What happens when midwives take the lead in providing maternity care? What kind of maternity services do women actually want?
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A Leading Role for Midwives? - published today by the independent Policy Studies Institute - is an evaluation of three midwifery group practices set up to implement the recommendations of the Government-sponsored report Changing Childbirth. The PSI evaluation finds that a proper assessment of all the implications of ‘rolling out' such schemes is essential and warns that caution should be exercised before there is a general move towards this model of care.
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The report by Isobel Allen, Shirley Bourke Dowling and Sandra Williams offers many insights into the ingredients of good and caring midwifery practice. However, in spite of undoubted benefits to women and midwives, there were considerable cost and resource implications in organising maternity services in this way, as well as dangers of overload and burn-out for midwives and the creation of tensions between midwives and other professionals which could be detrimental to the delivery of good maternity care.
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The three midwifery group practices were set up as pilot projects by the former South East Thames Regional Health Authority in 1994 with the aim of demonstrating the extent to which such practices could offer women more control over their maternity care without reducing safety; provide continuity of care and carer; offer choice of treatment, lead professional and place of delivery; and reduce duplication of services by clarifying the roles and responsibilities of all practitioners and professionals.
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The main findings of the PSI evaluation show:
- women were mainly very satisfied with the care they received from the midwifery group practices. They particularly liked the manner in which they were treated - as ‘individuals', as adults and as friends by midwives who were ‘on their side'. Those who had had babies before often compared their care favourably with their previous experience. However, the report urges caution in extrapolating from high levels of satisfaction with the practice of committed midwives who had chosen to come together to provide a particular model of care, and notes that the model in itself might not be the main ingredient of success.
- the midwives provided considerable continuity of care and carer and there were many reports of close and supportive relationships between midwives and women, illustrated by one woman who said: ‘I think every woman falls in love with her midwife...' However, many women did not regard continuity of care and carer as important as quality of care. Antenatal visits were often lengthy, frequently took place in the woman's home, and were often arranged in the evening or at weekends. There was evidence that considerable dependency could be created during pregnancy and in the immediate postnatal period which could not be sustained.
- the midwives themselves expressed great job satisfaction and improvement in their self-esteem. However, their workload was very high and unlikely to be sustainable in the long term. The midwives were characterised by dedication, commitment and pioneer spirit, but they acknowledged that there were considerable personal costs involved which impinged on their domestic and family lives. The report concludes that it is debatable whether their willingness to make such sacrifices was either feasible in their own interests or offered a model of working that could or should be replicated by others.
- the question of increased choice for women in their maternity care raised many issues of interpretation. Women were often unaware that they were being offered options, and the report explores important factors in the concept of choice, including how and by whom choices are presented, the nature and content of the information available to women, the extent to which an ‘informed choice' is possible without full clinical knowledge, and the extent to which professionals from all disciplines may influence women's choice. The report concludes: ‘There is often a fine line between seeking to empower users of services while at the same time not jeopardising their safety or health.'
- the report found a pressing need for the development of clear guidelines and protocols outlining the respective roles and responsibilities of all medical, midwifery and nursing staff in the provision of maternity services. Many of the GPs in whose surgeries the midwifery group practices were based felt they had lost clinical and personal contact with their patients during their pregnancies and were anxious about maintaining their role as family practitioners. Consultant obstetricians and GPs expressed concern about professional responsibility and accountability for women's maternity care. The report concludes: ‘It should be absolutely clear where the ultimate responsibility for the care and safety of all women and babies lie - in all situations and in all locations.'
- women often found themselves unclear of their relationship with their GPs having opted for midwifery-led maternity care, and few were aware that they could choose to see a consultant obstetrician in their pregnancy. There was evidence of tensions between hospital midwives and the midwifery group practices which affected the care given to women. The report highlighted problems of perceived disputes between different professionals, illustrated by one woman's comment: ‘I get the feeling that there is competition for being in charge and in control.'
- the costs of this model of care were difficult to identify in the absence of robust financial information but were accepted to be higher than more traditional models. It was not possible to provide a simple cost-benefit formula but the report offers guidance to purchasers and providers on the level and type of resources required to operate and sustain midwifery-led care.
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The report concludes that the midwifery group practices demonstrated many significant benefits to women and midwives alike in moving the delivery of maternity services away from the domination of the ‘medical model' of maternity care. However, it urges the importance of maintaining a good partnership between midwives and all other professionals in order to provide good holistic health care to women and their families. The report calls for an assessment of the lessons to be learnt from the achievements of the midwifery group practices in providing high quality maternity care and concludes that much of the good practice illustrated could be incorporated into existing services without necessarily increasing resources.
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Professor Terry Stacey, Director of Research and Development at NHS Executive: South Thames said: ‘The NHS firmly believes that the content and delivery of the service to consumers should be based as far as possible on knowledge obtained from research of high quality. This study is a rigorous research evaluation of three pilot sites from an exciting development in a new way of providing care during pregnancy. It provides an excellent example of how useful such evaluation can be. It confirms the successes of the pilot projects in many of their aims but also identifies a number of issues where some further ideas now need to be generated.
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‘The knowledge obtained from these pilot projects in South Thames will now be most helpful to other locations throughout the country where similar service development is being planned. The researchers and all those who took part in the pilot development projects are to be warmly congratulated. Their professional colleagues throughout the NHS and those for whom they provide care will now be able to benefit further from their success and experience.'
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