From MIDWIFERY MATTERS, Issue No.111, Winter 2006
Allison Ewing
Independent Midwife, Reiki Practitioner, Breathwork Practitioner
I HAVE HAD THIS TITLE floating around in my consciousness for several years.
It has been an elephant (whale?) gestation and I am still not sure whether I
will be able to convey what I have been thinking/feeling, but I am going to
give it a shot.
I deliberated about which journal to try to place it; whether to make it a fully
referenced research piece; whether it had been said before; whether I would
be preaching to the converted by placing it in Midwifery Matters. Then Linda
told us earlier this year that the Winter 2006 issue of Midwifery Matters was
going to be the first Scottish issue and the decision was made. This is written
by a Scottish midwife, living in Scotland, trained in England and has relevance
for the whole UK.
So here you have an opinion piece in the journal which kept me sane through
student midwife training and some years out of full time midwifery when I moved
back to a Scotland which, at that time (1997), still did not have the hand held
records I had been used to working with for a decade!
Are we a profession? Simple question really. Through my midwifery career I have
swung back and forward between two poles of thought on this. At first I welcomed
the move into higher education. Midwifery would finally get the recognition
it deserved, financially, academically and professionally. I now know that that
was incredibly naive. I thought that the class action taken by female graduate
occupational therapists in the early nineties could be a template to be used
for equal pay action comparing the remuneration of the mostly male medical profession
with the mostly female midwifery profession. Well, we all know by now that we
are even further from that possibility.
With the announcement of Agenda for Change and its promise of a single pay spine
for all NHS employees I thought, hallelujah, we will all be treated the same.
But! Wait a minute! Separate pay spine for medics, and the officers and other
ranks pattern is perpetuated. Some are more equal than others. Why on earth
did I ever think that it would be different from the "Cynical Degrading"
(my terminology) of 1988?
What has this to do with being a mechanical midwife, I hear you ask? Fully professional
autonomous midwives should be able to make clinical decisions with the full
backing of their clinical experience and evidence based guidelines. Most of
the universities are striving to produce these educated, questioning professional
midwives. Unfortunately, this type of midwife is the complete antithesis of
the 'flexible' 'reproductive health workers' which the NHS desires to have and
many of the most able of the midwives might be passed over in favour of those
who will 'fit in'.
Now, the next bit is anecdotal and I will probably be pilloried, but I can only
comment on what I have heard and observed. In some places in Scotland (and probably
in other parts of the UK) there is a pattern which goes like this: apply for
a job on 'bank' as there are few adverts for jobs; if you are able and liked
you might then be invited to apply for a temporary job; then, if your face really
fits, you might be able to apply for a permanent post. This pattern will ensure
that the status quo will remain. As an aside, the cynic in me would like also
to point out that when direct entry midwifery was introduced in Scotland, some
Trusts took the opportunity to employ the new graduates on D! (remember that
in Scotland there was never a minimum F and there is "no shortage of midwives"
- yet!)
What the NHS seems to desire is the automaton who will follow 'one size fits
all' clinical care pathways and algorithms, locally based protocols and the
local clinical opinions of another profession. This automaton will then sit
easily on the Agenda for Change pay spines.
The other alternative to employing 'expensive' midwives will be the introduction
of maternity care assistants. As a midwife who wants to be with woman I feel
that some of that role will be eroded further than it has been. The 'with woman'
role has already been undermined whether willingly or not.
Another anecdote
As an advocate, I accompanied a woman for a planned hospital birth last year
and in the 16 hours I was with her, she saw 6 midwives, 2 SHOs, 2 registrars,
1 consultant, 1 anaesthetist, 2 paediatric SHOs and uncle Tom Cobbley and all.
The midwife who admitted her to the delivery suite from the pre-labour assessment
unit was so busy being 'with notes", 'with CTG monitor' and 'with computer
monitor' (also centrally monitored at the 'nurses station') that I was the only
constant in my client's spiritual, emotional, physical and mental care. I had
been employed to provide continuity of carer in all the stages of pregnancy
and birth.
It was only after that experience that I finally understood part of what Stockton
was saying in her article in MIDIRS in 2003 (13.3 pp 347-350). She accused midwives
of being complicit in the move towards obstetric nursing and that doulas would
be the: 'future guardians of normal birth.'
I remember feeling indignant on reading it as I tend towards a 'Mary Cronk'
view of doulaing. On rereading the article I can see her point but, while acting
in a 'doula' capacity, I still felt helpless on many levels to help my client
avoid some interventions. I was very conscious that, had I managed to be there
as her midwife, I would have had to follow the hospital protocols and might
have ended up being with monitor' like the other midwife. However, as her midwife
I would also have been in a better position to question and challenge things.
