Midwifery in the NHS
In 1948, Aneurin Bevan launched the National Health Service (NHS) at Park Hospital in Manchester, England to provide healthcare to all people regardless of wealth. Nowadays, about 90% of the UK population uses the NHS for all their healthcare service from dental to surgery, prenatal checks to vaccines, general check-ups to emergency situations. While there is private health insurance available it only accounts for 4% of expenditure and will not cover pregnancy.
The advantage of the NHS is that everything is free at point of use and is paid for through general taxation, it provides flat rates for prescriptions and some services and everything is free for children through 18 (whilst in higher education). All midwives are trained through NHS courses and are trained in NHS hospitals: most midwives go on to work in such hospitals, while some go to birth clinics. Midwifery has changed a lot in the last 70 years from being independent healthcare providers to pseudo-nurses to technological attendant to severely lacking in number. The question has always been: what can our “universal healthcare” actually provide for our mothers?
History of Midwifery in England
Before we can look at what midwives are doing now, we have to see their history in this country. Midwifery was prevalent and used in England long before the NHS came into being. Druids dating back to the 4th century BCE were said to use girdles to assist the midwives in difficult births according to Henry, in his History of Great Britain. Other historical milestones in English midwifery include the man-midwife in the 16th, 17th and 18th centuries; midwifery manuals of the 17th and 18th centuries; forceps in the 16th century; and the medicalisation of midwifery in the 20th century. These all contributed to the modern healthcare system and midwifery as a profession itself in many different ways.
In the 1600’s men were expanding their purview of medicine and trying to increase their knowledge of the world, both of these resulted in “man-midwives”. The “man-midwife” is described as “the man who acted in lieu of a midwife, the medical man who delivered normal births” by Adrian Wilson in The Making of Man-Midwifery: Childbirth in England. This caused a lot of conflict between female midwives, men-midwives, and physicians that has still not resolved today. Arguments that men shouldn’t hold a woman’s position and that women, even in their own profession, should be subordinate to men are still heard today in maternity wards.
Along with the man-midwife came the forceps. These came at time when infant and maternal mortality were high. To combat these high mortality rates the forceps were used when it was deemed impossible to birth the child alive. Before, the child would have been killed in some way to make it easier to deliver and save the mother (or a fatal cesarean section would have been performed resulting in a dead mother); now the child could be “safely” pulled out. The most famous forceps were the infamous Chamberlen forceps, kept a family secret from late 16th century until 1813 after the deaths of most of the Chamberlen family. These physicians were said to hide their tools, blindfold women, and covered the procedure under blankets to keep their secret.
By the 18th century William Smellie was possibly the most significant obstetrician of the time, leading him to develop his own forceps, mimicking those already found in France. Throughout the 19th century we see a boom in the forceps in both design and use, nowadays with the higher rate of safer c-sections forceps are not seen as often, but they are still an integral part of obstetrical practice.
In the early modern period, midwifery manuals instructed the public about who should be a midwife, how to pick a good one, and taught midwives how to do their job. Sixteen texts on midwifery and gynaecology were written between 1640 and 1700. Not surprisingly these were mostly written by men and the messages hadn’t really changed since ancient Greece, with Dr. William Sermon in 1671 giving the same advice Soranus of Ephesus gave in 2nd century CE.
Luckily for us in that same year one woman fought against the tide on this; Jane Sharp wrote The Midwives Book which encouraged education for female midwives, appreciation for the natural order of the world, and the importance of care before, during, and after birth. Jane Sharp is so unusual because she is the only woman to have written a surviving midwifery manual before 1700. Most women of her era were not literate, let alone writing whole manuals for her fellow midwives. Nowadays, we have many more midwives writing for themselves, but Sharp is one of our foremothers in the field.
Finally, we come to the 20th century. In terms of midwifery the first hurdle was the 1902 Midwives Act. It required all midwives to be certified to practice, exempting legally qualified medical practitioners and those assisting in emergencies. This limited midwives who were already practicing by making them get certified before they could resume their practice. Interestingly enough, , this only limited female midwives and so many man-midwives would continue to practice unlicensed until this was resolved in 1926. They were regulated by the newly created Central Midwives Board.
This board divided midwives into three categories: certified, uncertified and untrained (handywomen), and certified and untrained (bona fide) midwives. Reid, 2012 describes how handywomen and bona fide midwives were phased out, but not entirely eliminated during this time period . This phasing out was done to decrease infant and mother mortality but it resulted in the uneven dispersal of trained birth attendants, in 1923 only 63% of rural parishes had a registered midwife with most of the rest having no-one at all registered there. By 1947, the bona fide midwife stopped practicing in light of new legislation making it even more difficult to practice and maintain relationships with the few families left who still used a traditional style midwife. And then in 1948, all midwifery was moved to the hospital.
Advent of the NHS
During the 1930s and 1940s a number of maternity hospitals were established in urban centers. By 1937, midwives had one year of training, while doctors often had no formal training in these hospitals. In 1948 County Health Committees became responsible for domiciliary midwives, the fees surrounding pregnancy and birth and home help service in difficult pregnancies. There were many advantages to working as a domiciliary midwife including building new homes. This meant more women were being employed and home birth rates dropped since there was no one there to assist in such deliveries. Amazingly, this was not the intended outcome for the Health Committees, to encourage people to give birth at home they were given a monetary grant not available to those delivering in hospitals.
