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Where now for midwives?

5 June, 2008

Where now for midwives?

Hundreds of midwives arrived in Torquay last month for this year’s RCM annual conference, and no-one who witnessed the programme could have been left in any doubt of the commitment and passion within the profession.


Hundreds of midwives arrived in Torquay last month for this year’s RCM annual conference, and no-one who witnessed the programme could have been left in any doubt of the commitment and passion within the profession.


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Midwives magazine: June 2006


The 124th RCM annual conference was held in Torquay last month, attracting a vibrant and diverse group of over 600 midwives from across the UK and all areas of the profession. Hearing addresses from the RCM general secretary and College president, the minister for health and guest speakers, delegates also participated in impassioned and articulate forum debates on issues important to midwifery.


Six motions were also discussed and voted on at the branch delegates meeting, and the RCM Council held the annual general meeting as required by company law. Attendees also chose between concurrent sessions and fringe events ranging from a perineal suturing workshop to a seminar on enabling non-English speakers to access services, and took time to look around the exhibition area, which for a second year included a chill-out zone offering free massage and reflexology treatments.


Ministerial address


After postponing her address from the opening session due to an emergency parliamentary debate, secretary of state for health Patricia Hewitt spoke to delegates following a flying visit to Torbay Hospital.Her polite reception contrasted with that at other organisations’ recent conferences. However, there was no shortage of hard questions for the minister, who dispensed with her planned speech to hear what delegates had to say, something she later stated had been ‘exceptionally useful’.


She said that the aim of one-to-one maternity care throughout pregnancy and labour was ‘a very long way’ off in most areas, but last year the groundwork was laid for its provision across the UK by 2009. And while overspending in a ‘small minority of areas’ was having an impact throughout the service, she hoped all involved would work together to get ‘back on track’ next year.


Most delegates’ questions related to the NHS financial crisis in England, including experiences of closures, low staff morale and few jobs for newlyqualified midwives, and she was asked whether she still thought this was the ‘best ever year’ for the service.While not answering this directly, she did promise to act on concerns voiced that maternity care assistants are being used to substitute for midwives, and that some maternity services are being required to make the same savings as expected in areas of elective care.


She also said that, though the Foster review of nonmedical regulation following the Shipman inquiry has not yet been published midwives would be involved in any changes and that ‘selfregulation has made a huge difference to safety’.


President’s speech


RCM president Maggie Elliott spoke about the relevance of the title of this year’s conference, and put present challenges and opportunities in the context of the College’s early history. Her address will appear in full in a forthcoming issue of RCM Midwives Journal


Guest speakers


Rona McCandlish

Rona McCandlish from the National Perinatal Epidemiology Unit (NPEU) discussed the evidence base for informed place of birth decisions, referring specifically to the NPEU structured review, a three-year Service Delivery and Organisation evaluation of maternity units (EMU) that has just begun in England and the National Institute for Health and Clinical Excellence (NICE) guidelines on intrapartum care that are under development. She highlighted the difficulties in assessing evidence without a consistent definition of what a birth centre is.


She said the EMU would look at existing services and the degree of women’s choice as well as assessing management, impact of transfer, outcomes for children and cost-effectiveness. She stressed the opportunity midwives would have to get involved in the development of the NICE guidelines, with the consultation process taking place from 22 July to 30 August.


Anna Walker


The Health Commission’s chief executive Anna Walker described her organisation’s role in improving maternity services among its wider remit to promote improvement of health and health care through the assessment of the performance of healthcare organisations in both the public and private sectors.


She stated its main areas of activity, which include the investigation of serious service failures and coordination of healthcare inspections. Emphasising an underlying desire to use these to help midwives in providing maternity services, she said the Commission aims to measure what really matters and work in partnership, as well as to have fair and open processes.


Jane Rogers and Sarah Marsh


Jane Rogers and Sarah Marsh presented findings from the Birth Place Choices Project, carried out over two years in Southampton and Portsmouth to identify factors influencing women in choosing where to give birth, whether information provision succeeded in increasing women’s awareness and to increase births in maternity-led units and at home.


They stated that what women want is to be listened to and involved in decision-making. Women trying to stay in control and feel safe can express this by saying what they do not want, demanding things that seem unreasonable, being overly influenced by staff members and marshalling additional advocacy. In line with previous research, the project found that perceptions of safety still affect women’s choices, but that midwives also remain the most influential factor in their decisionmaking, more women plan to deliver at home or in birth centres, and more actually did.


