There could be a bit of an argument here about whether the professionalisation of midwifery was a good thing.. Was it? Is it?
Yes, It's fantastic. It means that we are assured that any registered midwife we may employ as childbearing women (either independently, or through an NHS Trust or other organisation such as Neighbourhood Midwives, One to One or UKBirthcentres) has been through standardised training, - attending a set number of supervised births and other 'procedures' or interventions, and having been 'signed off' as fully able to attend women in pregnancy, birth and beyond and to refer those women on to other practitioners if anything deviates outwith the midwife's remit.
It also means that a midwife has an overarching professional body, now the NMC, (historically the Midwives Board, 1902 and the UKCC) whose remit is to act as a safeguard, a regulator, and a governing body.
Midwives rules, through their professional body (and this is obviously a bigger and wider discussion if we are to consider the profession across the globe) govern and guide the midwife in terms of what her practice may consist of, what her duties are, and how supervision works.
Supervision, as it is laid out in the Midwives' Rules, means that every practising midwife has a named supervisor. This is not the same as a manager, and may not even be someone working for the same organisation (although issues of pay and workload are starting to mean that individual organisations are getting possessive of their SoMs (supervisors of midwives). The SoM is the person who you can ring if you're at a home birth at 2am; ...it's been a long labour and everyone's getting tired and you are worried there might be a problem..have you tried everything? should you be worried? what might you have not thought of? The SoM is one of the people you can ring for support or advice. She will, in a non-judgemental way, help you to explore the options you may not have thought of, offer clinical advice, or help seek further opinion or help if needed. She meets with you regularly so you can talk about where you feel your weak areas of practise might be, where you'd benefit from some extra training and how to facilitate and support you to do that. She will be aware of how you practise, and where your midwifery path is taking you. It is a layer of professionalism that protects midwives and the public by recognising any gaps in knowledge before they become a problem, by allowing midwives to ask for help and support in a culture which allows her to do that without stigma and blame (important, because a midwife who is scared to ask for help or advice may not acknowledge, or may try and hide dangerous practice).
Supervision, for midwives, means that there is a statutory obligation to engage with it. I believe that when working well, this means that outside the structure of management, busy shifts and shift patterns and little time for reflection, midwives are obligated to pause for thought, and to do so in a useful, productive and supported way.
The downside of professionalisation is perhaps that a role becomes elitist (For that, look at the history of midwifery and how the lay midwives got the reputation as gin-bottle wielding witches whilst the well-to-do ladies could train as registered midwives). It also may become restrictive, and subject to the 'machine' that drives it. Again, historically we could look at the context of childbearing women who could afford choosing a doctor (just in case) rather than a midwife to be the paid professional at a birth; and at the introduction of the idea of teaching hospitals and that greater efficiencies would be gained by having all childbearing women under one roof.
Today, I think we are looking at the professionalisation of midwifery through another lens again. For many years my colleagues and I have discussed the notion of midwifery apprenticeships; of a midwifery school that would allow midwives to learn the trade outside the constraints of the NHS, in a way that would then allow them to choose how they worked - as home birth midwives, as obstetric nurses, as birth centre, or labour ward midwives... Midwives, as they learned, would be drawn to their field of expertise and could be mentored accordingly. For this they would need a strong professional body; one which would ensure the dissemination of good information - practice, research and experience, which would ensure all midwives in whichever realm they practised had good structures of support and mentorship, and which would be able to intervene early in case of any concerns. A regulatory body that consisted of midwives - experts in the area of practise about which they were called to make decisions- not one that comprises mainly of other professions and medical practitioners.
Instead, what I see is a profession where the vast majority of midwives barely get time to pee, let alone eat, so the idea of time for meaningful discussion or reflection is anathema; they practise defensively - carefully following protocol in order to not be caught out (perhaps in the belief that this is always safe, or is what women want, but that's for another discussion) - and only go to mandatory training when they absolutely have to/can get released. They are frustrated, compromised - and crucially, from a service provision point of view, they are interchangeable with one another to plug gaps in a stretched service. Their practise begins to resemble more and more closely that of nurses, and of automatons and they gradually are taken under the umbrella of the nursing profession and regulation - with a medical rather than a social model of care at it's root.
The NMC, in response to some terrible care and terrible supervision across the UK has responded by proposing the removal of midwifery supervision. I am not sure I fully understand as yet what is proposed to replace it. It has been suggested that management, performance management will plug the gap. But I am deeply worried about it.
The other layer to my concern is the professionalisation of birth practitioners. Indeed it may be tempting for myself, to become an un-registered birth doula, birth support -or lay midwife by any other name. It would remove many of the stresses and limitations on my practise, and would also give access to many of my potential clients who currently can't afford the fees I need to charge to cover the insurance premiums which restrict me, and which wouldn't pay out sufficiently in a worse case scenario anyway! Doulas are beginning to call themselves 'birth professionals' I have heard, and perhaps the term is used loosely, but all the same the lines are becoming blurred. Midwives' practice, through it's 'nursification', professional indemnity insurance issues (again, another discussion) and limitations therefore, is being eroded whilst the un-registered, often very knowledgeable and valid birth support population is growing- and with it women's knowledge and expectations. There are numerous well-known and well-written such birth professionals who are not midwives (or obstetricians for that matter). Some of them have written midwifery textbooks! I am concerned that, whilst there are many brilliant people providing these services, that without the framework of a meaningful governing body, organisation or legislative structure that dangerous gaps in knowledge or experience will go unchecked and women and babies will suffer.
In terms of social inequalities, the women who can afford the more experienced, well-known practitioner will do so, and therefore potentially be safer, and those who can't will choose the cheaper option. As we hear about more and more women free-birthing, those doing so without help at hand if needed, or with inexperienced help, will be in danger. We are also in professional danger as midwives, who may be called to attend a free birth. Without knowing the woman or her history, our clinical judgement is clouded. We can make the best decisions we can in the situation we are presented with, but whether our union and our regulatory body will support us is in very serious doubt. A good SoM on hand through a decision to attend a call is vital.
Free-birthing in a culture where there is expert help on hand if needed is one thing, but free-birth where many midwives have limited experience of normal birth, and where midwives who work outside the NHS are being limited in their practise carries greater risks. Women are now in a position of weighing up those risks and deciding sometimes that the risk of birthing alone is less than the risk that she perceives is carried by engaging with maternity services.
I am really worried about where maternity provision is going. I would just like to practise as a midwife and be paid a living wage to do so, in a way that is workable, sustainable and safe for both me and the families I care for. Please.
Suggestions and volunteers for a 'Midwifery Think Tank' welcome. Please be in touch.
