Astrid Osbourne
Consultant Midwife & Supervisor of
Midwives
SRN,SCM,PG Dip Professional Studies, MSc
Advanced Midwifery practice, Post Grad Cert
Supervision of Midwives
Astrid.osbourne@uclh.nhs.uk
AOsbo15084@aol.com
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We will look at our global history
We will consider where we are now
What political influences are pushing
maternity care?
Look at the innovations that the UK has
achieved in the National Health Service
Consider how midwife led care does work
Look at models of MW led care, home birth
and birthing centres
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OUR PERCEPTION
OF BIRTH IS
IMPORTANT:
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NHS started in 1948 – more than 50% of women
gave birth at home
The Peel report in 1970 called for ALL births to be
hospitalised on the grounds of safety [no evidence!]
1980’s the DUBLIN study and active management
of labour by early ARM, syntocinon from 4cms,
continuous EFM & constant support
1993/ 94 Winterton and Changing child birth - call
for back to basics
2004 National Service Framework standard 11
maternity
2007 Maternity matters – benchmark for care
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WHERE ARE THE MIDWIVES! They burnt us as witches
in the 15th century – right across Europe
Internationally Midwifery is loosing its position as the
MAIN provider of care for well women and their babies
Modern midwifery: In some countries care is entirely
medically led
Caesarean section rates continue to rise
The Birth Place Study published Oct 2011
Cost – primigravid cost £2,075 Hospital, £1,912 birth
centre, £1,793 home birth
Multigravid cost £1,142 Home, £991 Birth Centre, £780
home birth
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Normality in childbirth – most Consultant
Midwives/senior MW practitioners are engaged
in this area of care
Birth centres with no medical input
In the UK a third of pregnant women do not see
a Doctor at all during pregnancy and birth
NHS maternity hospitals are managed by
Midwives
Where teams of Drs and Midwives work together
the responsibility is shared
Normal birth is the forte of the midwife
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Create a homely atmosphere, demedicalise the
environment – hide stuff away – make the place
homely
Create a positive attitude to low intervention
Choice of place of birth and carers for women
including home, birth centre & hospital birth
Women having the opportunity to know their
midwife and to trust her/him
Education and training for m/w’s and Drs to
improve normal birth understanding and
confidence
Access to parent education and prep for birth
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I support MWs and Drs in the intrapartum areas –
plan as much normality into every birth with them
Discourage unnecessary intervention, formulate
personal plans
Give priority to mobilisation and normal labour
behaviours
Educate MWs and Drs – bring normality into all
aspects of care – teach in the universities
Work along side senior Consultant Obstetricians to
improve the normal birth rate; including revising
policy
Encourage normal birth in ALL settings
Audit & research [own and others]– dissemination to
all
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Essential for the midwife led care model is the
separation of high and low risk women [NSF 2004
& Maternity Matters 2007. NICE 2008 Midwifery
twenty twenty, 2010 ]
Acute care in high risk services must be
appropriately Dr led and easy to access by MWs
Low risk midwife led services across the
community in partnership with GPs and social
care
Easy flows from one process to another where
necessary
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Media pressure to be ‘rescued’ by medical science
Modern midwifery: our behaviour & our reaction to
pain/discomfort – some women are encouraged to
accept pain relief to comfort those around the
woman – including midwives!
Rising epidural rates – rising CS rates – increased
immobilisation during labour – unnecessary
intervention during labour
Women: are having heavier babies, are fatter, work
longer, control their fertility
Changing role of Motherhood – youthfulness
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We perpetuate the common belief that vaginal
birth is risky and CS is less so
Women want CS because they maintain greater
control
The belief that CS is safe, easy, efficient,
desirable & better for the baby
The belief that there is less pain, injury &
unpleasant emergency procedures
“Women’s choice”: ignores the power
differential between women & obstetricians
[Kitzinger 2005]
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World wide CS has increased from 25% to 70% in
developed countries
In some developing countries it is higher
Austria = 40%
Southern Italy = 50 –
60%
Brazil = 75%
South Africa [Caucasian
population only] = 70%
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Interventions were less frequent in MW led areas of
care
There was no difference in adverse outcome for
primigravid or multigravid women by place of birth
Women in a MW led unit were more likely to have a
normal birth
Primip women at home did slightly less well
62,036 low risk women were evaluated
27% 0f the home birth group were primigravid
Costs: Routine CS costs in excess of £3,000
Savings average for MW led home birth = £310
Savings for stand alone MW unit = £130
Savings for along side MW led unit = £134
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NAMED MIDWIFE - contactable
Birth choices for all women
Women followed through care by known carer/s
Follow the National Institute of Clinical Excellence
care pathway for A/N and labour care
Detailed birth planning
Follow up care by known carers
Equal governance – the same clinical standards for
quality and safety as in all other hospital settings
Seamless transition from one setting and carer to
another [low to high risk and visa versa]
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What is a Midwifery Team or Group?
An autonomous group of midwives who are
responsible for a group of pregnant women
Geographically based and working from
Community Centres and/or large medical centres,
any public building has potential
Group Practice offers whole care and continuity of
carers to women – INCLUDING BIRTH with
M/W’s known to the woman
Realistic birth planning, managed expectations and
a clear plan if risk becomes an issue
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Challenges: Growing birthing population –
predicted at approx 3% + across London yr on yr
Staffing challenges – shortfalls recognised across
Maternity services, Integration of staff – change
management & aging workforce
Cultural changes, new ways of working
To meet government [DoH] drivers for first class
care, standards, targets & CNST
Resources reduced by recession and historic debt,
inefficiencies and failure to modernise
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Electronic fetal monitoring in low risk labour is
associated with increased CS rates and has no long
term health gains
Epidural analgesia – increases the need for
instrumental birth
Epesiotomy as a routine intervention has no benefits
to mother or baby
Artificial rupture of membranes – may reduce the
length of labour [half an hour average] but causes
more pain & increases the uptake of pharmacological
pain relief – which influences movement and
vomiting
“This has been a
dream birth that
made this day one
of the most
beautiful days of
my life.”
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Natalie after her water
birth at the Bloomsbury
Birth Centre London