The 1950s was the transition period from community midwives to in-hospitals midwives. In 2012, Heidi Thomas created a period drama TV series “Call the Midwife” based on the memoirs of Jennifer Worth and other historical material. Both in real life and in the show we see midwives and nurses caring for mothers and babies before, during, and after birth. However, most of the photographs from this period feature district nurses since they were the ones taking on this role in the community. Stevens also demonstrates a lack of husbands, or men in general, since birth was still a woman’s work. This era also saw mothers making the decision for home births a lot more than we do now.
Midwives “had guidelines, not rules” about when a home birth was appropriate and would often consider a supportive family more important than cleanliness and home conditions according Susan Eckersley who worked as a midwife in London in the 1950s. She also explains how hospitals would provide taxis for midwives to carry their equipment (including gas machines for analgesics and heavy nurse bags) and that in emergencies the fire department would transport midwives — very different to the bicycle-riding women we see on “Call the Midwife”. Here we see a lot of support for the midwife that hasn’t been seen through time, nor in many places around the globe.
The late 1960s and 1970s saw the increase in the medical model of care and births in hospitals. The Peel Report by the Department of Health recommended that 100% of births should take place in the hospital in 1970 and with less than 1% of births taking place at home in 1980, and the country listened. The 1970s saw the rise of induction, Syntocinon, electronic fetal heart rate monitoring, epistiotomies, and obstetricians. The medical model of obstetrics treats a birthing person as ill and needs to be fixed (i.e. delivered of their baby) and employs a lot of technology to know as much as possible about what is going on with parent and child. This can cause a lot of distance between doctor and patient that women of the 1980s were not happy with.
The Short Report in 1980 continued emphasizing hospital birth with obstetricians, but mothers did not enjoy this process and started to rebel. In Memories of Nursing in 2016 we hear how as a result hospital conditions increased for expectant parents, though this did not solve the problem. The 1980s also saw the regular use of the ultrasound for all pregnancies, not just high-risk ones. The technological advances seen in these decades have remained into the modern day in most hospitals. his does not necessarily mean that they’re for the best though.
In the late 1980s and early 1990s many mother and healthcare providers campaigned to change pregnancy and childbirth care in England which resulted in the Health Committee Report on Maternity Services in 1992 recommending that a medical model of care was not appropriate for all women. “Changing Childbirth” (1993) helped support this as it promoted midwives as the ideal supporter for normal birth and identified the importance of choice and continuity in childbirth. This was a huge step for many midwives who had been saying the exact same thing for many years. This report paved the way for midwives to gain some of their autonomy back in the form of midwifery practices.
In the modern day midwives are overseen by the Nursing and Midwifery Council (NMC) and training courses last three to four years (though shorter courses are available to adult nurses). These result in a degree in midwifery that can be used at any NHS hospital or birthing center. Training midwives spend half their time in classrooms learning medicines, critical care, normal births, emergency births, and high risk pregnancies; then the other half of the time is spent in work placement in hospitals. Many midwives who are already qualified enroll in postgraduate course to stay up to date with the field and take part in clinical research. Midwives have lost their autonomy in hospitals though. In the hierarchy they are placed beneath doctors and while they can oversee normal births they must call in a doctor at the first sign of trouble and must go through their doctors for permission in certain case (usually giving medications). The only place midwives can find true independence in the modern healthcare system is in free-standing birth centers.
Midwifery Practices
The Albany Midwifery Practice (established in 1994 under the name South East London Midwifery Group Practice (SELMGP)) was one of the first midwifery centers in England and is a follower of woman-centered and carer continuity models of care. This practice works under the NHS though it is self-run by a group of “self-employed, self-managed” midwives. In their article for “Birth Models that Work”, Becky Reed and Cathy Walton, describe how their practice has had an increased rate of normal births, high home birth rate, low c-section rate and high breastfeeding rate as compared with national and local statistics; proving that the Albany Model of Care is effective and has improved outcomes for infants and birthing people.
More recently the Fatima Allam Birth Centre has opened in the Hull Women and Children’s Hospital in 2017. This center is staffed 24 hours a day by midwives providing individualized, supportive care for women with uncomplicated pregnancies. It aims to be relaxing and homely with mood lighting, music, birthing pools, and family members surrounding the mother while she is in labor, during the birth and after until she either goes home or into the postnatal ward just across the hall.
In the future…
Both the NHS and the World Health Organization (WHO) are studying the maternal and infant mortality rates and trying to get them down. In 2013, the WHO published a report saying that “serious morbidity enquiries are an important addition” to decrease maternal morbidity. In 2017, the NHS vowed to improve care throughout pregnancy to give more support to birthing people by “expanding access to specialist care for 30,000 more women each year by 2021”. This year the UK government, the NHS and universities have started collaborating to combat the midwife shortage by increasing pay, providing more places in training programs as well as different training routes and encouraging continuation of care during the pregnancy. Hopefully this can make up the 3,500 person deficit we are seeing in England. The UK government has recognized the need for midwives, but whether the universities and hospitals can provide them is another question.
