Special Report: Is NHS business model to blame for midwifery crisis?
There is a fundamental contradiction between the health business model and midwifery values which promote care, continuity and trust - mums are given inadequate support and midwives suffer.
Midwfery is beset with problems at present and, as we seek to deal with each crisis, there is no time to look at the source of the problems.
It seems to me that there is a clash of values. Midwifery is rooted in relationships and a tradition of generosity, which research and long experience has shown to have excellent clinical and social outcomes. Most women can birth well if they are surrounded by people who value them, listen to them and nurture their self-confidence. The NHS is now run on a commercial model: the imperative being to get more for less input.
In industrial terms this is called efficiency: maximum productivity for minimum cost. In any other context it is seen as meanness.
Maternity services have been centralised into large hospitals. Applying principles seen as ‘sound’ in business terms, units have been closed which would have been seen as large 10 years ago. Centralisation produces economies of scale or more output for less input and in maternity care the main input is staffing. So midwives can be moved wherever they are needed. Staff permanently feel they are working flat out. This is reputed to be a very efficient way to run a factory based on a production line; but we are dealing with people.
Women feel they are on a conveyor belt. Midwives feel they are treated as a cog in a machine. The bigger the unit and the more staff are moved about the more relationships are fragmented.
Trust doesn’t develop and fear flourishes.
If a large organisation is to be run for maximum efficiency management control is required to monitor and ensure that efficiency. Midwives cannot be trusted to do midwifery, as this might lead to care being given beyond the ‘efficient’ norm. Thus standardisation is required, a series of tasks which can be monitored rather than a continuing relationship. If the required tasks are performed then women can logically be neglected between tasks and the midwife’s attention given to other women, even when they feel most vulnerable in labour.
Defining labour care as a series of standardised tasks makes it possible to create such heavy workloads that midwives can’t give individualised care. This is justified as preventing really bad care but also prevents really good care from being the norm; though many midwives strive to give good care, often at great cost to themselves.
Considerable bureaucracy is needed to monitor efficiency, so costs rise, which leads to further cuts to keep costs under control. Such cuts are seldom to the bureaucracy, which is seen as essential.
These pressures damage midwives. They leave because they cannot give the care they wish which leads to less staff, further pressure on those who remain and leads others to leave. As job vacancies are produced, the opportunity is often taken to reduce jobs and save resources. So is the problem a shortage of midwives or a shortage of midwifery posts?
The pressures of cuts mean parts of the service which can be identified become separate products. Thus NHS antenatal classes have been cut and women have to pay for them. ‘Special’ antenatal classes, such as hypnobirthing, often have to be paid for. NHS midwives cannot give continuing support to childbearing women, so they employ doulas. Breastfeeding support is available, at a price. This discriminates against those who cannot afford the extras.
Commercial pressures and the value our society places upon technology have created a real fear of not using all the technology available. Yet this can have damaging results for individuals and increase costs, as with increased caesarean rates. That money has to be saved elsewhere.
Insurance is probably the ultimate example of a product so well marketed that it appears unethical not to have it. Yet its main beneficiaries are the insurance companies. Once insurance is required for practitioners, the insurance companies can control clinical practice.
This system is unjust. If a child needs special care, that should be available because the child needs it, not if it can be funded because someone can be blamed. Tight control and penny pinching may work in business, though some experts dispute this, but a different ethic is required for public services. Addressing only short term, easily measurable outcomes is not a commitment to the next generation. A society based on commercial values neglects care at its peril. Nowhere is this clearer than at the beginning of life. Birth is something that most women can do supremely well if they are trusted and supported. A good start has positive outcomes throughout life.
A further irony is that, for most women, midwifery care may well be cheaper than heavily managed hospital care. Yet so much that midwives are required to do flies in the face of this. Midwives are criticised because they lack resilience. It is more useful to see our current dilemmas as manifestations of a fundamental clash of values and the logic which follows from that, rather than blaming the individuals who suffer theses contradictions.
The logic of business and the logic of caring represent a fundamental contradiction that lies at the very heart of our maternity services.
* A longer version of this article appears in the spring issue of Midwifery Matters – Midwifery Matters
Midwives ‘trying to do the impossible
Midwifery is grounded in relationships and works best where midwives have trusting relationships with clients and colleagues. To achieve this we need a degree of professional autonomy and continuity in our relationships with clients and colleagues. Present values of fragmentation and management control thwart these relationships. Midwives’ professional commitments to their clients simply leads to their exploitation in the context of commercial values. This is shown where so many work extra unpaid hours rather than abandon vulnerable women. Trapped in this contradiction between their values and those of their employers, NHS midwives are torn apart. They are trying to do the impossible. Their leaders speak the rhetoric of midwifery while midwives work within the reality of a service aiming for maximum efficiency. They see clients’ needs but their workload means they cannot respond.