Positive Health Online

The hugely popular television programme Call the Midwife captured 9.8 million viewers on its first episode (Radio Times 7th February 2012). It is set in the 1950s East End of London, and depicts the true story of a young community midwife, based within a religious community of nursing sisters. One Born Every Minute also enjoys widespread interest and offers a contemporary view of maternity care. This is a ‘fly on the wall’ documentary following midwives and labouring mothers in a major maternity unit. Another recent programme The Midwives focuses on the pressures of being a newly qualified midwife in a large maternity unit in Manchester.

Why are these programmes so popular? Why has birth - and midwifery - suddenly become such a talked-about subject? Is it a sense of nostalgia which leads us to wallow in the past ‘glories’ of the 1950s, however hard life might have been? Is it a voyeuristic need to witness women giving birth, surrounded by 21st century technology? Is it the life stories which entrance us, or the ‘oooh-aaaah’ factor of seeing newly-born babies on screen? Have people become inured to TV soaps with their doom and gloom storylines and want something more realistic, more positive? Or is it simply that there is nothing better to watch?

Call the Midwife is notable for its realistic portrayal of life in the East End, and of midwives’ work when the NHS was in its infancy. There are some extremely accurate representations of pregnancy and birth, particularly the undiagnosed breech delivery managed by “Chummy” (played by Miranda Hart, who must have been extremely well briefed). There are a few minor errors - for example, measurement of the height of the abdominal fundus was not introduced until the early 1980s. Conversely, One Born Every Minute and The Midwives reflect modern maternity care in large regional centres. Unfortunately, many of the situations portrayed in these latter programmes focus on what makes ‘good television’. Seeing a woman in normal labour, coping well with contractions, whose midwife quietly monitors her progress, and whose partner sits reading the paper, is not exciting viewing. It is far more watchable if there are emergencies, women screaming in apparent agony or fathers-to-be behaving strangely.

Post-war clinical practice, particularly in the community, often combined maternity work with aspects of nursing, such as caring for the elderly. Babies were generally born at home until the Peel Report (Ministry of Health 1970) recommended hospital as the safest place to give birth, and the trend for the majority of babies to be born in hospital took hold. Midwives and nurses worked within a hierarchical framework in which the doctor was the most senior professional. The belief that “birth is only normal in retrospect” persisted until a backlash from mothers and midwives led to publication of the Maternity Care in Action (MSAC 1982, 1984) and Changing Childbirth reports (DoH 1993). These reports advocated that care should reflect childbirth as a normal bio-psycho-social life event and that women should be offered “choice, control and continuity”. Despite many initiatives attempting to instigate these principles, there was a continued emphasis in the late 1990s and early 2000s on avoiding risk, particularly given the increasingly litigious nature of maternity care.

However, more recently, considerable concern has been expressed about the state of the UK maternity services, by mothers, midwives, doctors, service providers and government. Maternity care needs to change to reflect consumer demands, and there needs to be a concerted effort to facilitate a return to the normality of childbirth. The Maternity Matters report (DoH 2007) aimed to ensure that all women have the opportunity to choose where to give birth, and the Birthplace Cohort Study (NPEU 2012) favourably compared risk factors for women giving birth in midwife-led units or at home with those for birth in consultant-led obstetric units. There is also an urgent need to reduce obstetric interventions in order to minimize long-term morbidity and to rationalize expenditure at a time of limited resources. The High Impact Actions for Nursing and Midwifery (NHS Institute 2009) identified Promoting Normal Birth as a key issue for change; the Maternity Improvement programmes (NHS Institute 2011) acknowledge that interventions carry a greater risk of complications than non-interventionist care. Caesareans now account for over 30% of births in some areas (Birth Choice UK 2011), despite increased morbidity for mothers and few apparent benefits for babies, and cost almost double that of a normal birth (NHS Institute 2009). 

Many viewers have been inspired by these programmes to consider midwifery as a career.  This is very timely, since there is currently a shortage of almost 5000 midwives across the country (RCM 2011), compounded by the ever-increasing birth rate, with 723,913 babies born in 2011 (Office for National Statistics 2012), and the fact that the midwifery profession has an ageing workforce approaching retirement. However, despite the increase in the number of applications for midwifery training from 31,000 in 2010 to 37,000 in 2011 (UCAS 2011), the majority of people still do not fully understand the role of the midwife.

