1. ‘Women and Midwives.. together we’re strong” Midwifery Led Care
Astrid Osbourne
Consultant Midwife & Supervisor of Midwives
SRN,SCM,PG Dip Professional Studies, MSc Advanced Midwifery practice, Post Grad Cert Supervision of Midwives

2. Today we will discuss what Midwives CAN do!
We will look at our global history
We will consider where we are now
What political influences are pushing maternity care?
Look at the innovations that the UK has achieved in the National Health Service
Consider how midwife led care does work
Look at models of MW led care, home birth and birthing centres

3. Normal birth is different for different people & professionals
OUR PERCEPTION OF BIRTH IS IMPORTANT:

4. Midwifery History: UK
NHS started in 1948 – more than 50% of women gave birth at home
The Peel report in 1970 called for ALL births to be hospitalised on the grounds of safety [no evidence!]
1980’s the DUBLIN study and active management of labour by early ARM, syntocinon from 4cms, continuous EFM & constant support
1993/ 94 Winterton and Changing child birth - call for back to basics
2004 National Service Framework standard 11 maternity
2007 Maternity matters – benchmark for care

5. Childbirth normality
WHERE ARE THE MIDWIVES! They burnt us as witches in the 15th century – right across Europe
Internationally Midwifery is loosing its position as the MAIN provider of care for well women and their babies
Modern midwifery: In some countries care is entirely medically led
Caesarean section rates continue to rise
The Birth Place Study published Oct 2011
Cost – primigravid cost £2,075 Hospital, £1,912 birth centre, £1,793 home birth
Multigravid cost £1,142 Home, £991 Birth Centre, £780 home birth

6. Areas of Midwifery practice that have started to be developed in the UK:
Normality in childbirth – most Consultant Midwives/senior MW practitioners are engaged in this area of care
Birth centres with no medical input
In the UK a third of pregnant women do not see a Doctor at all during pregnancy and birth
NHS maternity hospitals are managed by Midwives
Where teams of Drs and Midwives work together the responsibility is shared
Normal birth is the forte of the midwife

7. To keep birth normal:
Create a homely atmosphere, demedicalise the environment – hide stuff away – make the place homely
Create a positive attitude to low intervention
Choice of place of birth and carers for women including home, birth centre & hospital birth
Women having the opportunity to know their midwife and to trust her/him
Education and training for m/w’s and Drs to improve normal birth understanding and confidence
Access to parent education and prep for birth

8. What do I do as a Midwife Consultant in the NHS?
I support MWs and Drs in the intrapartum areas – plan as much normality into every birth with them
Discourage unnecessary intervention, formulate personal plans
Give priority to mobilisation and normal labour behaviours
Educate MWs and Drs – bring normality into all aspects of care – teach in the universities
Work along side senior Consultant Obstetricians to improve the normal birth rate; including revising policy
Encourage normal birth in ALL settings
Audit & research [own and others]– dissemination to all

9. Management of pregnancy risk
Essential for the midwife led care model is the separation of high and low risk women [NSF 2004 & Maternity Matters NICE 2008 Midwifery twenty twenty, 2010 ]
Acute care in high risk services must be appropriately Dr led and easy to access by MWs
Low risk midwife led services across the community in partnership with GPs and social care
Easy flows from one process to another where necessary

10. What Changed? The Political, Financial & Medical Revolution
Media pressure to be ‘rescued’ by medical science
Modern midwifery: our behaviour & our reaction to pain/discomfort – some women are encouraged to accept pain relief to comfort those around the woman – including midwives!
Rising epidural rates – rising CS rates – increased immobilisation during labour – unnecessary intervention during labour
Women: are having heavier babies, are fatter, work longer, control their fertility
Changing role of Motherhood – youthfulness

11. The CS epidemic: In the USA it is said that CS ‘keeps the vagina honeymoon fresh’ [Kitzinger 2005]
We perpetuate the common belief that vaginal birth is risky and CS is less so
Women want CS because they maintain greater control
The belief that CS is safe, easy, efficient, desirable & better for the baby
The belief that there is less pain, injury & unpleasant emergency procedures
“Women’s choice”: ignores the power differential between women & obstetricians [Kitzinger 2005]

12. The rising trend toward global CS
World wide CS has increased from 25% to 70% in developed countries
In some developing countries it is higher
Austria = 40%
Southern Italy = 50 – %
Brazil = 75%
South Africa [Caucasian population only] = 70%

13. Birth Place Study Results: Outcome
Interventions were less frequent in MW led areas of care
There was no difference in adverse outcome for primigravid or multigravid women by place of birth
Women in a MW led unit were more likely to have a normal birth
Primip women at home did slightly less well
62,036 low risk women were evaluated
27% 0f the home birth group were primigravid
Costs: Routine CS costs in excess of £3,000
Savings average for MW led home birth = £310
Savings for stand alone MW unit = £130
Savings for along side MW led unit = £134

14. Standards for Midwifery practice to promote normal birth
NAMED MIDWIFE - contactable
Birth choices for all women
Women followed through care by known carer/s
Follow the National Institute of Clinical Excellence care pathway for A/N and labour care
Detailed birth planning
Follow up care by known carers
Equal governance – the same clinical standards for quality and safety as in all other hospital settings
Seamless transition from one setting and carer to another [low to high risk and visa versa]

15. Service design for birth centre & home birth – social approach
What is a Midwifery Team or Group?
An autonomous group of midwives who are responsible for a group of pregnant women
Geographically based and working from Community Centres and/or large medical centres, any public building has potential
Group Practice offers whole care and continuity of carers to women – INCLUDING BIRTH with M/W’s known to the woman
Realistic birth planning, managed expectations and a clear plan if risk becomes an issue

16. Setting up Birth Centres and whole care systems that support normal birth
Challenges: Growing birthing population – predicted at approx 3% + across London yr on yr
Staffing challenges – shortfalls recognised across Maternity services, Integration of staff – change management & aging workforce
Cultural changes, new ways of working
To meet government [DoH] drivers for first class care, standards, targets & CNST
Resources reduced by recession and historic debt, inefficiencies and failure to modernise

17. A few Facts
Electronic fetal monitoring in low risk labour is associated with increased CS rates and has no long term health gains
Epidural analgesia – increases the need for instrumental birth
Epesiotomy as a routine intervention has no benefits to mother or baby
Artificial rupture of membranes – may reduce the length of labour [half an hour average] but causes more pain & increases the uptake of pharmacological pain relief – which influences movement and vomiting

18. Currently only 55% of women in London have a birth attended exclusively by a midwife – Drs don’t do natural, normal birth [they aren’t trained that way & don’t have time]

19. Finally ......Why Midwifery Care Matters to Women
“This has been a dream birth that made this day one of the most beautiful days of my life.”
Natalie after her water birth at the Bloomsbury Birth Centre London