Suzanne Tyler


Suzanne Tyler is working with maternity units around the country on sustainable innovation and spoke about new ways of working in the NHS as it goes through yet another set of changes.


Stressing the importance of understanding new costing structures under payment by results, she said midwives should take an active role in finding out who is setting tariffs in their Trusts and get involved in ensuring they reflect reality. She added that it was crucial to utilise recording systems since these will be used to set future tariffs. Midwives can expect increased scrutiny of maternity services, and it is important they make their case for how they contribute to better quality, more choice, less inequality, value for money, recruitment and retention, and increased access to services.


Chris Beasley


Chief nursing officer for England Chris Beasley said choice has increased in importance as ideas of quality and expectations have changed and grown, but that significant inequalities in health and health care still exist. She said services should treating people as whole individuals rather than a collection of symptoms. Choice in maternity services has featured in several publications including the White Paper Your health, your care, your say, but differs from other areas of health care since maternity services have no waiting lists, unpredictable demands and workloads, are already localised and need to be rapidly accessible.


Most potential for choice lies in who is the first point of contact and lead professional, antenatal screening, place of birth and pain relief.


Janine Wynn-Davies


University of Glamorgan senior lecturer Janine Wynn-Davies predicted that the future of midwifery would be influenced by women who attempt to sue midwives because they think that normal birth was not facilitated during their care.


She read the records of a fictional court case in which a woman who was awarded a risk assessment score of zero is claiming damages from her midwife on the grounds that she encouraged the unnecessary medicalisation of her delivery. The midwife characterised nonmedicalised births as ‘high maintenance,’ and said that keeping women on continuous fetal monitoring made it easier to attend to more women at one time. Playing the part of the jury, delegates found in the woman’s favour. Janine Wynn-Davies said the attitudes she had portrayed were derived from interviews with real midwives in the UK, and asserted that to ignore women’s desire for normal birth would indeed incur the wrath of the law.


Forum debates


Midwives: Jill of all trades, mistress of none?


BBC Radio Five Live health correspondent Sharon Alcock was guest chair for the first forum, and was joined by consultant midwives Helen Shallow, Debbie Garrod and Maggie Thomson. They discussed issues raised by the specialisation of midwives.


The importance of ensuring student midwives gaining adequate minimum experience of normal care was emphasised so that the profession can retain its guardianship of normal childbirth, regardless of specialisation. It was warned that some specialist midwives risked becoming highly skilled obstetric nurses otherwise, and that being a generalist midwife should be perceived as specialising in normal childbirth rather than as an almost derogatory term.


Delegates questioned whether the debate would even be seen as necessary if there were enough midwives employed, while others said specialists were needed to meet the demands of complex social problems and that this did not detract from normal midwifery.


Choice for women? Choice for midwives? Choice for employers?


RCM director of employment relations and development Jon Skewes chaired the second forum, with speakers Steve Barnett from the NHS Confederation, The Observer’s Jo Revill and head of midwifery Donna Ockenden. Steve Barnett referred to the drive for more personalised maternity services and the choices employers face in terms of support staff roles, regulation and numbers of midwives.


Jo Revill attracted criticism from midwives for her article saying women should be given elective caesareans without being ‘impeded’ by midwives. She told delegates that this was a logical extension of consumer choice and that there is nothing wrong in wanting to avoid pain. She stated that there is a lack of evidence on the risks and benefits of both caesareans and vaginal deliveries, though her suggestion that there should be a large randomised international trial was condemned and later withdrawn by her. Donna Ockenden asked whether choice for all is possible, especially when staff are threatened with cuts, but identified good practice examples as including creative expansion of the role of maternity support workers, promotion of home and birth centre delivery and midwifery-led care pathways. She said long-term leadership of the NHS and an appropriately funded long-term vision for maternity servies were needed for real choice.


Many delegates applauded Jo Revill’s courage in coming to the conference, but criticised her for having a simplistic view of the choices involved, especially when women wanted an elective caesarean from feeling scared or after a negative prior experience. Steve Barnett’s assertion that there was no tool to calculate adequate numbers of midwives was questioned, as was his failure to refer to Birthrate plus, but it transpired that he had not heard of it before.


A question of influence


The final forum was chaired by consultant midwife Dr Grace Edwards, featuring Montrose Maternity Unit team leader Phyllis Winters and consultant midwives Karen Jewell and Sally Price.


Phyllis Winters described how the staff of her unit had turned its fortunes around. Admitting that the initial driver for change had been the desire to save their jobs, with delivery numbers falling, transfer rates rising and the threat of closure, she said they decided to sell the unit, themselves and normal birth to local women. She went on to describe how this was achieved and how she now works in a wellused unit at which 57% births are in water.