The International Confederation of Midwives (ICM) stresses that birth is a normal physiological process, and midwifery practice is identified as being both

“a science and an art which is holistic in nature and grounded in an understanding of the social, emotional, cultural, spiritual, psychological and physical experiences of women, whilst being based on the best available evidence”  (ICM 2011).

The ICM believes that midwives should be the primary providers of maternity services, empowering women to take responsibility for their own and their families’ health through individualized, continuous care which facilitates women’s informed decision-making. The ICM and World Health Organisation define a “midwife” as

“a responsible, accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on her / his own responsibility and to provide care for the newborn and infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should include antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care”.  (ICM 2011)

The title of “midwife” is a legally protected one. No-one, other than a midwife or doctor, or one in training under supervision, is legally permitted to practise midwifery or to be the sole provider of care for a woman during pregnancy, labour or the postnatal period. In the 1950s, it was still necessary to train as a nurse first and then to undertake a post-registration course to become a midwife. Since the 1980s midwifery has been classified as a completely separate profession and a nursing qualification is not a pre-requisite. In truth, it can be difficult for nurses entering midwifery to relinquish their traditional view of ‘illness’ and to focus more on the ‘wellness’ model inherent in the care of women undergoing a normal life event. Midwifery is not nursing, although it includes some aspects of nursing care, for example, during labour or after a Caesarean. Whilst Call the Midwife is an accurate reflection of midwifery at that time, it does nothing to convince the public that modern midwifery is a discrete profession and that midwives are autonomous practitioners. Furthermore, One Born Every Minute and The Midwives reinforce the popular notion that having a baby is a high-risk medical ‘procedure’ which requires technology to ensure that labour progresses ‘normally’. Although midwives have enjoyed watching Call the Midwife, the other programmes have been heavily criticised, in midwifery journals and on the BBC’s blog and other online and face-to-face forums.

It is heartening to see the increase in the number of applications for midwifery, but applicants have about a 1:60 chance of obtaining a university place for midwifery. One of the commonest reasons for failure to gain a place is that applicants are unable to verbalize the role and responsibilities of the midwife; for example, stating that s/he wants to “look after babies” results in an automatic rejection. Sadly, however well these programmes sell, the media’s continued adherence to midwifery as nursing, and to childbirth as a medical condition, maintain the public’s misconception of midwifery and what a midwife actually does.

References

1. Birth Choice UK 2011 Hospitals with highest and lowest Caesarean section rates Accessed online at

www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/Tables/CS_HLtables.htm  July 2012.

2. Department of Health 2007 Maternity matters: choice, access and continuity of care in a safe service  Accessed online at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312  July 2012.

3. Department of Health  Changing  childbirth: report of the expert maternity group (Cumberlege report) HMSO London. 1993.

4. ICM 2011. Revised international definition of the midwife, adopted at the ICM Council meeting, 15th June 2011. Viewed online at www.internationalmidwives.org/Portals/5/2011/Definition%20of%20the%20Midwife%20-%202011.pdf  June 2012.

5. Maternity Services Advisory Committee 1982 Maternity Care in Action report: Part 1, Antenatal Care, A guide to good practice and a plan for action HMSO London.

6. Ministry of Health  Domiciliary Midwifery and Maternity Bed Needs: the Report of the Standing Maternity and Midwifery Advisory Committee (Sub-committee Chairman J. Peel), HMSO, London. 1970.

7. NHS Institute for Innovation and Improvement. 2011. Excellence in Maternity Services: maternity improvement programmes 2011-2012 viewed online at www.institute.nhs.uk/quality_and_value/introduction/improving_maternity_care.html  June 2012

8. NHS Institute for Innovation and Improvement 2009 High Impact Actions for Nursing and Midwifery Viewed online at www.institute.nhs.uk/building_capability/general/aims.html    June 2012.

9. National Perinatal Epidemiology Unit. 2012. The Birthplace Cohort Study Viewed online at www.npeu.ox.ac.uk/birthplace/results   July 2012.

10. Office for National Statistics 2011 viewed online at

www.ons.gov.uk/ons/rel/vsob1/death-reg-sum-tables/2011--provisional-/sb-births-and-deaths-first-release--2011.html

11. RCM 2011 State of Maternity Services report Viewed online on 30.11.11 at www.rcm.org.uk/college/policy-practice/government-policy/state-of-maternity-services 

Further Information

Expectancy offers a Preparation for Midwifery Studies course for aspiring midwives to help them prepare for interview and as an introduction to midwifery education and practice. See www.expectancy.co.uk