The past 18 months have been difficult for many free-standing birth centres and their supporters. In spite of this Avril Nicoll sees signs that a free-standing birth centre Utopia is within our grasp - and that it will make a real difference.
In a survey of Royal College of Midwives Stewards, 82 percent of respondents said their NHS area was in deficit and that financial difficulties were impacting on maternity service provision. The picture is depressing -frozen posts, no recruitment, reduced training, loss of senior roles and effective downgrading through service reconfiguration.
A third of respondents also said they had experienced temporary or permanent closure of a birth centre due to staffing shortages. Reports of weekend closures, reduced staffing and service reviews conveyed a sense of impending doom. The impact on users was said to include shock, upset, anger and distress, resulting in an increase in complaints, abuse and aggression.
So what do we do? Out of this melting pot of understandably strong emotion and overwhelming pressure, how do we brew up a maternity service that is worthy of women, babies and the midwifery profession. Do we need a miracle?
Just suppose then that you wake up tomorrow and find all the problems facing maternity services have been solved. You are now living in a free-standing birth centre Utopia. What does it look like? How has this happened? And what difference has it made?
Women and the midwifery profession have a history of resilience in the face of adversity. Whatever happens to us, we can find our own ways of coping - if we take the opportunity. This 'miracle question' of Solution Focused Brief Therapy is an established way of helping people to recognise and draw on all the resources available to them, internal and external, that will enable them to work towards their preferred future.
For researcher and childbirth activist Jo Murphy-Lawless the miracle has already begun, even though she is in Ireland, where there are no free-standing birth centres yet. She describes the unexpected development of two alongside midwife-led units, the huge determination to see midwifery done differently and the quality and calibre of midwifery research - "Every so often, you wake up and the angels have thrown dust over you from the heavens." Jo's Utopia is growing out of struggle and is down to "changing hearts and minds on a wider scale".
Introducing free-standing birth centres in Ireland will further establish the independence of midwifery so, with colleagues, she has been exploring "how to make that closed door open in a different way from before". Realising you are not alone, harnessing the energy of young people, gaining international support, thinking laterally and attending conferences all signal growing confidence and change.
Jo remembers a television clip of the first woman in Ireland to have a waterbirth. She got that chance in Drogheda and thought it was the most fantastic thing ever. "We know from sociology research that women can so rarely speak about choices and alternatives, because they don't know about them. The fertility rate in Ireland is still quite high. Imagine what it will be like if even 10% of women have really good births under midwife-led care - that will begin to sway hearts."
When free-standing birth centres are threatened with closure there tends to be a groundswell of passionate support from women who have glimpsed Utopia. Emma Gawn noticed the immediate feeling aroused by the Jubilee Birth Centre near Hull - "Wow! What a different environment!" - and describes it as "better than being at home, so peaceful." Even when the midwives are really busy, Emma says "you wouldn't know, because they are so focused on supporting you with their huge belief that your body can do what it is geared up to". Importantly, Emma says this Utopia puts you as a woman in control, managing the experience, with the midwives building a bond and confidence, and offering possible tools and strategies.
Sarah Roberts, who ran the successful 'Save the Grange' campaign, shares Emma's passion. Her vision is that free-standing birth centres become the maternity equivalent of GP surgeries. The first port of call is a midwife and there is an expectation that women give birth in a free-standing birth centre, only being referred to a specialist if there is a clinical need. She says "It's an opportunity to provide excellent joined up services, from one framework, across the country. A birth centre could be a ward in a community hospital. It seems so simple to me!"
For Sarah, Emma and many other advocates for free-standing birth centres, the availability of inpatient postnatal care is essential to Utopia. While women can go home straight after the birth, others can choose to stay for midwifery help with specific issues such as breastfeeding, or because they recognise in themselves a need for more professional support. Sue Breslin, midwifery manager in Shropshire, is sad to see the national average 1.6 day postnatal stay as a target. "It is not my finding that women are better off at home so soon after birth, especially the birth of their first baby. Women breastfeed more confidently and are better prepared for going it alone when they have had a couple of days of postnatal care, especially when that is provided in a low risk, comfortable place, where the midwives are there purely to help them and where they are welcome. We offer discharge from 6 hours to 10 days, and a drop-in 24 hour service."
