Putting women at the centre of care
Maternity care has rarely been under such scrutiny as it is now and, as midwives, some of the coverage can be hard to hear. Gill Walton, the RCM's general secretary and chief executive, explains why we must listen in order to learn and move forward.
As midwives, being ‘with woman’ is at the heart of what we do. It’s part of our identity – it’s the literal meaning of midwife. Being with woman means ensuring that she has the right information, including risks and benefits of choice, to make the decisions that are right for her and her baby. Midwives act as her advocate in ensuring those decisions are articulated and, most of all, to ensure her safety and well-being and that of her baby. Being with woman doesn’t just apply to labour and birth, but to the whole pregnancy and in the postnatal period, being a reassuring, trusted presence throughout.
There have been points in history – including in the not-so-distant past – where this presence has been undermined. And with it, the trust women have in their own bodies has also been undermined. The shift to more medicalised birth, from the 1960s through to the start of this century, took away some of women’s autonomy and choice. The systemic pendulum swung too far in one direction, where intervention became the norm: women lying in bed, attached to a monitor whether they needed it or not, labour not progressing because they were immobile. A cascade of intervention that wasn’t good for women and babies and left them feeling disempowered. It wasn’t good for midwives either. We began to lose our confidence in our skills to support women through physiological labour and birth.
Then, at the turn of the century, things began to change. We began to speak more about physiological – ‘normal’ – birth, and we began to advocate it. This became Government policy, a policy that came from a good place – to reduce the over-medicalisation and over-intervention of labour and childbirth – but, as is so often the case, there were unforeseen consequences. Targets to reduce caesarean sections were imposed by NHS England and trusts were under pressure to keep them low. Indeed, those who had low caesarean rates were lauded as successes, regardless of how they were achieved or what the outcomes were.
In some places, the pendulum swung too far to the opposite side. Instead of over-medicalisation, there was under-intervention. We went from too much too soon, to too little too late. Both of these are a risk to safety for women and babies.
Last week, I was interviewed for The Sunday Times about this, seen in part through the lens of what happened at Shrewsbury & Telford NHS Hospital Trust, which is subject to the largest review in NHS history. In that interview, I reiterated the RCM’s position that maternity care must put women at its heart, emphasising midwives’ role as being ‘with woman’. That is the central point of the swing of the pendulum – not intervention for intervention’s sake and not a lack of intervention when it is needed. It’s about using our skill, our professional judgment as midwives, to understand women’s needs, to know when they need our support and encouragement and when to act, to escalate and intervene.
To be truly ‘with woman’, we must put her needs, her safety, at the heart of our practice. For some women, that will be supporting her through a physiological labour and birth with little or no need for intervention. For others, it will mean supporting her through a range of interventions, from induction to caesarean and ensuring that the midwife remains an advocate and continues to ensure the experience remains a positive one. That is why we as the RCM, we as midwives, should advocate for women to have the right birth at the right time in the right place.
What the RCM will advocate for is more time for midwives to spend with the women in their care, to answer their questions, to hear their concerns and to give them our best professional advice, as set out by our professional Code. That means we need more midwives, better support and training for those already in the service and more investment in maternity services to make them the safest in the world. We need strong committed management and leadership and investment in governance and oversight so that we can see and act when things are going well and not so well. And we need a culture – bottom up and top down – that enables us to learn from mistakes, so that we can be honest with women, and each other.
We know that midwifery is THE public health intervention that is proven to improve outcomes. Safer care, delivered by a well-resourced, highly qualified workforce, which is able to raise concerns in a supportive workplace: maternity services that value staff and provide women-centred care. That is what the RCM stands for and what we will continue to fight for.