experience continuity of care repeatedly report higher levels of satisfaction, an increased sense of agency and control, and more positive birth experiences. After the birth, as the NFWI/NCT report highlights, almost one in five women are not seeing a midwife as often as they need to, let alone one with whom they have a relationship. This is a vital yet neglected time for maternal mental health.
We know this – all of this – and have done for some time. We know that relationship-based care is better for women, and we know that we need many more midwives to raise services up to this standard. We also know that this is what midwives themselves want, with many feeling burnt out by a system that – as one person who had left after 30 years in the NHS anonymously told me – demands that they are “with computer”, rather than, “with women”.
Indeed, the recent Maternity Review highlighted “continuity of carer” as one of the key priorities in improving birth. And yet, in the current system, it seems to be harder and harder to come by. Women who I meet via my organisation, the Positive Birth Movement, often report fragmented care experiences in which they have to repeat their histories to each new midwife, a situation which is at best frustrating, and at worst dangerous. Getting the birth you want in the setting you wish for can also be a tough battle: home births can be denied due to lack of staff, midwife-led units closed or full, and higher-risk women such as those with twins or breech babies left feeling they have limited options in a system that is over-stretched and depersonalised.
One solution women could opt for, and which I chose for my own second and third births, has also just been removed: the option of a self-employed independent midwife. These midwives, with huge expertise in normal birth, can – for a fee – attend you personally at every step of your pregnancy, birth and postnatally, in your own home. However, this week the Nursing and Midwifery Council has ruled that the insurance arrangements of these midwives – the 82 members of Independent Midwives UK – are insufficient, in effect shutting them down, with many of their clients being left without a midwife. The charity Birthrights has said that the decision “directly jeopardises the health and safety of the women it (the NMC) is supposed to safeguard”.
NHS England has today offered assurance that the Better Births initiative, now being rolled out in pilot schemes following the recommendations of the Maternity Review, will provide women with “access to a small team of midwives for continuity throughout pregnancy, birth and postnatally”. We can live in hope, but right now, this level of care – which both women and midwives want and deserve – seems a long way off, and conveyor-belt care, or worse still, being treated like cattle, is more likely.
• This article was amended on 18 and 20 January 2017 to clarify that the NMC’s ruling related only to the insurance arrangements of the self-employed independent midwives who are members of Independent Midwives UK. An earlier version also said the decision meant the NMC had “effectively shut them down overnight”. The NMC disputes that; its statement about the ruling points out that it wrote to IMUK and its midwives in August 2016 to say it did not consider that their indemnity provision provided appropriate cover.