Sue and her colleagues have made remarkable strides towards Utopia. The hub and spoke model sees one obstetric unit supported by one alongside midwife-led unit and 4 free-standing birth centres. The area has around 5000 births a year. It is proud to have the lowest caesarean section rate in the country, and a paper on service outcomes going back many years is due for publication. A consultation on reconfiguration of services said "Shrewsbury and Telford Hospital NHS Trust has evaluated its maternity services and decided to retain the current model of care." Births in the free-standing units are up, as are home births, and the service hopes to see 30% of all women giving birth in a low risk unit or at home in 2008.
The model of care is supported by current quality benchmarks and birth outcomes, recruitment and retention of staff and a limited capacity at the consultant unit. It also meets requirements of the national policy on accessibility and choice. Shropshire is a large county with a wide spread of population. The stability of the population and the workforce, plus the voluntary responsibilities midwives take on in their communities outside of work, also provide the free-standing birth centres with a close community feel. The midwives are part of the community and are fully embedded in all aspects of community activity in the areas they serve. They are very protective of their units. Many local people were born in these units themselves and GPs are supportive of local care. As many services as possible are offered in the free-standing birth centres with the aim of ensuring women only travel to the consultant unit if absolutely necessary. Similarly all requests for a consultant unit booking appointment are sent to a midwife assessor. If there is no reason for the woman to see a consultant - and if the woman has not specifically requested the appointment - the request is put back to 'low risk' care.
In Shropshire, the aim is to provide a service that a mother would want, not what the service wants to provide. Sue accepts that strong leadership is essential and always lets decision makers know her personal opinion - that she is proud of the free-standing birth centres, that they are an asset and that she will defend them against unfair criticism. But she adds, "What you cannot underestimate is the value of having staff side by side with you all these years working in these units and knowing their communities. Their practice is whole. These units have given them confidence and skills and they don't want to go back to a task-based system of care."
Midwife Gail Graham would welcome this Utopia of compliments and support. For a time she believed she had found it with the team at Wakefield Birth Centre in Yorkshire, but changes and cuts were imposed to save money and the elements that made it a special place to work and birth in were lost. But Gail may never have had this knowledge of how things could be, had she not joined the UK midwifery list and begun to question her practice. "It's painful to admit that I conformed. I was desperate to fit in. I did 4 hourly vaginal examinations. I wasn't confident enough then but, at the birth centre, we were all like-minded and the more women I saw having normal labours the better I got. We want women to be confident and empowered, but the midwife needs to be empowered first."
In her current post, Gail finds ways to use her knowledge and skills in spite of the unhelpful environment, locking the door when a woman is in labour so that people don't come in uninvited. She encourages midwifery students to develop their listening and seeing skills, to make allowances for differences, to challenge artificial time constraints and to be comfortable being 'hands off'.
Gail's Utopia sees free-standing birth centres and the Independent Midwives Association's NHS Community Midwifery Model at the heart of maternity services, and she takes heart from the fact that this is already beginning. For Gail, caseloading is important and free-standing birth centres are ideal for accommodating both team and caseload midwifery. In her Utopia the Royal College of Midwives is solidly behind the plan, as are managers, and there is more satisfaction for midwives and mothers, one-to-one care and more midwives returning to practice. Midwives are autonomous practitioners with a shared philosophy who, instead of managing a labour, are guided by it.
As well as responsiveness to individual women, user groups are essential to Gail's Utopia, as they are champions for what women want. At Wakefield when a user group said uniforms made the centre feel like a mini-hospital, this requirement was overturned and "it made us far more user-friendly."
Sure Start midwife Jilly Rosser agrees that strategic user involvement in free-standing birth centres is key to their success. User representatives are not caught up in the NHS culture. They have the knowledge to challenge decisions that are not evidence based and bring much-needed imagination and ambition to a management committee. Jilly is a member of a group campaigning for free-standing birth centres in Bristol. She finds user representatives participating in the Maternity Review prepare well, read all the papers and constantly bring the project back on course.
