The De-Medicalisation of Midwifery

The midwife profession is currently in a state of flux according to Susan Baines, Expert Midwifery Advisor for the Care Quality Commission and lecturer of midwifery at The University of Salford. By Ali El Moghraby.

“It’s a wonderful profession to be in”, says Susan, “but professional confidence and resource and time restrictions within the NHS are severely impacting on the true business of midwifery.”

Having spent 40 years as a nurse, 29 of which as a practising midwife, Susan is concerned about the future of the profession.

For example, she welcomes the new NICE guidance (2014) regarding second time mothers having a choice of home birth if they are deemed low risk. But she also believes that this choice is suitable for most mothers as well, as long as they have the right midwifery support and a joined up team approach to managing any issues.

“If women are to regain control of their choices for childbirth then the midwifery profession needs to return to a degree to its pre-medicalised form,” says Susan.

Paper or Person?

Labour and delivery has been getting more medicalised for a long time now. The profession is well aware of it, as are most women planning for the birth of their child. But as they research their options and make choices for how they want to bring their baby into the work, Susan believe that too often the midwife pigeon-holes them into being ‘high risk’ just because of the forms she has to fill in.

“For example, as soon as a woman turns 40 she is deemed high risk,” says Susan. “She could be fitter and healthier than the average 20 year old, but as soon as her midwife ticks the box that says she’s over 40, she’s flagged up by the computer as high risk.”

This immediately impacts on her pregnancy and birthing choices. “Her midwifery care now takes her down a path this is not supporting what we know about the woman and her capabilities,” says Susan. The woman may be denied the option of a homebirth or of giving birth in a midwife led birthing centre. Straight away, the chances of medical intervention in her labour are significantly increased. “We have to get away from this business of going to see a woman straight away with a form,” says Susan.

Susan supports the mindfulness approach as one of the ways to achieve this, including when caring for women shortly after the birth of their baby. “Midwives visiting a woman in her first days as a mother should put their notes away, sit and simply watch and listen to her,” she says. “That way the woman can better articulate what she is really feeling and is more likely to benefit from the interaction. This gives the midwife a better opportunity to support her more effectively. The notes can be filled in afterwards in the car.”

Doubt has Crept In

It is Susan’s view that midwives are too busy filling in paperwork and not listening to what women, their bodies and their babies are saying. As a result, some midwives have lost their confidence in being able to support choice and actually see the women’s body as being able to perform naturally.

“We now practice such defensive midwifery and are so fearful of litigation that we are doing things for all the wrong reasons,” explains Susan. “We are taking a woman down a path and taking away her choices at each step.”

Susan highlights the rise in the rate of free birthing as a symptom of women’s lack of confidence in their midwives. “The women who are free birthing don’t want any medical people around them at all,” explains Susan. “What does it say about us as a profession when women are actually moving away from us as midwives? In my view, they don’t trust us because we are so medicalised, we are so rigid in our view, and we are so frightened,” Susan explains. “That’s a real issue.”

“You cannot give women the choices that they want in a system that simply doesn’t allow it,” says Susan. “There needs to be more awareness of independent practitioners if only because they offer women a choice other than hospital. There are many excellent independent midwives out there who actively support choice safely.”

Time for One to One Care

Many midwife degree courses are oversubscribed, yet there is a severe shortage of midwives in the UK (the Royal College of Midwives says that the NHS needs 4,800 more).

This has two implications in the context of trying to make midwifery less medicalised.

The higher volumes of women that have been labelled ‘high risk’ go into hospital as prescribed by their risk assessment. But as Susan explains, the number of hospital midwives just doesn’t allow them to always receive the one-to-one care that they have apparently gone into hospital for.

“More often than not, the delivery suites are really busy, the midwives on shift are stretched and then all of a sudden, it can become worse when several other women in labour are admitted,” she says. “They have all been deemed high risk and so should be monitored closely by their own midwife, but I can be impossible – the midwives may be required to help out in other delivery rooms thus taking them away from their woman in labour”. The midwives are trying their best but there simply isn’t the time to always provide one to one care. This is not only unsafe but demoralising and stressful for all concerned.

While encouraging more home births should provide the level of one-to-one care that hospitals struggle to deliver, too often women who have booked a homebirth are left severely disappointed when there isn’t a midwife available when they need them.

“We hear it all the time,” says Susan. “The woman is in labour but we have no one to send out because we are really short staffed and have a full delivery unit. She ends up in hospital, anxious and fearful with her choice having been removed. The bottom line is that for some women, technology and medicalised care can be a life saver, however for most women they need to regain trust in their natural physiological ability to birth their baby,” she says.

The Future

The good news is that the profession is changing. In March 2015, the Nursing and Midwife Council launched its new code of practice for nursing and midwives. “The new code has been amended to better support individualised care and promote professional accountability regarding choice. It is aimed at placing the women at the centre of everything we do,” says Susan. “It is about trying to keep birth normal, trying to listen to the mother and allow her to make choices.”

For Susan, the real future of the midwife profession lies with midwives themselves and their ability to work closely with women. Additionally, she sees the importance of doulas. “Half the time we midwives are not with the women anymore, we are with technology,” she says. “We are often not even in the same room as the woman when they are in hospital. So how can we call ourselves midwives when the term itself means ‘with woman’? Doulas are normal women who get to know their mothers well and who offer continuity and practical and emotional support.”

“There is evidence to support the fact that women do better in labour if they have the continued support of a doula,” concludes Susan. “At the end of the day, all women want is a friendly caring person to help them believe in themselves.”

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