Had I not been a qualified midwife and was simply acting as a doula, I don't
think I would have experienced these conflicting feelings and I have to admit
that only to have to be 'doing' the 'touchy feely' part of midwifery could be
appealing. I feel that the use of doulas, while a cheaper option for the woman
than an independent midwife, is not the long term solution to the problem. Even
if it is harder, I wish to remain an autonomous midwife rather than act as an
adjunct to the system. I feel that were I to abandon my role as a midwife and
practise as a doula instead, I would simply be shoring up the system and perpetuating
it.
But then again what do women themselves want? Maybe they just want somebody
kind and competent to 'deliver' them? The manager of the unit in which my client
gave birth told me that most of the complaints she receives are from women who
feel they didn't get their epidurals in time! I am told that women don't care
who is with them for the birth and "that the women in [insert town of choice]
are different"!
Most of the midwives my client met were kind and caring and competently looked
after her. Out of the six, only one was 'prickly' at my presence and she was
the one who had admitted her to delivery suite. Of course, my clients are self
selecting but, when I first met her, I asked her if she had considered having
a doula instead. She had decided against that as, although she wanted at least
one familiar face at the birth, she also wanted the midwifery care in the antenatal
and postnatal period too.
What do the midwives want? With the tightening of the belts in the NHS Trusts
in England and Wales and the job losses, midwives who have got jobs will not
rock the boat if they have mortgages to pay and mouths to feed.
What does the NHS want? As mentioned above, mechanical midwifery is what it
wants. To be fair, it is not just our profession. Medical colleagues in other
disciplines are complaining that they are no longer able to exercise much of
their clinical decision making skills to prioritise patients for surgery. An
oral surgeon of my acquaintance tells me that it is the place of the patient
on the waiting list and not clinical need that determines when they will be
seen.
I began to see the bigger picture when I was taking a "Health and Public
Policy" module as part of a top up midwifery degree three years ago. The
lecturer pointed out that many Government health policies had been "written
on the back of a fag packet" and usually as a knee jerk response to some
high profile health catastrophe: Alder Hey, Beverley Allitt, Harold Shipman
etc.
These have all, understandably, provoked wider efforts to control all the health
care professions, completely ignoring the fact that midwifery has had Supervision
for decades and that, because of this mechanism, far fewer midwives, proportionately,
have been reported to their regulatory body. The NMC and the supervisory mechanism
are quite capable of chasing and chastising their own "radical midwives
and mavericks" (quote from a senior midwife).
So where does this leave us? Does midwifery have to sink to a nadir before it
can be reborn again?
The DoH in England and Wales and the Scottish Executive wish to have tighter
and tighter regulation with more adherence to CNST or CNORIS insurance requirements.
This will leave less and less wiggle room for independent practitioners as in
the next two years it is possible that there will be further calls for the requirement
to have compulsory indemnity insurance to be a registered practitioner.
If the NHS Community Midwifery Model is adopted this will solve that problem.
However, the different way in which health is funded in Scotland will need a
modified approach unless Scotland adopts the DoH model. For example, the Trusts
in the Greater Glasgow Health Board went back to being divisions of the Health
Board in 2004 and employees went back to being employed by the Board and not
the individual Trusts! It has gone full circle. This may make it more difficult
to get the local funding for an OMOM style caseloading practice to be set up.
Call me a pessimist, realist or pragmatist, but I think it will have to get
worse before it gets better. It is amazing that the process which is experienced
by the majority of 50% of the planet's population is not given more real recognition.
Many more erudite writers than me have recognised that the gender issue is so
strong and one knows deep down that if it was men who had to experience childbirth
that priorities would be vastly different. The maternity services will probably
have to be squeezed even harder before many women will notice and complain.
Perhaps it is already happening. When I started as an IM six years ago, I was
averaging 2-4 clients a year. Last year I attended 14 births.
I am repeatedly told up here that the women have to want it and the request
for change has to come from them. Meanwhile, we will have Advanced Midwifery
Practitioners (aka mini doctors) performing forceps and ventouse to lighten
the load of the obstetricians, while the midwives who wish to be with women
and practise the art of 'watchful inactivity' will be sidelined. In Agenda for
Change, there is precious little recognition of the skills needed to facilitate
a safe, peaceful home water birth. In Glasgow, as in many places I imagine,
previous G Grade Community Midwives are given Band 6, while Labour Ward Gs are
given Band 7.
I have jokingly told colleagues that we should have a Campaign for Real Midwifery
Practice (CAMP or CRAMP!) along the lines of the Campaign for Real Ale (CAMRA).
Perhaps the ARM could be the Association for Real Midwifery? If the NHSCMM is
not universally adopted (incidentally, I can't square the circle of the call
for fewer post code lotteries in care provision while stating that local areas
should develop local health policies. Does not compute, Captain!) and Independent
Midwifery is more or less outlawed with changes in the requirement for Indemnity
Insurance, will Real Midwifery be forced underground?
Updated
November 29, 2006
LW