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Month: August 2017

Private Midwives in the NHS

Private Midwives in the NHS

The Sunday Times published an article recently about private midwives attending births at NHS hospitals: “Mothers Take Own Midwives Into NHS Hospitals”. This is definitely becoming more common, especially now that NHS trusts are inviting it to happen by contracting with companies like Neighbourhood Midwives and Private Midwives:

Ten NHS trusts have signed partnership deals allowing one private company to book rooms in their hospitals and centres for women to give birth helped by a private midwife. The mother then pays the company.

I can understand why this is happening, but I have mixed feelings about it. On the one hand, many trusts are under severe financial pressure, with midwifery shortages and hiring freezes, and literally not enough staff to care for the number of pregnant women in their trust. Creating an option for some of that responsibility of care to be taken up by private midwives helps to ease the burden on their over-stretched service. Renting out rooms and equipment to private midwifery companies also generates more money for cash-strapped trusts, so you can see the appeal. We also know, by overwhelming evidence, that continuity of carer produces better outcomes across the board, from shorter labours to fewer cesareans to better neonatal outcomes, as well as increased satisfaction reported by both women and midwives alike. At the moment, though, continuity of carer is hard to come by in the NHS, but is something that private midwives are much better at providing, so it makes a lot of sense that women who are able to are choosing private midwives because this is the type of care they desire.

In 2016, in response to the Kirkup Report which investigated the tragic failures at the Morecambe Bay NHS Trust, NHS England announced a new scheme to give women more options in choosing their maternity care provider, ostensibly as a way to address the shortfalls which led to the Morecambe Bay tragedies, as well as increasing women’s ability to have a named midwife or case-loading midwife (i.e. to have continuity of care and continuity of carer). This scheme is currently being tested in several NHS trusts, called “Maternity Choice and Personalisation Pioneers”, and basically amounts to women being given a £3000 “birth budget” and then allowing them to choose where and how to spend their money–either on NHS services or private services which contract with the NHS, exactly as described in the Times article above. Which all sounds very good on the surface, but I’m worried that this is just a way to privatise the NHS through the back door. As soon as you begin to allocate personal budgets to women, you’re pulling funds away from the general NHS pot, which is already operating on a shoestring and severely underfunded. If more money is diverted to private midwives and organisations providing private care, there will be less and less available for NHS, which has expenses (such as providing and maintaining actual physical hospitals) not accrued by private companies, who would be using the NHS facilities.  Also, it runs the risk of pulling low risk women (and their funding) out of the NHS pot, which leaves less money available for women with more complicated pregnancies, who would have to rely on NHS services if they weren’t a good candidate for low-risk private midwifery care.  There is a lot of thoughtful commentary out there on why a £3000 birth budget might not be such a good idea. For one thing, in some areas (such as London), £3000 wouldn’t fully cover the costs of hiring a private midwife, and my understanding is that the NHS has put provisions in place which would prevent women from taking the NHS budget and then supplementing it with their own money in order to purchase more expensive care. Also, women using these birth budgets can only use them on private midwives who have been contracted by the NHS, which means that they couldn’t use the budget to help pay for the services of a self-employed independent midwife working outside of the NHS. And in fact, the fate of the self-employed independent midwife (i.e. a private midwife who works outside of the NHS, and works for herself rather than being employed by a private company, such as Neighbourhood Midwives) is very uncertain at the moment anyway, thanks to an incredibly obtuse decision by the NMC (but that’s a conversation for a different day, certainly).

In my mind (and on my wish-list) is the option where the NHS is fully funded, the shortage of 5,000 midwives in the NHS is filled, and women are given true informed choice about the type of care and services they would like to have, including case-loading and one-to-one midwifery care, i.e. continuity of care and carer.  This is something the NHS has struggled to provide, and something that women are clamoring for.  When there is a shortage of midwives and a budget crisis, I suspect there isn’t enough staff to truly provide that kind of care in numbers that aren’t overwhelming to the individual midwife. I’ve already spoken to many NHS midwives in my very brief tenure so far who have discussed how they used to case-load, but over time found it to be too exhausting, so they switched to a different modality. Or about how home birth services that provided case-loading care gradually disappeared when the core midwives who were part of the team became burned out or fed up or too exhausted to continue, and no new midwives wanted to take on the role. Imagine how different a service like that would look if it was staffed in such a way that a midwife could personally attend…I dunno…20-35 births per year, tops, and truly give each woman the fullness of her time and energy and attention through their entire antenatal/ labour/ postnatal journey, while still feeling like she had down-time and time for self-care and time to see her family. Imagine what maternity care in a world like that would look like!

