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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.

 

 

Sleep and “Self-Soothing” Roundup

Sleep and “Self-Soothing” Roundup

There is so much conflicting information out there on sleep, and so many messages you’ll hear on why having your baby “sleep through the night” is the holy grail of parenting and that if your baby isn’t hitting this milestone by (insert whatever age you like here), it’s a disaster or they’re not a good baby or you’re not a good mother or you’re allowing them to create bad habits etc. etc.  But the truth is that every baby is unique, sleep needs vary tremendously between kiddos, and learning to “sleep through the night” is a developmental milestone that you can’t really force a baby to hit before they’re ready, just like you can’t force them to sit up or crawl before they’re ready. Also, it’s important to remember that even as adults we wake up several times in a night (because we’re thirsty, or hot, or cold, or have to use the toilet, or had a bad dream, or heard a loud noise, or are stressed about something, or uncomfortable, or or or…), but the difference is that as adults we have learned to roll over, self-soothe and go back to sleep. Babies are still learning this skill.  It takes years for them to fully master it, and until they do, they often still need our help, input and reassurance to fall back asleep. Meeting a baby’s needs is not “creating bad habits”; it’s being responsive and attentive to the baby’s needs, which in the long run will create more security and independence.

Strangely enough, discussing sleep and self-soothing is a very “controversial” topic. On parenting boards and facebook groups and public forums, there are strong advocates for sleep training, using either “controlled crying”, “gradual extinction” or “crying-it-out” (CIO) methods as a way of teaching a baby to sleep through the night. There are equally strong advocates against these methods. Because every parent is exhausted (EXHAUSTED!), there is an unending market for books, sleep gurus and training methods as desperate parents (understandably) look for ways to get more sleep. And not surprisingly, the message you get from mainstream sources, news articles and “how to get your baby to sleep” books suggest that a baby who isn’t sleeping through the night by (insert whatever age you like here) is a problem that needs to be fixed. But what I am more interested in looking at is the actual science behind these differing approaches. Research into sleep, such as what Professor Helen Ball at the University of Durham is doing through the Infant Sleep and Information Source, is still a relatively new field, but there is a growing body of evidence which is beginning to refute the claims of the many (insanely popular) sleep experts and authors and gurus who recommend this or that sleep training technique.  The following is a round-up of some of these articles.   

First, Sarah Ockwell Smith has a great article on realistic sleep expectations for babies. As you can see, there is A LOT of normal variation in this, and even if one baby is ready to sleep through the night at 8 months, another baby might not be ready to do so at all. Each kiddo is unique and has different needs. 

Sarah Ockwell Smith also has a good article on what’s really happening when you teach a baby to “self-soothe”. Unfortunately, sleep training methods don’t really teach our babies to self-soothe. This is a developmental skill which they can only learn with time and maturity. Instead, it teaches a baby to stop signaling her distress. Babies are smart and they very quickly learn that if crying doesn’t bring a response, it would be better to conserve their energy instead and not use a method that doesn’t work. A study done in 2012 by Middlemiss et. al. monitored the cortisol levels (i.e. stress levels) in 25 mom+baby pairs and found that at the beginning of the study, the mom and baby were synchronised in their stress response, meaning that when the baby was stressed and signaled this to the mother, the mother responded to this with a rising cortisol level of her own. In other words, if baby was distressed, mom was distressed, and their cortisol levels were in sync. By Day 3 of the study, after using a gradual extinction sleep training method, the researchers found that the baby was no longer exhibiting stressed behaviour, but the baby was still distressed (as demonstrated by high cortisol levels). Meanwhile, because the baby was no longer signaling its distress, the mom’s cortisol levels had decreased, indicating that she was no longer in sync with her baby (at least in terms of cortisol levels).

Calm Family wrote a very detailed response to the BBC One’s recent airing of Panorama, Sleepless Britain, which addresses many of the ways “sleep issues” are portrayed in the media.

The Analytical Armadillo, another IBCLC blogger, has also written a good analysis on what happens during self-soothing, and that even though it works (and it does work), it’s not necessarily harmless.

Evolutionary Parenting looks at the science behind exposing our kids to stress, and what’s actually going on neurochemically in their brains when this happens. 

Uncommonjohn also looks at the science behind self-soothing

The Milk Meg writes about the many reasons our babies wake so frequently in the night.  

And while this doesn’t actually get into the science behind it, Mama Bean Parenting documents quite…succinctly…the many, many, many messages we receive in our society which tell us that a baby that doesn’t sleep through the night is a “problem”.

Finally, Dr. Sears has some good suggestions on ways to get more sleep without using CIO methods, as does Dr. Jay Gordon in this article. The Milk Meg also has some ideas on ways to gently night-wean breastfeeding babies.

And one final disclaimer, since I know this is an incredibly sensitive subject for many parents. I understand the desperate need, the overwhelming desire, to somehow find a way to get more sleep! We’ve all been there. Many of us are still “there”.  Parenting is exhausting, and waking frequently with our babies in the night is not at all conducive to our modern lifestyles. I absolutely get it. And I have many clients and friends who have used sleep training methods, sometimes with very good results–hell, I’ve attempted a few of these methods myself with my first son out of sheer desperation (but wasn’t able to follow through with them). I am in no way judging the reasons why parents might turn to these methods, and I have nothing but empathy for the desperate exhaustion that makes these methods seem like the only answer. Getting more sleep is a positive thing for everyone involved, and allows us to be better parents, and in our bleary, sleep-deprived states figuring out how to get more sleep seems all-consuming and anything promising a quick fix seems like mana from heaven. But it’s important that we as parents do careful research and make informed decisions before deciding on a parenting course of action. Our media and society is saturated with messages about sleep and ways to “fix” it, and nearly all of these messages usually recommend some form of sleep training. That is one side of the debate. All of the articles I have posted here are the other side. It’s important to understand both sides before making an informed choice.

As a midwife, asking “Is your baby waking regularly and feeding regularly?” is a much more supportive and useful question for new parents instead of “Is your baby sleeping through the night?”. Most likely, a normal and healthy baby who’s feeding regularly and growing well will NOT be sleeping through the night, so rather than make parents feel like there’s something wrong, it’s much better to emphasise what’s absolutely right about this scenario. And then look for other ways to support exhausted parents to sneak a bit more sleep into their lives.