Karen Jewell spoke about how a group of supervisers in Cardiff had influenced and helped midwives through a process of change. She noted that subtle approaches can be more influential in the long run than bold ones, and that collective influence from joint goals and shared knowledge can lead to the most sustainable outcomes.


Sally Price advised that to make a difference at strategic level it was important to ‘get your own house in order’ before assessing and using available evidence and education. She stressed horizon scanning, prioritising and taking a person-centred approach to partnerships. Identifying key people in positions where they can make a difference and effectively influencing them is also crucial. Delegates were also reminded of the importance of the Department of Health’s Standards for better health.






The first motion said the RCM should support midwives in establishing a lead role and specialist pathway in the model set by the government’s children-focused agenda. Proposer Bev Thorne said she did not disagree with the multiagency and collaborative approach involved, but that there were concerns midwives’ role could be reduced to simply referring women on to other services. In the discussion that followed, it was stressed that it was up to midwives to actively involve themselves in defining what their role should be. The motion was carried.


Electronic fetal monitoring


The second motion called for continuous electronic fetal monitoring (EFM) to be designated as having prescription only medical device status to help prevent its unnecessary use and reduce its recognised associated risks, such as more caesarean sections among low-risk women. Proposed by Jo Parker, it would mean cardiotocography machines would be locked away and only used with valid reason and after being authorised by two practitioners.


Delegates said it was up to midwives to use common sense to ensure EFM was used appropriately, and that additional bureaucracy would not help. It was pointed out that midwives were the people using them unnecessarily, and that they need to be more confident in their position. Other delegates said that, regardless of where responsibility lies EFM use has not changed sufficiently in recent years and that regulation is required.However, the motion was defeated overwhelmingly.




In the most controversial and hotly debated motion,Marlene Sinclair called on health departments to ensure that epidurals are only provided when clinically indicated. Delegates were assured that this was not a cost-cutting measure, but one to promote normality and to counter increasing use of epidurals, morbidity and medicalisation.


Many spoke both for and against, with one stating that feeling disconnected from delivery could adversely affect mother-to-baby attachment. Others added that negative press coverage of the motion had not taken account of a word change that sought to shift the debate from whether women who wanted epidurals that were not clinically indicated might have to pay for them. Those opposed said that it threatened the reputation of midwives as promoting women’s choice and might encourage elective caesareans among women who would otherwise choose an epidural.Marlene Sinclair said the motion was not about taking choice away, but that women need to know the risks involved in having epidurals. The vote was too close to call, and the result – defeat for the motion – was announced later that day.


Delegating to support staff


The fourth motion, proposed by Clare Cutlan aimed to require the role of maternity care assistants/ maternity support workers (MCAs/ MSWs) to be defined further to ensure they are employed to complement and not to substitute for midwives.


The 2004 NMC circular Guidance on provision of midwifery care and delegation of midwifery care to others was referred to as stating that midwives remain accountable for the appropriateness of delegating tasks to other members of the caring team, implying that they should also lead in ensuring MCAs/MSWs have a clear role, are adequately trained and do not overstep their responsibilities and abilities.


All delegates who took the podium spoke in favour of it, while saying that midwives should take care not to exploit MCAs/MSWs and noting that midwives apparently still did not agree on what MCAs/MSWs should actually be doing. The motion was passed.




The next motion expressed concern at reports of Trusts failing to appoint qualified midwives to vacant positions and called for the government to guarantee sufficient resources to meet its last election manifesto pledge to provide one-to-one maternity care. Proposing, Kath Jones said secretary of state for health Patricia Hewitt had admitted the need for more midwives but had neglected to commit to employing enough. Beverley Reyes- Roberts pointed out that obstetric consultants are secure despite the NHS financial crisis in England, and GPs remain secure and well-paid.


Many midwives spoke in support of the motion, with impassioned pleas against apathy and for actively pressing for more midwives. The motion was overwhelmingly carried.


Breastfeeding in public


The final motion, proposed by Claire Wood congratulated the Scottish Parliament for making it an offence to stop mothers breastfeeding in public and called for similar legislation throughout the UK.


Claire Wood stated that breastfeeding rates were ‘poised on the brink of recovery’ but that society still has a strange attitude toward it, often regarding it as unwelcome, embarrassing or disgusting and relegating it to the bathroom. Many delegates spoke in favour, saying it would help counter the sexual objectification of women. The motion was carried.







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