From MIDWIFERY MATTERS, Issue No.94 Autumn 2002
Rosie Parkes
When Margaret asked for articles from us here in the South for this issue of Midwifery Matters I thought I had nothing to say, and then I decided to write a letter to see if there are others out there who feel like me. It has turned itself into an article which asks: "Can we continue to do the job we love throughout life´s changes?"
I must emphasise that I know I am in the very fortunate position of being able to stay at home while my children are small. Having this option has given me the time to write this. Perhaps if more working mums had the choice we would all choose to do the job we are good at, in the right way for us and our clients. For those with young families, home life should always be more important than work; many midwives choose shift patterns, or clinic work because it fits in with home life or just because there is no other way of continuing to be a midwife.
Based in the community full time for ten years, I found huge satisfaction in carrying a caseload, building relation ships, meeting clients at booking, caring and supporting, discussing, preparing, teaching, planning, giving continuity of care and carer, working through the birth and the enor-mous changes afterwards. The 'buzz' from attending a woman and her partner, whom you have got to know, throughout their birth is unsurpassed and I don't need to describe it to any midwife reading this magazine. I appreciate that I was enormously lucky to have this fulfilling experience of midwifery, I know that unfortunately some midwives never experience this.
My midwifery partner and I had a close working relation ship based on similar ethos and working practices. We booked around 200 women annually and cared for a large proportion of them ourselves, approximately 11% had home births, and we managed to care for at least another 4% in hospital on the domino system. We rarely felt the need to stay on call if the client knew the second midwife.
It was sometimes mooted by colleagues that we were 'possessive' of 'our' women, and didn't want to leave them to the care of a midwife unknown to them. On one occasion I was told that I treated them like private patients! How wonderful! Yet we found that, without exception, when a relief was required in the patch for any length of time, the midwife, whatever her background, would want to stay on call for a particular woman with whom she had built up a relation ship antenatally, in order to care for her through birth, especially for a home birth. I am sure that goes to show that when we know the women, we put more in, we want to work harder, we get more job satisfaction; and of course women and families get a lot more out.
Since I 'retired' from the patch to be a mum I do occasional hospital bank work. My admiration for the midwives based there is enormous. Ours is a small unit and I believe the staff/client ratios to be good compared with elsewhere in the UK, the midwives all know each other and work together well. Their job is hard, without the rewards that prolonged contact with a client brings. Midwives have to turn into theatre nurses, intensive care nurses and back into midwives again! As well as being midwifery experts they simultaneously run an office, keep constant records/charts and give detailed hand-overs to colleagues. These midwives admit, get to know and discharge women continually as they try hard to give good care to several women at once. The time spent on the computer and producing piles of paperwork is enormous, they answer the phone, organise bed moving, staffing rotas, support junior doctors, remem ber different consultants' wishes, teach students, attend ward rounds and meetings, draw up guidelines, oversee cleaning, meals, ordering stocks, etc. etc. Midwives get very practised at it and quickly become 'good' midwives if they can manage all this smoothly as well as giving care.
I can hear many midwives thinking. 'she was just spoilt in the community, real life in here is a shock and she can't cope'. That is true, but I don't want to cope with that system. I'm not clever or good enough to truly be 'an advocate' for a couple who I'll never see or talk to again, and I've got the choice (at the moment). It is too hard to choose between a mother in tears or answering a bell; to choose between helping a breast feed or doing discharge notes on the computer. These jobs need to be done of course, but the present system of fragmented care produces so much more paperwork.
I believe that one of our most precious roles involves giving time, giving one-to-one support and encouragement to a primip in early labour. This builds up a woman's confidence in herself and in her midwife for when things get harder to bear. How can you choose between this and a post-operative patient needing to sit up and talk through her experience? I believe that the largest part of our job is to just be with women, to listen a lot and sometimes to talk, to praise and reassure. It all needs to be done, and the midwives doing it are wonderful.
