Who'd be a midwife?
They're at the sharp end of NHS cuts, the rise in Caesareans is making their work more difficult – and now the birth rate is soaring, too. Charlotte Philby finds a profession labouring to keep up
Charlotte Philby is a writer at The Independent with a weekly column on motherhood in The Independent Magazine. She was shortlisted for the 2013 Cudlipp award for excellence in popular journalism for her undercover investigative work, and writes for various cultural magazines.
Saturday 26 November 2011
It is 9am in the operating theatre at London's Elizabeth Garrett Anderson maternity unit, one of the country's busiest labour wards. Midwife Michelle Thorne is recording her first birth of the day: a baby boy weighing 8lb 10oz, born by elective Caesarean. His mother was transferred here from a nearby private clinic – where treatment will set you back £10,000, but where they are not equipped to deal with high-risk cases – to deliver her son who was in an 'extended breech' position.
At the clinic she left behind, the rooms are akin to a five-star hotel suite, stocked with Molton Brown products and a bottle of champagne to toast the newborn. But here, on an NHS ward, the new mother is left to recover from abdominal surgery with her hour-old son on a post-natal ward crammed with 40 other women, plus their babies, and just three midwives on ward duty, one of whom quips: "You're lucky around here if we give you a sanitary towel".
The EGA wing at University College Hospital offers some of the finest maternity care in the UK and attracts people across the land to its lauded labour ward and birthing centre. But huge shortfalls in funding are threatening the quality of the services on offer. So overstretched are maternity staff at state-funded clinics across the country that midwives are seriously concerned about the quality of care they can offer.
The situation, says Cathy Warwick, General Secretary for the Royal College of Midwives, "is very close to breaking point". Despite the best efforts of its staff, she adds, NHS London is already in crisis. Just last month, an investigation by the Care Quality Commission at the Barking, Havering and Redbridge University Hospitals NHS Trust, following the death of two women in the care of its maternity services, found the trust needed to deliver "fundamental and wide-ranging improvements". A midwife elsewhere, at one of the capital's most respected units, says: "Sometimes you feel like shouting, 'This is ridiculous'. I'm looking at these women and thinking, 'I can offer you safe care, but it's inhumane care; I can look after you without letting you die, but I can't make it a nice experience'."
But as I learnt this time last year, around the time my own daughter was born, safe care isn't always a given. A week after giving birth, I popped into my local bank to ask after a young employee who was due around the same time as me. At her empty desk was a wreath: soon after giving birth, her colleague explained, while still on the post-natal ward, the first-time mother had complained of chest pains. Preoccupied staff, her family say, ignored her repeated cries for help, failing to notice the 24-year-old had suffered a haemorrhage. Less than an hour after giving birth to a perfectly healthy boy, the woman was dead.
This is an extreme case. Pregnancy-related death in this country is still relatively low; the most comprehensive recent report on maternal mortality, by the Centre for Maternal and Child Enquiries, found that between the years of 2006 and 2008, "261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities," with infection overtaking haemorrhaging and thromboembolism as the most common direct cause.
Indeed, many of the women I've spoken to over the past few months have had good experiences, such as Ruth and Matt who I meet at the EGA's birthing centre, which is dedicated to natural delivery; their midwife, Helle, sits at the edge of a low bed brimming with cushions as Ruth moves between the birthing ball and a birthing pool in her own personal suite – a service open to anyone deemed at 'low-risk', though Helle says not enough people use it.
But to varying degrees, horror stories involving maternity care at NHS hospitals, ranging from dirty wards and missed blood tests, to aggressive or absent staff, seem to have become commonplace.
Debra Kroll is a community midwife in central London, and advises the Nursing and Midwifery Council, whose responsibility it is to ensure staff are following the professional code and to take action where necessary. She says standards are only going to get worse: "The biggest frustration for someone with my experience is not being able to support new midwives coming through". If staff are unsupported, she adds "then care is not safe".
A friend of mine who has just qualified after three years' training is troubled by her experience as a student midwife: "There were times when I was doing things on my own that I shouldn't have been doing," she says. But "the most shocking thing" was the atmosphere among the midwives. "It can be dog-eat-dog; everyone's on edge, and people don't like their practice being questioned."
In the past 20 years, the birth rate in Britain has risen by 22 per cent. At the same time there's been a surge in the number of older women giving birth for the first time, and of women getting pregnant who are obese or have pre-existing medical conditions. This means that more support is needed in pregnancy, labour and the recovery period, creating a complex workload for midwives.
I spend a morning with Debra Kroll at the James Wigg Practice in north London, where she works two days a week as a community midwife. "The biggest issue," she says, "is the complexity of social and medical needs. Women come to us with language barriers, social and medical problems. There are very large pockets of social deprivation, so the need for extra social services is huge."
