Birch Midwife & Lotus Doula

better late than never but here is part 5 – hope you enjoy it

Centralisation of Childbirth

The Peel report of the 1970’s has already been mentioned but another major factor in the implementation of the medical model of birth has been financial. The centralisation of services has huge cost saving. When resources are concentrated into one place then fewer resources are required. Whether this is equipment, infrastructure or staff, the less of these that are required the lower the cost, but this a very simplistic way of looking at costing and cost saving. In 2006 the Department of Health discussed the issue of the huge financial deficit in NHS budgets.  Many Trusts found themselves in dire financial circumstances. This led to NHS Trusts looking at rationalisation of services in an attempt to rectify the situation. In 2006 many birth centres were closed across the country. Statements issued from the various trusts involved all stated that staffing or under use were the major factors in the closures, but it seems ironic that all these issues all seemed to surface just as trusts were being told to redress their financial issues or face sanctions. The Comprehensive Spending Review of the Government in 2007 required a 3% efficiency requirement on all public sectors organisations meaning NHS Trusts had to make comprehensive strategies for increasing productivity as well as reducing costs. Rationalising and centralising services may be a logical way to reduce costs whilst still providing services but only in the short term. Long term this may create many more problems especially within the maternity setting where it has to be accepted that for the majority of women childbirth is a normal and natural event not a medical emergency.

Obstetrics and gynaecology speciality has the second highest claims rate for NHSLA and the highest monetary claims (NHSLA, 2009). Many claims made to NHSLA result from a perception of a ‘lack of assistance or care’ and ‘failure/delay in treatment or diagnosis’. With the centralisation of maternity services to large consultant units which are impersonal and not necessarily local to the individual, causing issues for transport, where each person is processed by number and condition not as an individual will lead to greater dissatisfaction and consequently more complaints and claims. A large amount of claims means a higher level of levy on the trust and the speciality by NHSLA. Still attempting to reduce costs each trust strives to reduce the levy not by increasing care provided but by trying to lower their premiums.

Each premium or Clinical Negligence Scheme for Trusts (CNST) level provided through the NHSLA commands a different payment amount for the Trust. For each level a different set of standards has to be met. Having ploughed through the standards set there is little with regard to providing a high quality caring environment, no provision for assessing the psychological and social support for women using the service. The standards are mostly concerned with the development and implementation of guidelines with reference to NICE guidelines and auditing to ensure compliance with these guidelines. There are standards set which stipulates set types of training for the specialty but no actual audit of what is actually being taught and by whom. It is all a paper exercise in an attempt to reduce litigation not by the provision of care but the ability to say we did all we could clinically and therefore it was not our fault.

In March of this year (2010) it was also announced by the Department of Health in response to the pre-election budget delivered on 24^th March 2010 that the NHS needs to make £4.25bn savings over 2 years. This is to be part of the efficiency drive to cut NHS spending by £20bn announced by the chief executive of the NHS in June 2009. Whilst having these spending cuts hanging over the NHS it has still managed to increase the number of managers within the NHS by 12% (BBC News [online] 2010). This is an example of how the NHS sees the bureaucracy of its own self to be of greater importance than the care being provided.

To my mind it seems logical to centralise services where large costly pieces of equipment are needed but in an area where the main provision by the NHS is a caring midwife for what is ostensibly a normal physiological event it seems that providing this service away from a central point eg small units, birth centres at home, is not going to vastly increase costs and in actual fact the reduction of the use of interventions which has been proven to happen when birth is treated as a normal physiological event in a calm and comforting setting would actually reduce NHS costs in the long term.

Medicalisation of Childbirth

Jowitt (1993) said

‘…with very few exceptions, technology has no place in childbirth’ p13.

For thousands of years women have been birthing babies without the necessity to have lots of technology or consultant hospitals. Not all babies survived and not all women did either but enough to perpetuate the human race to populate the entire world. In a recent bulletin from the WHO (2010) it was found that in China there was a direct correlation between increased institutionalised birth settings and an increase in caesarean birth to levels well above their recommended rates. WHO (2010) went on to say that institutionalised birth was not the only factor in the increase but that also the medicalisation of antenatal care contributed.

