Maternity Care: Where are we going now the world has changed, and how will we get there?

The world changing global Covid19 pandemic has thrown us all, everywhere, into an existential crisis. For midwives and all of us working in and with maternity services, the responsibility of this crisis is profound.

Not only does our care in this pandemic have an impact on present generations, but our work in policy and organisational development, and the decisions we make about our future, will influence the safety and quality of care for future generations. The need to safeguard quality and previous progress is critical (Renfrew et al 2020).  It is difficult to think and plan when the world has been turned upside down, but decisions made now will be vital to our future.

The ‘midwifery crisis’ that has emerged in the UK cannot be blamed entirely on the pandemic. Understanding the deep roots of this crisis is vital if we are to recover from the devastating effects of the pandemic, as well as ensure that the progress made to ‘transform maternity’ before the pandemic, is preserved. The process of this transformation must, of course, be reviewed in the light of our present circumstances. But there should be little doubt that transform we must. The UK has some of the most progressive maternity services policy in the world; the transformative change arising from this policy is essential if we are to provide safe high quality maternity care in the future. It will also help resolve problems manifest in the current midwifery and maternity crisis.

How do we then, amidst the fear, loss, great uncertainty, pressure of responsibility that surround us in this crisis and turmoil, preserve and continue the progress that has been made?

It is, I think, a matter of heart, for the emotions, empathy not only for those we care for, but also for the staff suffering the moral distress and psychological trauma of a working situation that often feels impossible. We need wisdom to plan and consider the fundamental changes to be made, and to use the extensive knowledge available to us. We need to gain confidence from the many examples of successful leadership and establishment of transformative change, despite current difficulties.

We need the courage to recognise the reality of the challenges we face, the deep-rooted problems that need radical change of culture, structure, systems of care, and overhaul of the evidence that is used as a basis for our practice and organisations.  We need courage also to speak up on topics that have been rendered unspeakable, and about the way problems may have been intensified.

In truth, and difficult though it might be to accept, most present-day maternity services are unsustainable in their present form.  It is not just a matter of inadequate resources and staffing, although this is an important factor. Most services are highly fragmented, with large gaps in provision and pathways. The focus is mainly on centralised acute medical services rather than primary, public health-oriented midwifery services. The current service does not work for the needs of diverse populations of women their babies and families, or to resolve the effect of profound socio economic and ethnic inequalities.

Neither does the current service work for women who need and want intervention, or for those who need and want physiological birth. “It is a classic lose-lose situation. Risk is not diagnosis, and when it is treated as if it is, health care becomes unbalanced and ineffective for the majority who use  it”(Personal communication: S. Downe). This is well known in medicine in general.

This over diagnosis of ‘disease’ or to put it another way ‘the risk of extreme risk aversion’, is becoming, ‘the thing that can’t be named’ in maternity care, one of the few areas of health care where the majority using the health service start off healthy, and should remain so” (Personal Communication: S. Downe. ) Keeping childbearing women and their babies healthy would mean that there is more time and resources for those who need more intensive medical care and interventions. This is a “win-win situation” (Personal communication: S. Downe).

The overuse of intervention has increased complexity in services that are already impossibly complicated. Rates of interventions are rising exponentially.

For example, 1 in 3 women now have an induction of labour. Moreover, a survey of 2000 women by Birthrights found that only 1 in 4 women felt the information they received prepared them for induction. Now, in the UK, caesarean section rates are at their highest ever, over 30 %. Yet the evidence behind the need to optimise caesarean section use, ensuring access to caesarean section when needed and wanted, but avoiding unnecessary use, is ignored.

Supporting normal physiology is essential to avoiding unnecessary interventions. Healthcare practitioners are expected to follow evidence based practice, they will promote practices proven to be beneficial in supporting the normal physiology of labour, birth and the postnatal and neonatal periods.

This ‘thing that can’t be named’, 9Personal communication: S. Downe),  a serious and fundamental problem that is not being spoken about, needs open, informed, respectful and tolerant discussion in public forums, in the media, and with professionals. Neither will we resolve the problem of escalating rates of intervention safely unless we are free to include in our discourse consideration of the vital contribution to short- and long-term health, wellbeing, and strong relationships, that support for the normal physiology of childbirth makes (Downe and Byrom 2019). Understanding normal physiology, understanding how that physiology might be supported, and recognising deviations from it, is crucial to high quality and safe care.

Transforming maternity services based on current policy will take us a long way in developing safe high-quality care. Midwifery continuity of carer is a mainstay of maternity transformation and is a gamechanger in terms of safe, personal, evidence-based practice, care delivered through human relationship. NHS England, Scotland, Wales, and Northern Ireland have  plans to give most women access to continuity of carer over the next few years.

New midwifery standards have been established by the NMC. These aim to transform midwifery care for everyone. Standards of proficiency for midwives and for pre-registration midwifery programmes are based on the right of every single woman, baby, and family to experience the best and safest care possible during pregnancy, birth and postnatally.

The changes that are needed to transform maternity, putting policy into practice and education, may seem daunting at this time. But high-quality care, services where staff can give of their best, is an important source of satisfaction for staff. High quality care will help develop resilience and sustainability. Respect and kindness to staff, good terms of employment, and adequate staffing and resources, are an essential part of safe high-quality care. Building the blocks of preparedness, adequate resources for change, and full engagement with staff, and adequate support, will be vital.

The existential crisis of the Covid19, the loss, the fear, the uncertainty, is also a crisis of meaning. For those receiving care in the maternity services, now and in the future, there is one certainty that will help us forge a way ahead. This is the certainty that safe quality care around the critical and sensitive period of childbirth gives the best start to life. The work we do means so much. We should, in our work, forge a better future.

I would like to thank my colleagues in the professorial advisory group, Professors Helen Cheyne, Soo Downe, Billie Hunter, Mary Renfrew, Jane Sandall, Helen Spiby, Tina Lavender, who worked together through the pandemic, for the thinking, reflection, writing and discussion that have influenced this blog.

 

Professor Lesley Ann Page CBE

Visiting Professor

Midwifery Florence Nightingale Faculty of Nursing Midwifery and Palliative Care

Adjunct Professor

University of Technology Sydney

Reference:

Downe S and Byrom S eds (2019) Normal birth research, theory and practice in a technological age: Squaring the circle. Pinter and Martin, London.