It’s been another week in the British news so naturally that means there’s been a barrage of maternity-related articles. An order to investigate Scotland’s maternity services, the continued fall-out from the tragic case in Greater Manchester where a mum and her baby both died, failings at a large NHS trust, Wes Streeting performatively shouldering the blame of all maternity-related failings, and a rather odd plea for all universities to change their midwifery curricula based on some google searches.
There are significant issues within our maternity services – don’t for a second think I’m saying there’s not. And where individuals have acted in a way that causes harm they absolutely should be accountable for that (once HR, always HR). But underpinning all of the above (and more) is a discourse that’s rooted in misogyny, gross misrepresentation, and a dark glimpse into the future of midwifery provision.
For years there’s been a witch hunt against midwifery. In fact, it can be traced back to 2015 and the release of the Morecambe Bay Report. The report cited multiple failings; from systemic issues regarding the adequacy of staff training and siloed-working, management failings, investigative bodies failings, and “a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care” (note: the phrase ‘normal birth at any cost’ was ONE person’s reflection – more on that in a bit). Yet despite the multiple issues, it’s this last one – and in particular the comment from one midwife – that’s been grabbed hold of and shaped the way midwifery is viewed over the last decade. What do we call it when we ignore all the other evidenced factors that have led to harm being caused and focus solely on the actions of individual midwives (midwives who are, remember, nearly all women). Misogyny seems a pretty good word for it.
This misogynistic approach to how maternity services issues are investigated and reported threads through all the many, many reports and investigations that have occurred in the interim decade. Right through to the horribly tragic case under Manchester Foundation Trust where the inquest has recently been reported on. Again we see systemic issues (on-call for a home birth after a 12 hour shift – this is obviously unsafe practice, a computer system that’s not up and running properly and that staff aren’t confident using – of course this is going to mean access to information and note taking is more difficult), we see failings from both midwifery and obstetric clinicians, there’s remarks about Jen’s birth plan reported in such a way as to invite criticism and victim blaming (even though the coroner’s report itself declared the birth plan as entirely reasonable). According to the coroner it’s the gross negligence of the midwives there on the night of the birth that led to both deaths but we gloss over the fact that neither of those midwives should have been there anyway. Lorry drivers are limited to 9 hours work a day because it’s recognised that if they go over this they’re potentially unsafe and putting their lives, and lives of people around them, at risk. The dissonance is astounding.
And where does this leave us? Naturally it’s not funding and systemic changes that would support safe practices across all birth place provision. Nope. It’s a knee-jerk reaction through policy (that I’ll bet 50p hasn’t been coproduced with its service users like it’s meant to be), that places restrictions on women and birthing peoples’ choices. MFT have implemented an out of guidance home birth panel where all OOG home birth ‘requests’ are sent, to be discussed at a roundtable of stakeholders. Although of course, damningly, the family themselves aren’t allowed to be present. It’s hard to get facts out about this panel because MFT refuse to answer emails, attend meetings or respond to FOI requests which have a legal duty to be responded to. Word on the street, however, is that many of the home birth requests being received are being called OOG, and many many of those are being refused. It would be lovely if the trust provided some transparency around these figures. Gloucester has now pulled its home birth provision entirely because it works to the same model as MFT, citing ‘safety concerns’ (although let’s be real, they weren’t a safety concern until this tragedy really hit the news were they?)
No – this leaves women and birthing people with the choice of giving birth somewhere other than their preferred option, or choosing to go ahead without healthcare staff present. Neither of these is necessarily a safe option. Despite home birth being presented as a risky choice the fact remains that the vast majority of serious incidents happen in hospitals, and that even planning a home birth means your chance of needing an intervention is lower without an associated increase in poor outcomes. Freebirth is a fantastic choice – for some people. But it should never happen because someone’s forced into it through lack of alternatives.
It’s not just place of birth policies that have been affected by this drive against midwifery, and against birthing people’s choices. A small but vocal group are influencing decision-makers to believe that “normal birth ideology” is the cause of all tragedies and poor outcomes. This is fuelling the belief – despite the evidence – that midwives, and only midwives, are responsible.
Firstly, if the “cult of normal birth” was in any way effective, we wouldn’t have induction rates that hover around 40% or c-section rates that push 50%. If there was an ideology to coerce women into having physiological births it’s not a very successful one. The majority of births aren’t physiological births – so how on earth can this type of birth be the cause of all the issues? The math ain’t mathing.
And let’s take it further. Midwives are experts within their scope of practice; a scope which includes ‘low-risk’ (or physiological, or…normal) birth. It’s entirely appropriate that they’re educated in physiological birth. Only, according to the above article all reference to normal pregnancies and births should be removed from curricula. How, then, can a lecturer teach their students about a fundamental part of their practice? Well, for those who think that women and birthing people shouldn’t have the respect and dignity to make their own informed decisions about their pregnancies and births it might not be too much of an issue – everyone on to the conveyor belt of interventions in the name of safety (although remember, the actual evidence doesn’t support that an increase in inductions and c-sections leads to better care and a reduction in harm).
These conversations often miss the crucial difference between ‘promoting physiology’ and pursuing ‘normal birth at all costs’. Promoting physiology means keeping things as close to the biological norm as possible, even when interventions are necessary, because this supports the health of both mother and baby. In contrast, ‘normal birth at all costs’ is not, and never has been, an NHS policy and would be justifiably problematic. This isn’t a mistake: the blurring of distinctions is a deliberate, calculated act to further what one might call an ‘anti-normal birth ideology’.
But it’s ok because midwives aren’t on their own on this are they? They’re being supported, reassured and fought for by their professional bodies aren’t they?
Aren’t they?
Aren’t they?!
The nmc have written an accusatory letter to all universities instructing them to only deliver what’s on the approved course material – like universities have the time to go off piste and teach whatever the hell they like. There is, arguably, a big conversation that needs to take place between course content and the reality on the ground for students and NQMs but this involves transparent, honest and above all else collaborative working from all stakeholders.
The RCM are so disinterested about the future of midwifery within maternity services that they chose to not participate in an NHS England consultation on the professional strategy for nursing and midwifery. The consultation may have had its faults but abstaining entirely shows why so many midwives are frustrated with their professional body and trade union.
In fact, both nmc and RCM are so well-respected and such an important bastion for midwifery that they’ve been sidelined from the national review into maternity care in England entirely. So that’s a national review without two of the biggest organisational stakeholders for midwives. Make that make sense.
Next stop – goodbye to midwifery as an autonomous profession, and hello to obstetric nursing. Goodbye to empowered service users through informed decision making and birth choices, and hello to good girl now do what I tell you.
Fundamentally, everyone deserves access to the safest maternity care and that includes care from a midwife. One person’s safety is not the same as another person’s. Therefore we should be fighting to not just preserve but strengthen maternity provision. To make sure that every single person has access to what will help them, whatever their situation. And let’s not forget midwives either – they have the fundamental right to work in a system that’s safe for them, and where they’re not subject to a barrage of misogynistic toxicity at every turn.
