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National policy on care provision in the United
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Changing Childbirth (DH 1993) symbolised the beginning of change in English maternity care policy. It recognised that services needed to change and put women at the centre of care. This was to enable for the first time, women to take part in decision-making about their own care. In the UK the government’s agenda and current maternity policy, promotes the importance of services that are both flexible and individualised and fit with the needs of women (DH 2004). It values and guar-antees their views, and what they value will be acknowledged and respected (National Institute for Health and Care Excellence (NICE) 2008). The Maternity Matters policy document (DH 2007) recommends that women should be given choice within maternity services; with guarantees of being able to make informed choices throughout pregnancy, birth and the postnatal period.
Choice of birth place for women has become a central focus for service providers. A major research project has been undertaken into the place of birth in England; the results support a policy of offering healthy women with low-risk pregnancies a choice of birth setting. Women who plan to give birth in a midwifery unit and multiparous women planning birth at home, experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes (Brocklehurst et al. 2011). Nulliparous women with planned home births also have fewer interventions, but do have some poorer perinatal outcomes.
Women are encouraged to access maternity services as early as possible; the Maternity Matters report (DH 2007) suggests that self-referral into a local midwifery service would speed up and enable that early access. Direct access pathways such as these could benefit women on multiple levels; however the anticipated beneficial outcomes of this have not yet been researched.
How women and partners view their care provision is highly influential; direct access to mid-wives can help to normalise the concept of childbirth. Previously, women went to their General Practitioners (GPs) to begin their childbirth journeys, which implied that a doctor was required in all pregnancies. This may instil a belief that things can go wrong and that medical assistance is required in all cases, thus perpetuating a perception that childbirth is risky and that pregnant women need rescuing by medicine (Wagner 1994). Midwives must protect the midwifery rela-tionship and the underpinning concept of birth being normal, to prevent future erosion of that tentative midwifery lead in maternity care. Returning to a system where women are referred to a named consultant in all instances would be a threat to this fundamental aspect of care.
The Vision and Strategy from the Department of Health (DH), Public Health England, NHS England and the Royal College of Midwives (RCM) is clear in its support of midwifery led services for improved health and wellbeing, with women being screened and risk-assessed at the initial booking interview and throughout childbearing to determine the need for referral to other appropriate health professionals (DH, Public Health England 2013).
Read this information in more detail:
[Available online] https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/208815/midwifery_strategy_visual_A.pdf Highlights:
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Midwives will be the first point of contact within accessible maternity services for women.•
Midwives will deliver innovative, evidence based, cost effective, quality care across integrated health and social care settings.•
Midwives will offer support as the lead professional for maternity care to all healthy women with uncomplicated pregnancies.Further reading activity
123 For women with complex pregnancies, it is suggested that midwives will still be the key coordinators of care within the interprofessional team, while working closely with obstetricians, GPs, health visitors, maternity support workers, breastfeeding support workers and social workers to enable women and families to access the care and support they require.
Activity 6.2
Read this information in more detail:
[Available online] www.gov.uk/government/publications/midwifery-services-for-improved -health-and-wellbeing Highlights
From a woman’s perspective identify what you think a woman would want to know when she goes for her first booking appointment with the midwife.
Individualised care of a woman
It is understood that women accessing maternity services in England have choices and are required to make decisions within the antenatal period, about who cares for them and where to give birth. These decisions are influenced by their circumstances, level of ill health and poten-tial risk of adverse outcomes.
