ARM’s Proposals for Change : A New Era in Maternity Care

by | 22 Jan, 2025 | Campaign | 0 comments

Midwifery Matters, Tell Your MP!

Maternity services are in crisis. Midwives are demoralised and women are fearful. There is currently little evidence from the new Labour government that they are prioritising maternity service issues. ARM has a series of proposals that it wants to highlight. In addition, ARM plans to work collaboratively with other groups who share common ground on how the maternity service can be transformed.

Over the years ARM has regularly highlighted the failings of the NHS Maternity service; the over medicalisation leading to inappropriate interventions, the ineffective ways of working, the focus on organisational needs rather than the woman’s needs, the historic underfunding, the bullying culture affecting both service users and staff. It seemed ironic then, that as various reports1 into individual maternity services in England were published it was the ‘normal birth ideology’2 that the media focused on and demonised. The tragic stories of women’s ill treatment by midwives has been hard to read but not altogether unsurprising (but not excusable) given the fear that plagues the staff (both midwifery and obstetric) of most English labour wards. They are afraid of being under investigation, of being reported to the NMC, of losing their PIN3. They practice defensively, their main objective is to survive their shift without incident.

Beyond maternity care, we know that all public services are in crisis4 that there is an ever increasing gap between rich and poor and that many people are more unhealthy earlier in life because of their poor housing and low incomes and the stress this causes5. The impact of stress on maternal and fetal wellbeing is only just beginning to be properly understood6.

Against this backdrop and recognising the likelihood of change in government ARM worked on a pamphlet in June/July that finally was given the hopeful title:
Our Proposals for Change : A New Era in Maternity Care

The pamphlet format was chosen as it was thought to be a simple, userfriendly approach to introduce key information, the plan being to send it both electronically and in hard copy to all members of parliament, and key stakeholders. We wanted to show that increasing medicalisation isn’t the panacea the media portrays; that improving outcomes for women and babies requires a more nuanced and multi layer approach that recognises the importance of relational care; that those who care must also feel cared for, that physiology matters; that pregnancy and birth cannot be seen in isolation but rather within the wider societal context.

The five member group working on the pamphlet represented NHS midwives from various perspectives; a final year midwifery student, a Professional Midwifery Advocate (PMA), a midwife working with women to overcome trauma and a caseload midwife, independent midwifery was represented by the fifth member. We also asked those attending our Summer meeting to name the two most urgent issues that should be addressed.

Drafts were circulated amongst the ARM steering group for further input. In addition, the AIMS Campaign team kindly reviewed an initial draft providing helpful recommendations which informed the final iteration.

We struggled with the limitations of the format; trying to avoid overloading it with type but not wanting to miss out key information. ARM believes there is an existential crisis in NHS midwifery and the decision to focus on it exclusively was deliberate. The reality of 21st century midwifery care is disturbing and depressing. It is being strangled by a system that values number counting and clock watching7. That said, there are still pockets of excellent practice but these are always under pressure to justify their existence and often stretched to the limit when there are staffing issues8. There are also midwives who work tirelessly supporting women to birth well against the odds.

We needed to address the core issues: midwifery care is fragmented, there are few opportunities to develop the midwife woman relationship. Midwives are losing their skills in facilitating physiological birth while some midwives have never been exposed to them9. We are approaching a point where almost all NHS midwives will only see birth through a medical/obstetric lens.

Context

The pamphlet opens with an overview of the current situation in maternity care. It deliberately begins with the most recent figures available, showing that increased medical intervention in recent years has not demonstrated the promised impact on the stillbirth or maternal mortality rates. This is significant given the level of increase in both the caesarean section and induction rates. The caesarean section rate in 2023/24 is likely to be above 40% in England (digital.nhs.uk) and while the induction rate is more difficult to obtain accurately, the official rate is 34% in 2022/2310, while our members report rates consistently in excess of 40%. This represents an approximate increase of 14% in the former and a very conservative increase of at least 10% in the latter over the last 10 years.

This shift in the way birth happens has consequences for women and their families. It has consequences too for birth workers. There is little spontaneity. Birth is scheduled, women are processed and the maternity unit runs to an assembly line format. The antenatal and postnatal ward become like holding bays; women waiting to be transferred to the labour ward or go home.