Part-time community based work could be an option, but the numbers of women I would meet if I were involved in a whole area caseload would be enormous and the possibility of booking and caring for and then attending the birth of a woman would be very slight, let alone meeting her again on subsequent pregnancies etc. The numbers of part-time midwives, plus sick/holiday relief often means that even in teams, women still meet a large number of carers.
So how can someone like me, who loves the job, practise part time and give good one-to-one continuity of care? Independent midwifery, I hear you say, is my other option; but I don't particularly want to do this, and, fortunately, so far here on the Isle of Wight there hasn't been a big demand. I truly hope the NHS services can continue to supply most women's needs, but sadly I am becoming more pessimistic about this. Overtime payments to midwives attending domino births have been cut, midwives love their job but, quite rightly, they are not going to work for love. Our clients have to demand what they want (and deserve), and a lot of them don't know what they need to ask for.
Recently, with support from my supervisor, I have been able to give total care to a couple of friends throughout their pregnancies and births, and this has brought back all the old rewards. It has restored my self confidence, which goes very quickly when you stop working. It has also updated me, induced me to read and use my brain again (because it wasn't all straight forward), and given me 'the buzz'. We all need support from our colleagues, but there is nothing quite like being responsible for planning and making the deci sions with your client yourself. This overall one-to-one care is the true practitioner status that the independent midwives are used to; no Trust guidelines, policies, no safety net of colleagues around you, no doctors immediately on hand. You make appointments to meet at places and times convenient to both of you. The downside, of course, is that, like an independent midwife, you must stay on call for the birth 24 hours a day for perhaps five/six weeks, and it is hard to organise life with two children; a regularly absent husband and living on an Island like this!
So we need partners, perhaps two but no more to relieve us when necessary. Why can't midwives like myself organise ourselves into small practices within the NHS framework, thus maintaining our hands-on experience and keeping ourselves up to date? Couldn't we take a small number of cases annually and be remunerated for them? I believe managers and supervisors already do this in some places to keep their hands-on experience, and to get 'the buzz' I'm sure! One argument against this is that it would create an unfair two-tier system, and how would we select our caseload? I say that the system is unfair already, women strike lucky (or not) depending on the consultant they happen to be booked under - and whatever his preferred practices happen to be; they strike lucky as to whether the labour ward is busy or not, whether there is a staff change just before they give birth; whether their midwife truly supports breastfeeding (contentious, but true) and in scores of other ways. If the small, part-time team became popular with women and midwives then we would know what women want, and strive to move in that direction. Giving one-to-one care would make it easier to audit practice such as referral and intervention rates, breast feeding rates etc., all of which have been shown to improve in other set ups of this type.
'Teams' have of course been tried, sometimes very successfully, but because of the overall staffing of birth numbers they have been required to book a predetermined number of women. Often this has been far too many and burn-out has occurred followed by 'failure' of the team approach. If the money could somehow follow the woman we could undertake 4 or 40 cases a year, depending on our individual circumstances and the set-up of our practice. Over the years the Isle of Wight has been trying hard to get more continuity of care and I do believe real efforts have been made to think of ways of organising our system differently. But we are small, there is only a finite amount of money, and midwives here are in short supply. Interestingly, while birth numbers have dropped the WTE midwife numbers have remained the same, but we still seem to need more staff. Is it because of the increased intervention rates/observation/nursing requirements, increased record keeping/paper work, more home visits/women leaving hospital earlier? Is it because women have higher expectations? Minimal numbers of core midwives will always be needed in the hospital. for women needing 24-hour care and for emergencies. But because of our small numbers, we are working with minimal numbers of midwives anyway, so there are no extra resources to fund or staff an additional type of service. Should I be content to stay at home and/or do a little totally fragmented midwifery (I find it difficult to call that real midwifery)? Are there other midwives working within the system who would like encouragement to book a few women for total pregnancy care? Is there a system existing that would allow me to work within the NHS, with a partner, booking a handful of women at a time? It sounds like Utopia even as I write the question!
LW updated February 4, 2005