Margaret Jowitt
I can hardly believe that it is five whole years since CHANGING CHILDBIRTH was published - and six since the Winterton Report.
I suppose, like most ARM members, my expectations were too high. But we had good reason to have high hopes. A Conservative Government Report was recommending what we all had long worked for, surely nothing could go wrong now! At last, women would get the sort of maternity service they had been requesting for so many years - an end to cattle market obstetrics, the start of more personal treatment in childbirth. In five years time, we thought, CHANGING CHILDBIRTH would have been implemented. The maternity services would have changed beyond recognition. Midwifery-led care would once again become the norm - ARM's Vision would be well and truly on its way.
Instead, the NHS machine has ground inexorably on in its own sweet way and the vested interests of purchasers and providers appear to have won the day. Midwives are overworked, underpaid, demoralised and stressed out. Epidural and caesarean section rates are soaring.
What has gone wrong? It would be easy to blame it on finance. Apart from pump priming money there was to be none extra, CHANGING CHILDBIRTH was to be cost neutral. Many of us still believe that it could be afforded within the present constraints; most pilot studies have shown that, apart from initial money spent on setting-up costs such as equipment (e.g. mobile phones) the financial implications are not unduly onerous. The trouble is that midwives do not control budgets. We can shout until we are blue in the face that the hidden costs of not giving women what they need in childbirth far outweigh the short term costs of a few extra hours of midwifery care for each mother. Nobody takes any notice of the fact that allowing mothers more control in childbirth leads to better emotional well being and a happier start to motherhood. Has anyone costed this outcome? Does treating postnatal depression come into the obstetric budget, and if not, why not?
Even in the short term, financial benefits should accrue. Every failed vaginal delivery costs an extra £1,000 or so according to the Audit Commission. Are midwives who deliver babies at home given the credit for preventing caesarean sections? Flawed though it may be, the 1994 Home Births Study did seem to show that home birth reduces the risk of caesarean delivery by about half. No, we can't blame it on money. Where there's a will there's a way. Midwives have not been lacking in will, but they have been paying the price for trying to implement CHANGING CHILDBIRTH with little support from anyone else and they have run out of steam.
There have been endless pilot studies, all showing that consumer satisfaction is better with midwifery-led care, with marginal gains in terms of perineal trauma. But suturing material is cheap and how many women complain that their sex life has been ruined? The money that could do so much to transform women's experience of birth gets spent on more and more epidurals, more and more caesarean sections. There is none left to spend on what really matters - giving each and every woman a midwife to be with her during labour - preferably a midwife she knows, preferably a midwife in tune with ARM's philosophy, but any midwife would do for a start. It is truly scandalous that labour ward midwives are expected to oversee several labours at once. Can this country really claim that it does not have the financial resources to provide a midwife for each and every mother in labour? It could well be that mothers labouring at home do better simply because they have the constant presence of a midwife in labour.
The politics of the maternity services stink. What do epidurals and caesarean sections represent but jobs for the boys? And they are expensive jobs at that. Despite their far lower salaries, midwives are becoming scarcer. In order to pay for high profile, high tech novel departments of early pregnancy diagnosis (which incidentally, artificially reduces the stillbirth rate), normal childbirth has remained the Cinderella of the maternity services. The obstetricians have created their little empires and they are going to hang on to them for dear life.
I have tried hard to tone down my grave misgivings about the obstetricians' involvement in normal childbirth, but on this fifth anniversary of CHANGING CHILDBIRTH I can restrain myself no longer. Why do we allow these people, who have precious little experience of normal childbirth - and aren't even interested in it - to dictate where, when and how a woman will give birth?
CHANGING CHILDBIRTH has done little but give ammunition to demanding women like me to get what we want from the system. It saved me the cost of an independent midwife for my last birth (sorry, Ros). Some of us are now better informed, we know our rights - unless, of course, the consultants take us to court. But most women are left to flounder on in a system that seems so set in its way that nothing could possibly shift it.
Unfortunately CHANGING CHILDBIRTH has also given ammunition to some consultants who are presenting caesarean section as a choice for all women, and are looking forward to a 50% caesarean section rate. However, for choices not in tune with their philosophy, such as home birth, they can always find a plausible reason for denying women that particular option. But of course the real reason why home birth is considered medically inferior is that it hits doctors where it really hurts - in their wallets. CHANGING CHILDBIRTH threatened both GPs and consultants by attempting to transfer power back to women - midwives and mothers. Since women without money are powerless the medical establishment could ensure that the Report was not implemented as originally intended. It said to midwives, 'you want it, you pay for it,' and pay for it they have.
Childbirth will not change until doctors do only the job they were trained for - and until they allow midwives to do theirs without hemming them in at every turn with labour ward protocols and veiled threats of disciplinary action. CHANGING CHILDBIRTH cannot be implemented so long as we hang on to the existing buildings. We need to divorce normal childbirth from the consultant maternity unit. We need a midwife-led unit in every district to cater for at least half the childbearing population. A friendly neighbourhood birth centre staffed by friendly neighbourhood midwives and friendly neighbourhood ancillary staff. Not expensive, clinical, purpose-built units. but converted houses with good road links to consultant units for women who need a little more help. Places that can be a source of support and advice, perhaps even providing food tokens during pregnancy for deprived women, to help reduce the premature birth rate which is the highest in Europe. A venue for NCT classes, perhaps. Truly a home from home. And let's not maintain the fiction of calling these birth centres "Isolated GP units". We must give credit where credit's due - and payment only when payment is earned. Let's stop paying people for work they are not doing and start paying those who are doing it - we do have a Labour Government after all!
Perhaps we could have a new bonus system for consultants - payment by results - the lower the caesarean rate, the higher the bonus. (Even I wouldn't dare to suggest that maternal satisfaction could be used as a yardstick!). Could this help fund the poor chaps' Medical Defence Union dues and help them to practice a little less defensively?
Taking normal delivery out of consultant maternity units would release resources for women who do have problems. The doctors would have more time to do their real job, caring for women with problems, and less chance of pathologising normal birth and making more work for themselves and their colleagues. Hospital based midwives would have a real chance to get to know their clients well before they were admitted in labour. We simply must stop processing women and babies in an archaic hospital-based system and put birth back into the community where mothers and babies belong.
Carry on dreaming - one day ARM's "Vision" will become a reality.
Margaret Jowitt (Editor)
AH updated 16 September 1999