Pat Schan
FIVE YEARS have passed since the handing down of the tablets of stone from the mountains of Westminster and it seems an appropriate time to stop and think. Are we better off? Are women better off? A voice deep inside tells me "No". I often feel as if I am standing in the middle of a maze - going forward and thinking it makes sense and then reaching a wall which stops me going any further until I figure out the next bit. Changing Childbirth was our great hope of turning the tide back to midwifery-led care and empowerment for all, but the reality is rising Caesarean section and Epidural rates and decreasing numbers of babies being delivered by midwives (ENB, 1997). There seem to be pockets of excellence reported all over the country, yet a normal delivery, i.e. a birth without any intervention, becomes more and more unusual. Midwives congratulate each other for "getting a normal delivery"!
One of our biggest problems is that we can't measure quality. The ultimate aim is a well mother and baby at the end of labour, and so long as our facts and figures show that is happening, it is very difficult to look closer and try to analyse and measure the experience as good or bad. Midwifery efforts such as Standards Groups and consumer liaison help, but really have little effect. How can we underline the fact that with our current practices we are laying down the blueprint for future generations and they will accept technological birth as normal?
We do not have the big stick of randomised controlled trials that obstetricians wave, but when you see a family in their own home, with their new baby, you do not need multi-centre trials to tell you that this is better. Yet we continually have to justify decent midwifery care, both at home and in hospital. Is there any one out there questioning the cost implications of one in five women having major abdominal surgery?
If we are honest, maternity services on the whole are in disarray - underfunded and overstretched, being held together by tired and demoralised midwives who feel dispensable and undervalued. The knowledge and skills of midwives are recognised within our profession, but are barely acknowledged by the people with real power - the obstetric hierarchy and the media. These are the people that women listen to and are influenced by. How can we change a whole generation which now consider technological birth to be the norm and are grateful when the doctors step in to "save" them? Elective caesarean sections and epidurals are sold to women as the ultimate informed choice for the feminist, yet I consider having the birth of your baby controlled by machines and conducted by an unknown man (or woman) in an operating theatre the epitome of disempowerment.
Before we all congratulate ourselves on how bad doctors are and how midwives can save the childbearing world, let's be honest about the state of the profession. We consider ourselves the guardians of normal childbirth but that is becoming less of a fact, with the numbers of midwives as sole carer dropping all the time. The reality is that, on the whole, midwives are exhausted and fed up. The constant struggle of working on labour wards staffed by four midwives at a time coping with shifts that usually have at least two epidurals and then the inevitable caesarean section, water births, premature labours, terminations, high-dependency care of eclampsia, etc, etc., are taking their toll. Many midwives now have more skills than junior doctors and are expected to undertake all these tasks as well as being with women. In my unit we have reduced the use of Pethidine down to about 3% of women, but it is very difficult to persuade women and midwives that alternatives such as massage and support will work when it is impossible to provide one-to-one care. At least a part of the senior midwife's shift is always taken up with phoning around trying to get staff to cover the next shifts. Midwifery managers struggle with impossible budget constraints - how can you explain about giving quality care to a general manager trained in hotel management? There are now hospitals where non-midwives are managers of the unit. Now this is really worrying - on the whole midwives understand each other and understand women's needs - remove them from the first line of management and we are in big trouble.
Community midwives fare no better - 24 hours on call at a time - which can involve a full day of visits and clinics and in our area up to two or three times in the night to home births or helping on labour ward. This is a service run on goodwill and loyalty - cheap at £15K a year!
Choice, continuity and control - At what cost?
AH updated 16 September 1999