The pamphlet speaks about the impact of increasing levels of induction on midwifery workload and the knock-on impact on workload and retention. Most midwives want to provide sensitive, individualised care, but the systems in place don’t support this. Women are having unnecessary interventions often by midwives who do not believe they should be done. Overtime, this is demoralising. Midwives either leave or simply switch off11. This in turn leads to insensitive and impersonal care that contributes to women’s poor experience and in some cases trauma.

Midwifery Education

The education of midwives is key to developing a high quality maternity service. ARM believes it is important that the bursary system is reintroduced to allow for a more diverse workforce and in particular mature students and those who have already had children to become midwives. This cohort was historically a regular feature of midwifery courses but since the bursary was abolished, their numbers have fallen dramatically. The bursary is a non-income assessed personal allowance that covers the entire degree programme and allows those with dependents to avoid getting into debt. This system is currently in place in Scotland.
All professional groups benefit from greater diversity, midwifery is no exception.

Student midwives exposure to physiological birth is very limited, many students never see a spontaneous unmedicated birth12. This lack of exposure has been seriously impacted by the increasing rate of inductions. More and more women are falling into a category where induction is recommended but without robust evidence to support it13. Women are too fat, too thin, too old; their babies are too big or too small. As a result the numbers of women birthing in birth centres, particularly stand alone birth centres, has also fallen and the opportunities to attend such births are becoming increasingly rare14. Developing experiences via simulation might be a way forward. However, the experience of physiological birth in the moment cannot be replaced for its impact on students’ understanding of birth and their development as midwives.

Retention

Midwives need to have good pay and working conditions. The new government’s timely pay increase for nurses and midwives have appeased midwives’ concerns about pay for now15. However, on-call payments that particularly affect midwives providing caseload care or a home birth service need to be revised upwards to recognise the imposition on one’s personal life and for example, make it possible for midwives who require paid child care cover to work in this way.

The working conditions of midwives are variable. They regularly report they can’t take their allotted breaks due to staffing levels or high levels of activity. This is obviously not good practice and midwives who are dehydrated and hungry probably do not perform to the best of their abilities. Positioning maternity services within secondary health care prevents midwives time being used effectively. It also means that women’s time is not considered. If women are concerned during pregnancy they are expected to ring a helpline and speak with a midwife who doesn’t know them or their circumstances. They may be asked to come to the hospital to be checked. Often they have to wait hours in a Maternity Triage department. If they were cared for within a caseload model it is possible that the woman could be seen at home or in a community venue and only if required at the hospital16.

Midwives have at least five training days a year to help ensure they remain current in practice developments and skilled in dealing with emergencies. Little or no time is spent in developing midwives communication skills, in particular how to support women with decisions around birth. Many midwives are afraid of telling women that they can choose not to be induced, that they can take time to decide what they feel is best for them. They fear push back from management or their obstetric colleagues, or they lack confidence in initiating such a discussion. Sometimes, sadly, they don’t have the time or motivation. We know from women that it is often the way in which they are treated and spoken to that causes the greatest pain and upset17. Midwives need to have time away from the clinical sphere to hear women’s stories and what women need. Some may need additional support to learn new ways of communicating and caring.

There is an ‘obsession’ amongst NHS Trust Risk Teams about interpretation of the fetal heart trace using cardiotocography
(CTG) monitoring in labour. The CTG monitor is considered to be a very poor screening tool for fetal wellbeing and yet the number of training hours spent on it are considerable18. This time and funding could be better spent on helping midwives to understand what women need from them on their childbearing journey.

Regulation

ARM believes that the NMC should be replaced by a new regulatory body led by professional and lay experts, and that the current Fitness to Practise model needs to be completely transformed to one that is compassionate, learning, retentive, and upholds women’s choices and autonomy. The NMC is a dysfunctional organisation with a punitive approach to registrants, backlogs of more than five years, and according to Nazim Afzal’s Independent Cultural Review19, has a culture of systemic bullying and racism. There is a deep-rooted bias against midwives of colour and independent midwives. Many cases
have been dragging on for years only for the registrant to be found to have no case to answer when the hearing finally takes place. Midwives are emotionally and financially drained and often decide to come off the register, despite not having done
anything wrong other than facilitate women’s choice. In some tragic cases they have been known to take their own lives or suffer long-term health problems. It is estimated that at least 27 midwives and nurses have committed suicide following referral to the NMC since 201620.