This means hours spent filling in forms: "I do a clinic from 9am-1pm; that brings at least another three or four hours of paperwork." Just finding referral appointments in other departments, Kroll adds, is a job in itself: "All the other clinics are full too, everybody is under pressure".
There simply aren't enough midwives on the ground, and it's not just the south of England which is buckling. The West Midlands, Yorkshire and the Humber and the north-west are among a number of regions suffering crippling shortages. Nationwide, more than one-third of heads of midwifery have been told to cut staffing levels; two-thirds say they haven't enough people to cope with current pressure. Cathy Warwick says, "It's about to get worse".
During his election campaign, acknowledging pressures which left NHS staff "overworked" and "demoralised", David Cameron promised 3,000 extra midwives. Then he changed his mind. The Government has decided to keep the number of midwives in training next year at the same level as there were this year, but that's it: from then on, there will be no plans to safeguard the number of midwives in training and, crucially, no protection whatsoever for the number of jobs. Meanwhile, pensions are being reviewed, and basic terms and condition and incremental pay rises for staff across the NHS are all coming under attack.
Michelle Thorne, a midwife, is stationed on the high-risk ward at the Elizabeth Garrett Anderson, which deals with women with conditions such as gestational diabetes, and those awaiting C-sections: Caesareans here account for 29 per cent of deliveries, compared to the national average of 24.8 per cent. There are just four beds here, so once an operation is complete, if all goes well, mother and baby are taken down to the post-natal ward to recover; a large portion of Thorne's day involves moving between wards, looking for free beds and for duty midwives to hand over care of her mother and babies to, before completing more yet paperwork.
This morning ("a particularly quiet one") she struggles to find anyone to hand over care to on the post-natal ward. The first midwife she tries – one of three women already in charge of 40 babies and their mothers – tells her flatly, "I've got enough on my plate". There should always be one nurse on duty solely dedicated to babies on antibiotics, but today there are not enough staff, so between them they are looking after these as well as their usual share of the ward.
Meanwhile, one of the three midwives on duty is in the middle of telling a woman that her baby has been diagnosed with Down's Syndrome: "Sometimes any number of tests can't pick it up," Thorne explains, as we go back to the ward. "Who's doing the antibiotics then?" someone asks. "They're sending a nurse up from downstairs, so they say..."
"No more beds," Thorne notes as we head back upstairs. What does that mean? "If there are no beds, the pressure's on to discharge someone." Things start to get a bit busier around this time, she says: "As long as it's controlled it's great. It's just when it gets out of control..."
Thorne qualified in 2005, after years working as an intensive care nurse. She says she loves aspects of her job: "I wanted to do something to help women". Is it what she'd imagined? "Not really. I thought it would be nice and natural and all about pushing out a baby, like what you see on the telly. It's more challenging than that."
One of her colleagues, who has worked at the hospital for 20 years, says there have been "many changes" recently. For the better? She frowns. "Gosh, no! Everything's more difficult, complicated." With management faffing over protocol, excessive form-filling and not enough hands on deck, she says staff are preoccupied. The first thing that gets swept aside, "is looking after the women and babies."
According to the Royal College of Midwives, there is already a shortfall of 4,700 midwives in the UK. "In order to replenish the number who will retire over the next decade," says Warwick, "we need to keep the same number that is coming into service now, over the next 15 years." But – assuming there are any jobs left – one wonders how the NHS will continue to attract new talent into the sector.
The pay's not bad. The starting wage is typically £21,176, slightly more in London, for an average 37 hours a week, though unpaid overtime is part and parcel of the job. Thorne does three days on, four off, with an hour's lunch break per shift. "Half an hour," a colleague who is clocking off corrects her, "if you're lucky". It's 10am, and this midwife was supposed to be off at 8am, after a 12-hour shift: "That's the way it goes," she shrugs.
The real problem is that with so many other pressures on their time, looking after women – the reason most midwives are surely drawn to the profession – has become a marginal portion of the job. As Sarah Davies, a senior lecturer at Salford's School of Nursing, Midwifery & Social Work, puts it: "Midwives are trained to meet the needs of mother and baby as the primary focus, but as they are rushing about, they don't have time to ensure safe and supportive care. They're not satisfying their own needs."
On the day I visit her clinic, community midwife Debra Kroll spends much of her morning between antenatal appointments, dealing with the case of a young pregnant woman whom she has reason to believe is subject to domestic violence.
Domestic violence is one of the most common indirect causes of maternal death, according to a report by the Centre for Maternal and Child Enquiries. The fact that all women no longer have just one midwife for the duration of their pregnancy, with whom they can build a trusting relationship, Kroll believes, makes dealing with sensitive issues such as domestic violence much harder. Sarah Davies agrees. "Women need to spend time with and learn to trust their midwives, to work in partnership," she says. "When you get to know somebody it's much safer: they're more likely to confide about difficult issues. Where care is fragmented the effects can be deeply damaging."