As a student midwife I learnt many things but two of the most important were the principles of non-maleficence and beneficence.

Non-maleficence means that our first priority must be to do no harm with our actions and balanced with this the principle of Beneficence which is that actions should be done to benefit the situation (UCSF School of Medicine, 2010).

Medicalisation just because an intervention has been invented is not an act of non-maleficence or beneficence unless full unbiased research proves the benefit of the intervention or treatment is outweighing the risk. The introduction of cardiotocography (CTG) in the 1970s is an example of how an intervention can medicalise childbirth with little benefit to the vast majority of those who received this intervention. Since its introduction many research findings have been produced which state that CTG confers little or no benefit for women and babies who are low risk, and actually increases operative interventions with their own inherent risks (MacDonald et al,1985, Thacker et al, 1995) and it is now commonly viewed that CTG use should be restricted to those women who are experiencing a complex pregnancy and birth.

Routine elective caesarean section for breech presenting babies as recommended by the Term Breech Trial (Hannah et al, 2000) is another example of how medicalisation of childbirth has had a major impact on women and babies. Since Hannah et al’s (2000) original recommendations opinion has been divided as to whether this is the best course of action in all instances but the effect of this and also the blanket introduction of CTG’s has had a much more profound and damaging effect on the provision of normal birth environments than just the actual intervention itself. These interventions are examples of how the medicalisation of childbirth has and can lead to the deskilling of midwives. Murphy-Black (1991) observed the reduction in midwives skills in auscultation of the fetal heart using a pinard and many midwives have not even been privileged to witness a breech birth let alone have the experience to feel fully competent in being the lead professional. This medicalisation of childbirth is having a profound effect on our profession and our ability to provide women with midwives who have a wide range of experience to facilitate normal physiological birth for women.

Moving childbirth into the medical field also disempowers women. Henley-Einion (2009) writes about the medicalisation of childbirth and explains how the patriarchal changes in moving from women supporting women in childbirth to a more medicalised and scientific approach moved childbirth into the realms of a male dominated hospital system with a greater reliance on experts in the scientific field with their complex words and scientific language creating a barrier to women being a part of the process encouraging them to be a passive recipient of treatment. The reduction in physiological birth has created a whole generation who have no experience of childbirth without medical and scientific input.

The prevailing attitude within the maternity wards is that of looking at each woman as not as an individual with a name and aspirations but as a condition. Many times, both as a student midwife and as a qualified midwife, I have listened to the handover of care and been have been complied in the treatment of women this way. The handover, not of Ann Other who is labouring and has a cervical dilatation of 6cm but, of room 3 who is 6cm. The handover of the ‘epidural and synto in room 6’ as apposed to Anita Person who has had an epidural and is currently receiving a syntocinon infusion. The clinical and medical information being the person, detracting from the individual who is experiencing childbirth, all reaffirming the importance of the medical and not the individual.

As a student midwife and a mentor to students I have also become frustrated with the way in which midwifery education has reinforced the medical model of care. A student midwife is required to conduct the ‘normal delivery’ of 40 babies in order to qualify but those 40 ‘normal births’ can be induced, augmented and with epidurals in situ. Midwives can qualify having never experienced a physiological third stage, a waterbirth or a homebirth. Students can’t count the long hours of supporting a woman who is labouring and birthing physiologically but requires a manual removal of placenta at the end of it but can count the woman whom she has never met and births 5 minutes after the midwife enters the room.

Universities appear to be trying to instil physiological birth into the programme but until the requirements of qualification, and the culture of the labour wards they are training in, are looked at, many midwives can, and do, qualify with out what I consider to be the prerequisites of a midwife who can support a fully physiological birth.

I am not having a go at the student midwives, their mentors or the lecturers but I am having a go at the system that perpetuates this hideous form of education for midwives!!!!