Jilly, a founder of the Birth Centre Network UK, has a long history in the midwifery profession as an innovator and influencer. She has a strong public health focus and is "interested in the messy complexity of women's lives. I want to help them make the most of it." She believes that Utopia can never be achieved in consultant-led units, where fear is the main driver and there is little appreciation of the role of hormones in childbirth. While Jilly originally thought that home birth was the preferred option, she came to realise that it didn't appeal to all women and midwives. Furthermore free-standing birth centres have other benefits - "You can help midwives to lose their fear and gain confidence in themselves and in birth because of the environment, support and opportunity to learn from others." Women can then have a good birth experience with a midwife who is kind, gentle, skilled and good at listening. Because they are part of a team, the midwives - including those with children - can make their life work.
In Jilly's Utopia, GPs have nothing to do with maternity care. The default position is that women book for a free-standing birth centre or home birth, provided they fit the criteria, and 70% have out-of-hospital births. This reduces the haemorrhage of midwives from the profession because they can choose a working situation which suits them. And, because the environment around birth is not based on fear, decisions are more rational and birth safer.
But this Utopia does even more. In her work Jilly is confronted by "dreadful problems with parenting, as a lot of women have not themselves been mothered adequately." She believes "The potential for changing the experience of motherhood and parenting is vast. Women can come out of giving birth feeling they can do it and are good at it. Their hormones make them fall in love with their baby and their baby fall in love with them. Breastfeeding rates increase. Being well supported in the early days can have a miraculous effect on mothering."
Patricia Purton, retiring Director of the Royal College of Midwives in Scotland, would like such arguments for free-standing birth centres to get more strategic commitment from the NHS. While in Scotland there has been terrific support from the centre, in Utopia this is matched by priority at NHS board level for a normality service rather than a bias to acuteness and disorder. Instead of the scrutiny always falling on free-standing birth centres, Utopia for her sees the focus on their contribution to the overall service. "I believe that, if we can hang in there with free-standing birth centres and keep the midwives buoyant and secure, we will get things into balance." Given changes in demographics, finding this balance may include the rationalisation of smaller free-standing birth centres.
According to Patricia, the Royal College of Midwives also has to strike a balance. On the one hand, it has the benefit of its committed membership. On the other, these same members may be so committed to their particular service that they feel devalued if it is threatened. "We see midwives who are absolutely exhausted with trying to make it work. They have dwindling numbers of women and managers who don't understand. They may have spent their entire lives trying to make these services work. They may have previously made a huge transition from triple duties to single duties, and they are shattered." In Patricia's Utopia, the NHS is better at change management and puts in the time, energy and affirmations which might make it easier. Decisions are taken more quickly and involve the wider community.
One shattered midwife - we'll call her Mary - works in a small free-standing birth centre in England that is to go in a rationalisation. In her Utopia there is more recognition of the great value of a local, readily accessible service. It is promoted vigorously so it has maximum use. Midwives feel able to stand up for their service, as those at Stroud do, rather than being fearful of the consequences if they speak out.
In Utopia, Mary isn't working so many extra hours, has more energy and is more cheerful. She makes definite appointments with women and knows she will be able to keep them. Staff have more regular meetings so that little niggles don't get out of proportion and her work environment is improved.
So how does Mary cope in spite of all the pressures? "I know that under this I still really love being a midwife -being with a woman who has had care, and knows the outcome is the best it could have been, the baby has had skin to skin contact and is breastfeeding well." Mary also thinks there are little things she could do to make a big difference to how everyone copes with the change - such as making more effort to say good things to her colleagues and thinking before saying bad things. She also recognises "I need to look after myself more", and wonders if it is worth being more open with management about how stressed and pressured staff are.
Adela Stockton realised that, to look after herself and be true to her values, she would have to leave NHS midwifery. She now indulges her passion for supporting normal birth as a doula and homeopath, and has published a guide to emotional wellbeing through pregnancy and birth (
However challenging the current climate is, it seems we don't have to look too far to catch tantalising glimpses of our free-standing birth centre Utopia. It is indeed a force to be reckoned with. Perhaps we do need a miracle, but all change starts with a small difference that makes a bigger difference. So just take a moment...and suppose that miracle lies in you...
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