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The big story: Blurred lines

17 November, 2017

The big story: Blurred lines

Women have always been able to hire independent midwives and give birth in private hospitals. But now they are increasingly hiring non-NHS midwives to give birth on NHS premises. 

Women employing non-NHS midwives to care for them is nothing new. But hiring non-NHS midwives to care for them as they give birth in NHS premises is a more recent trend. And it seems to be growing. 

It is a service that the company Private Midwives, formerly called UK Birth Centres, offers across the UK and Ireland. The organisation has collaboration agreements with 10 NHS organisations across the UK, covering 18 services – a process that took about two years to complete – which means that women can hire a private midwife who will accompany her to an NHS unit and retain full responsibility for her throughout birth, unless complications demand obstetrician input.

Director of midwifery at Private Midwives Linda Bryceland is a former NHS HoM. She says that the firm, which employs 70 midwives, essentially ‘rents a room’ in the NHS. 

‘The NHS still gets the NHS tariff and we pay an additional fee to rent the room. We provide the care under our indemnity. If the client has risk factors then we put together a collaborative plan of care that includes their obstetricians,’ she says. 

Where a client wants to hire a private midwife and an agreement is not in place, the private midwife will provide all care up to the birth and the early stages of labour, at which point clinical responsibility is handed to the NHS team. The private midwife will act as a ‘professional birth partner’, says Linda, offering support to the woman in an advocacy role. 

‘It’s never a case of “us and them”,’ says Linda. ‘We work closely with the NHS and, in fact, some of our midwives work as NHS bank staff too.’

That integration of non-NHS and NHS staffing is, of course, commonplace. The RCM found that, in 2016, UK maternity services spent £20,915,939 on agency staff and £67,380,121 on bank staff (RCM, 2017).  

Flexible scheduling

The lines between private and public in maternity care have been blurring elsewhere too. For example, the Neighbourhood Midwives service is being delivered in Waltham Forest in partnership with NHS Waltham Forest Clinical Commissioning Group, Barts Health NHS Trust and Homerton University Hospital NHS Foundation Trust.

It was launched as a two-year pilot in Waltham Forest with an aim of offering more continuity of care with the same two midwives caring for a woman throughout pregnancy, birth and postnatally. It too offers a more accessible service for women with midwives scheduling appointments around the client’s needs, with visits at home an option. 

Private Midwives says that demand for its services is on the up – in the past five years, it has risen from dealing with 50 women per year to more than 500. Why might this be the case when the cost of care from early pregnancy, birth in hospital with a pool and six weeks’ postnatal care is £6000? 

In part, it is continuity of carer that is so appealing to women – they know the midwife with whom they have built a close relationship over multiple appointments that are more frequent and longer than those in the NHS. The flexibility and access to expertise is also a draw, with midwives going out to women’s homes in the evening or at weekends for appointments lasting one or two hours, including birth and health education. This appeals to professional women – about 40% of the client base are working women for whom the NHS system of appointments is difficult. They may work and live some distance apart, making it hard to attend clinics or classes. Around 10% of the clients are either international women who are not entitled to NHS care or British women who feel strongly about having a certain type of birth that the NHS won’t offer: for example, those who want a waterbirth but are over the recommended BMI.

Then there are those who need extra support. ‘Half the women we see have experienced an element of birth trauma and, for some, it’s led to a degree of post-traumatic stress disorder,’ says Linda. 

She adds that most clients are not wealthy, but working middle-class couples, many of whom take advantage of the interest-free payments over 12 months.

Stretched NHS services

Jon Skewes, RCM director for policy, employment relations and communications, says that the NHS offers choice for women but it cannot make the same guarantees that private provision does.

‘There may be the guarantee of a waterbirth, for example. Or the guarantee of continuity of carer, which of course there is strong evidence for, as policies in England and Scotland say,’ he says.   

Most births continue to take place within the NHS and there are moves to improve maternity services in areas such as continuity of carer, seenin Better births in England and Best start in Scotland, he says.  

But the service is stretched. Jon points to the RCM’s 2016 State of maternity services report, which describes NHS maternity as at crisis point, with a shortage of 3500 midwives in England alone.

‘I’ve not seen evidence that people are, at scale, moving to the private sector for maternity. Does it offer greater safety or choice or quality? The evidence doesn’t suggest that one is better than the other.’


RCM. (2017) Agency, bank and overtime spending in UK maternity units in 2016, October 2017. See: https://www.rcm.org.uk/sites/default/files/RCM%20Midwifery%20Agency%20Bank%20and%20Overtime%20Spending%20Report%202017%20-%20Embargoed%20until%200001-%20Tuesday%2031st%20October.pdf (accessed 20 November 2017).

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