Supporting Women

ARM wants every woman to have the option of their own named midwife with whom they can develop a trusted relationship to see them through their childbearing journey. The midwife would be part of a small team locally based and with each midwife having a defined caseload of women. We know this model works for women and in particular hard to reach groups. It has been recommended by numerous reports into maternity care and there is a large body of evidence to support its positive impact on
maternal and newborn outcomes21. It works for midwives too, if it is correctly resourced and supported.
Implementing this model of care requires commitment, resources and a vision for the maternity service that values the woman’s voice above all others.

What can you do?

ARM is asking all members to join the effort to transform the maternity service to one that understands the importance of the midwife-woman relationship and values and respects the physiology of childbearing for the benefit of women and their babies.
We are asking you to write to your MP explaining the need for urgent action. Please encourage colleagues, family and friends to write as well. You can find a copy of the pamphlet, letter templates and the contact details for your MP here.

Let’s work together to make a difference!

References
  1. Kirkup, B. (2015). The Report of the Morecambe Bay Investigation. Department of Health.
  2. Wilson, C. (2023, October 30). How the battle over ‘normal’ births is still damaging NHS maternity care. iNews.
  3. Alexander, C. R., & Bogossian, F. (2018). Midwives and clinical investigation: A review of the literature. Women and Birth, 31(6), 442-452.
  4. Dunn, P., Ewbank, L., & Alderwick, H. (2023, November 3). Nine major challenges facing health and care in England. The Health Foundation.
  5. Kulakiewicz, A. (2022, October 17). Housing and health: A reading list (Research Briefing CBP-9414). House of Commons Library.
  6. Coussons-Read, M. E. (2013). Effects of prenatal stress on pregnancy and human development: Mechanisms and pathways. Obstetric Medicine, 6(2), 52–57.
  7. Derry, R. (2008).The Tyranny of Time: Tensions between Relational and Clock
  8. Time in Community-Based Midwifery. November 2008. Social Theory & Health 6(4):342-363.
  9. Reed, B., & Edwards, N. (2023). Closure: How the flagship Albany Midwifery Practice, at the heart of its South London community, was demonised and dismantled (1st ed.). Pinter & Martin.
  10. Darling, F., McCourt, C., & Cartwright, M. (2021). Facilitators and barriers to the implementation of a physiological approach during labour and birth: A systematic review and thematic synthesis. Midwifery, 92, Article 102861.
  11. NHS Digital. (2023). NHS maternity statistics, England, 2022-23: Deliveries – time series. NHS Digital.
  12. Barker, K. (2016, December 2). Reasons why midwives leave. BMJ, 24(12)
  13. Davison, C., Ritchie, E., & Watts, N. (2023). Midwifery students’ confidence to support physiological birth: An international study. Women and Birth, 36(Supplement 1), S1.
  14. Middleton, P., Shepherd, E., Morris, J., Crowther, C. A., & Gomersall, J. C. (2020). Induction of labour at or beyond 37 weeks’ gestation. Cochrane Database of Systematic Reviews, 2020(7), CD004945.
  15. Coxon, K., Chisholm, A., Malouf, R., Rowe, R., & Hollowell, J. (2017). What influences birthplace preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a ‘best fit’ framework approach. BMC Pregnancy and Childbirth, 17, Article 103.
  16. Church, E. (2024, July 29). Nurse pay to rise by 5.5% for 2024-25, government confirms. Nursing Times.
  17. Forster, D. A., McLachlan, H. L., Davey, M.-A., Biro, M. A., Farrell, T., Gold, L., Flood, M., Shafiei, T., & Waldenström, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: Results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth, 16, Article 28.
  18. Thomas, K. (2024). A report by The All-Party Parliamentary Group on Birth Trauma. Secretariat of the APPG on Birth Trauma and CEO of the Birth Trauma Association.
  19. Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and Birth, 33(5), 411–418.
  20. Rise Associates. (2024). The Nursing and Midwifery Council independent culture review: July 2024. Nursing and Midwifery Council.
  21. Devereux, E. (2024, July 25). Fitness to practise: 16 die by suicide while under investigation. Nursing Times.

 

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