But I know well enough that this is wishful thinking. I’m not sure what the right solution is here. Women want (and absolutely deserve) individualised, unhurried care from the same midwife throughout their pregnancy, birth and postnatal period–and rightly so! If this can’t be provided by the NHS, I understand why women would try to seek out that type of care privately, and also why the beleaguered NHS might think that contracting private midwives to provide it is a good idea. But I also know that there are thousands and thousands of excellent NHS midwives who also long to be able to provide that type of care in the first place, and if they could work in a system that allowed for case-loading and continuity of carer in a humane model that didn’t require each individual midwife to completely drain herself dry, there would be no need to contract private midwives in the first place.  Where do we go from here? It will be very interesting to see how these birth budgets are working out in the pioneer trusts, and whether they can actually create the kind of change their creators are hoping for.

 

 

Holding Space

Holding Space

Recently, a good friend of mine, Elizabeth Purvis, who works in a magical, nurturing, life-coaching space (she would term it manifesting, I’m pretty sure) posed a very simple, but pithy, question: “What does it mean to hold space?”  And just this very evening, I was tagged in a post giving compliments and shout-outs to beloved midwives, and the idea of holding space bubbled to the surface again in my response. I’m taking it as a sign that the Universe is telling me I really need to write a thing or two about this idea of holding space, so here goes!

What DOES it mean to hold space for someone?

In one of the best articles I’ve read about this to date, the author, Heather Plett, defines it in this way:

[Holding space] means that we are willing to walk alongside another person in whatever journey they’re on without judging them, making them feel inadequate, trying to fix them, or trying to impact the outcome. When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.

Heather then goes on to explain eight things which a person does when they’re “holding space” for someone, including giving people permission to trust their own intuition and wisdom, only giving as much information as the person can handle, ensuring that they keep their power through the process (or in other words, not taking their power away from them), keeping our own ego out of it, making them feel safe enough to fail, giving guidance and help with humility and thoughtfulness, creating a container for complex emotions, fear, trauma etc., and allowing people to make different decisions and have different experiences than we would choose for ourselves.

Which means, to my way of thinking, that midwives are the original space holders! (And, for the record, although I am writing this post with midwives in mind, holding space at a birth is in no way the sole purview of midwives! Doulas, nurses, doctors, partners and family members can also be exemplary space holders! The pictures for this post are taken from my first labour, and the woman seen in each of these photos–watching, murmuring, encouraging, pouring water over me, massaging hour after endless hour–was my good friend and beloved doula, Kristen, who held space for me like no one’s business through fifty. six. hours. of labour. I would have been lost without her, and still to this day cannot thank her enough for what she did for me.)

Holding space is what midwives do, day in and day out. When I read a woman’s birth plan, I’m always very conscious of the fact that I’m holding a woman’s hopes and dreams in my hand, which is no small thing to be entrusted with. We all know that birth plans don’t always go according to plan, but as a midwife you’re a facilitator, keeping the woman’s desires and expectations foremost in your mind while helping her to navigate the journey that she’s on. You’re the guide, the translator, the sherpa. You can read the environment and terrain, you have a map, and as you’re traveling with her, your job can include any of the following: reassurance, support, course correction, managing expectations, cheerleading, nonverbal cues, preventing interruptions, creating silence, actively listening, validating, explaining, teaching and demonstrating.  If the birth veers away from the hopes and dreams and expectations, the manner in which you support a woman through the transition has a resounding, life-long impact on her. Research has demonstrated this again and again: if care is delivered in a compassionate and respectful way, if a woman feels like she was listened to and was part of the decision making, if true informed consent is given, then the woman can come away from a birth still feeling empowered and whole even if none of it went according to “plan”. If respect is lacking, if imbalanced power-dynamics are at play, if decisions are made without input, if actions occur without explanation afterwards (not to mention thorough, supportive debriefing), then a woman often comes away from her birth feeling disappointed (at best) or traumatised (at worst). And we know these feelings carry into the immediate postpartum period, which not only increases the risk of postnatal depression, but also shapes the woman’s identity as a mother, and impacts her agency and her belief in herself, which in turn has a knock-on effect on her children as well. Again, no small thing to be entrusted with! Doing this well means choosing your words very carefully. Planting seeds without being proscriptive. Breaking news at just the right moment, in just the right way, without overwhelming the couple. It’s constantly walking a tight-rope, a balancing act of myriad pushes and pulls–energy levels, personalities, non-reassuring fetal heart tracings, medical realities, hospital policies, staffing levels. It’s knowing that every room in the birthing center is full, so best not to mention the birthing tub that she can’t have. When you start to think about the complexities, it all begins to feel quite daunting, and yet the best midwives I know feel like their work is a calling rather than a job, and love their work so fiercely that (almost) they would do the work for free (and to be honest, I think this is something the NHS is well aware of, and takes advantage of to the fullest, which is not a good thing by any means).