Women and their partners are able to choose between Midwifery-Led-Care (MLC) and Consultant-Led-Care (CLC) (DH 2007). MLC is when all care is provided solely by midwives, who are fully accountable for all care provided; women remain within parameters of normality, without any cause to consult with an obstetrician (NMC 2012). CLC is when care is overseen by an obstetrician from the very beginning of a woman’s pregnancy, or at any point where a devia-tion from the normal occurs. Obstetricians are accountable for the advice and decision-making in relation to birth complexities; whilst the wellbeing of the mother and fetus is still monitored by midwives throughout the pregnancy. Midwives continue to practise within their professional accountability for their individual practice, whilst referring back to consultant obstetricians for advice on any developing ill health and decision-making. If a GP continues to provide some of the antenatal surveillance, this would be termed ‘shared care’, with the care being shared between the primary healthcare providers (GPs) and secondary care hospital provision, often called the acute services (DH 2007). The team approach goes further to include other health professionals and practitioners such as managers, sonographers, phlebotomists, Children’s Centre organisations and smoking cessation teams. Individual specialist midwives also exist in some areas, focusing on specific needs such as, for example, healthy lifestyle, infant feeding, substance misuse, mental health and supporting specialist medical disorders. All serve to provide a service that can provide seamless care for all women and their families.
These different models of care currently reflect different philosophies of care in pregnancy.
The biomedical model, which has historically decreed the traditional model of pregnancy, is one that holds a medicalised approach to pregnancy, where technology holds supremacy, promotes observation of physical characteristics of pregnancy and measurement of wellbeing (Jomeen 2010). This medical model observes the pregnant body as a mechanical device where wellbeing can only be ensured by a process of monitoring and examination to avoid any fetal or maternal problems (Davis-Floyd 2001). This is in contrast to the holistic model of midwifery
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where care is women-centred and reflects the concept of being ‘with women’; where there is a partnership between a woman and her midwife (Hunter et al. 2008). Care naturally focuses on not only the physical aspects of wellbeing, but her emotional and social wellbeing, recognising the individuality and uniqueness of each woman. How NHS Trusts operationalise the links between the professions still needs to be determined.
The determinants for the model of a woman’s care are her parameters of ‘normality’ and therefore should be the case for the majority of women. A systematic review undertaken by Sandall et al. (2013) compared midwife-led continuity models and determined that women should be offered and encouraged to ask for this model of care. Some women within the midwife-led system require medical review; after review they may then be determined as sat-isfactory and go back to MLC. Some women are complex and so do not meet the strict MLC criteria; however obstetricians still require midwives to monitor care in the community, being ready to refer to them when a deviation is noted. Improvements could be made in the opera-tional processes of this system to support midwives in monitoring care of complexity. This demonstrates how the midwife’s role straddles normality and complexity, supporting the medical role for caring for ill-health with an opportunity to appropriately normalise some aspects and be woman-focused.
A review into the socioeconomic value of the midwife by Devane et al. (2010, p. 16) illustrated that when women were randomised into MLC, they were less likely than women randomised to other models of care, to have:
. . . amniotomy, augmentation/artificial oxytocin during labour, regional analgesia (epidural/
spinal), opiate analgesia, instrumental vaginal birth and an episiotomy . . .
Furthermore, women receiving MLC had more antenatal visits; were less likely to have anal-gesia as well as anaesthesia during labour; were more likely to be attended by a midwife they knew and had higher perceptions of control in labour and birth (Devane et al. 2010). This illus-trates how MLC can be cost effective through a philosophy that works to reduce the interven-tion culture, promotes relainterven-tionships and ensures continuity of care and carer.
This chapter continues by examining clinical care provision from a woman-centred perspec-tive; highlighting her needs through the woman’s journey and demonstrating how she might present. Further discussion and depth of thought about clinical issues can be found in publica-tions elsewhere. Evidence based practice ensures some standardisation to the best way of conducting care and guides professionals in their advice and decision-making. Consulting national and local guidelines as well as up to date research, on an ongoing basis will ensure sound knowledge on which to determine best practice. Keeping abreast of changes made to policies such as screening and care recommendations is vital to maintain a professional status.
This section sets the scene and highlights an ethos of care provision acknowledging that guide-lines are guidance and might not always be pertinent or agreeable to individual women. Mid-wifery craftsmanship is celebrated and put forward as a platform of normality from which individual women may differ.