The Department for Health and the World Health Organisation both agree – as do all of the midwives I've met – that case-loading midwives (that is, assigning them to a number of pregnant women whose care they oversee from start to finish), rather than using a rotational system (in which midwives move between antenatal, post-natal and labour wards and see whoever happens to have appointments while they're on their shift and which is by far the more common model in hospitals today) is the best form of care. Cathy Warwick adds that continuity of care, such as that offered by caseloading, "has been proven to ensure improved health of babies, fewer cases of post-natal depression, increased number of women breastfeeding, and fewer emergency C-sections".
One problem with that, notes my midwife friend, is that few people are actually willing to do it: "You can't say exactly when someone will give birth, so the hours are unpredictable; you can end up being on call twice a week." Caseloading also creates a stronger emotional connection between midwife and client – which on the plus side is more satisfying but which can also make it harder to leave the job behind at the end of the day.
As a new mother recovering from an emergency Caesarean that followed a failed induction, I was shocked by the level of basic care I received in hospital. Having been induced – a common procedure when you're overdue, even if you're young, fit and healthy as I was – my boyfriend and I had been left alone in a room for hours at a time, without anyone topping up my medication. This meant that in the end, after four days of being attached to a monitor, but rarely catching a glimpse of a midwife, I ended up needing an emergency C-section. At an additional cost of about £2,500 to the NHS, compared to the average £1,000 for a natural birth.
In the 16 hours I spent in hospital after surgery (I was discharged early in order to free up beds) there was no one around to help me establish breastfeeding, or even pick up my baby when she needed feeding, my boyfriend having been sent home since our daughter was born outside of 'visiting hours'. I was immobile after the operation and heavily drugged. Repeatedly, my calls for help went unanswered. Sadly, my experience appears to be a pretty standard reflection of childbirth in Britain today.
While I had impeccable antenatal care that was so good it made up for the fact that clinics were often overrunning by several hours, post-natal care seems to be in particularly bad shape (after all, if you're short-staffed the priority is understandably to get midwives on to the labour ward, and the obvious place to pull them from is the recovery ward).
In a 2009 survey by Netmums, 35 per cent of women report being left alone during labour or shortly after birth. Fewer than half of those questioned in a similar review of 1,260 first-time mothers by the National Childbirth Trust last year said they received the advice and support needed after giving birth. Half didn't have any access to a midwife after delivery.
Cathy Warwick believes this is a serious concern for both mothers and staff: "Midwives know women are not getting the level of care that they need after birth, which is a time when they are vulnerable and in need of support." If things don't change soon, she worries that not only are we at risk of letting women down, but of making the midwife's job impossible, too. "There's an inherent satisfaction in this job," she says. "But in our very busy units we're pushing that to its limit."
Warwick can remember a time when midwives visited mothers every 10 days from the day they were discharged from hospital – "more frequently after a Caesarean or if there were complications". Until five years ago it wasn't uncommon for women to be seen after birth by a midwife four times. Warwick says, "Now you're lucky if you get seen once, way below the guidance from Nice [the National Institute for Health and Clinical Excellence]."
It doesn't help that natural delivery – traditionally directed by midwives – has never been so unpopular in Britain. The number of women having Caesareans has doubled in the past 30 years, accounting for 24.9 per cent of births in the UK in 2009. The growing number of emergency Caesareans is widely linked to an increase in inductions, with recent proposals by Nice suggesting that the number of Caesareans available on the NHS could rise significantly. But however they happen, a surge in surgical births should mean that post-natal care from a midwife becomes more important, not less.
In recent years, says Debra Kroll, "there's been a big backlash against natural birth". Women (and men) have been questioning whether natural birth is an outmoded form of delivering babies when there are relatively safe and pain-free alternatives. But, in fact, claims that C-sections are a pain-free alternative for those who are 'too posh to push' are misleading. As I discovered, you're lucky to be given 24 hours on the ward to recuperate after surgery that involves cutting through several layers of muscle and tissue.
An increase in Caesarean numbers would be disastrous from a midwifery point of view, says Kroll. "Who's going to look after these mothers and babies? We're already pushing women through the system so fast."
The bottom line, says Cathy Warwick, is that Britain's NHS midwifery service needs more staff and a more efficient way of working, one less bogged down by targets and forms, and more interested in women. "At the moment the system is like a big sausage machine," she says. "We used to talk about the alienated worker in the car factory, who only fitted the clutch or the gear stick and so didn't care what happened to the car." This, she concludes, is what the system is making of midwives. "Unless something is done very soon to change things, we'll have a real crisis on our hands."
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