And you’re holding space not just for the woman, but for the partner as well, who is on their own journey from partner to parent, and often needs encouragement and guidance on how to better hold space for the woman too.  It’s hard to watch someone you love going through pain and doing something so difficult, and this can sometimes make partners feel helpless, scared and even guilty.  I’m sure many other birth workers can speak about births they’ve been at where the partner wasn’t holding space in a helpful way, and how a simple word–maybe try rubbing her like this…I don’t think she can answer those questions right now…why don’t you sit here and then she can lean back against you in between contractions…would she like a sip of water [handing water bottle to partner, so that they can then offer it to the woman]…speaking in whispers if peace and quiet is called for…demonstrating through your own example how best to support her–can make a big difference in a partner’s ability to more optimally support their loved one. And then, of course, there are those moments when the love is so beautiful and present in the room that you feel privileged just to be able to witness it, and no input from you is even needed. I can think of many such moments at births which even now can bring tears to my eyes when I recall them. A toddler telling her mother that she’s doing great. A partner making his girlfriend laugh in between contractions which otherwise have her crying in pain.  A husband telling his wife that her vulva is every bit as beautiful now as it was before the difficult repair she just had (I kid you not, this is actually something I overheard at a birth; talk about knowing just the right thing to say at just the right moment!).

Holding space as a midwife means creating an environment where the woman in labour feels safe, able to do or say whatever she wants, growl or pace or moan in whatever way feels right, but also an environment where she feels protected and contained (and hopefully in such a way that this protection and containment is invisible and completely non-intrusive). If I’m doing my job well, I’m the safety net, the life-guard on duty, watching and observing but for the most part doing very little.  If I’m doing my job well, I can create an environment where the woman feels free to listen to her body, to follow her own instincts and labour in the way that seems best to her, ideally supported by her partner and support team more than by me.

Holding space also means seeing the big picture for the woman. She is lost in her labour, moving from one contraction to the next, unable to see in front of her, or behind her. It means supporting her in the moment when she is convinced that she can’t do it–even when you know she still has a long way ahead of her, and things are only going to get harder. It means telling her, sometimes again and again, after every contraction, that yes, she can do it. Yes, she IS doing it. Yes, she can. Yes, she IS. It means having faith–faith in the woman’s body, faith in normal birth, faith in her strength, in her perseverance, in her ability to push her baby out–and holding that faith for her even in the moments she she has lost her faith. It’s like shining a torch for her, a light in the distance that she can walk towards, a voice calling her when she’s lost in the maze of labour. It’s knowing that YES, she can do it, and never wavering in that belief, even when she is convinced that she can’t. You can’t do the work for her, but you know that she can do the work for herself. You give her the gift of that faith, and when the woman does climb the impossible mountain that she was convinced she couldn’t climb, afterwards she feels like she can do anything. The faith you held for her becomes a truth that she believes about herself. That is what you’re holding.

Holding space is also protective. Birth is wildly unpredictable, and uncontrollable. Birth plans don’t always go to plan. Hopes and desires for specific outcomes can be trampled. The baby sometimes has very different ideas about the manner in which s/he would like to be born! And sometimes there are true emergencies which require quick, focused action with very little time for communication until after the fact. Sometimes holding space is about preserving a woman’s dignity through the chaos. Sometimes it’s about literally giving her something to hold onto–a hand as you race back for an emergency cesarean, a familiar voice that she can hear through the beeping machines and commotion. Holding space means giving a woman time to grieve and process (after the fact) and a warm, non-judgemental listening ear to allow her to debrief. Postnatal listening and letting a woman tell you her birth story (and sometimes she needs to tell it over and over) can help her to understand and contain the experience.

Which brings me back to two of my favourite quotes about midwifery (and about holding space), from the Tao te Ching, written by Lao Tzu in 5th Century BC China:

The midwife completes her work by doing nothing. She teaches without saying a word. Things arise and she lets them come. Things leave and she lets them go. Creating, not possessing. Working, yet laying no claim. And when her work is done she forgets about it, and it lasts forever.

 

Imagine that you are a midwife.  You are assisting at someone else’s birth.  Do good without show or fuss.  Facilitate what is happening rather than what you think ought to be happening.

If you must take the lead, lead so that the woman is helped yet still free and in charge.  When the baby is born, the woman will rightly say: “We did it ourselves”.

What does holding space mean to you?