(If you’re wondering what the National Maternity Review is, or want some easy and fun to read background knowledge, see parts one and two).

You know what? I've come to realise I often like people with tattoos.

I think it shows fun and decisiveness.

When I was a teenager and many friends were getting tatts I could never get it together enough to choose - my ideas included a jigsaw piece, a quote from Emily Dickinson (the soul selects its own society, then shuts the door), and a small snow capped mountain.

But I had a sort of 'permanence fear'. Training as a midwife seemed small fry in comparison to being inked.

Anyway, this 'permanence fear' is something I've learnt to address, and good thing too, because once your words and views are out into the world, they stay.

And it's so important for women to state their strong views, regardless of this fear.

I bet the authors of the National Maternity Review felt the weight of what they were writing.

Government reports don't just disappear, they hang around for people to quote from years later. Whether or not the review had an impact on English maternity care will be looked at in the future.

I do hope that this means what's been written about caring for midwives in the National Maternity Review will have been deeply considered, and will be implemented.

What's Going Wrong With Looking After Midwives Currently

As you know if you've followed Midwife Diaries for a while, providing an empowering professional environment for midwives and other maternity staff is one of my all time favourite topics. I'm convinced it's one of the key overlooked factors in getting care right for women. The National Maternity Review agrees with this.

Firstly, there are still staffing issues in England.

The review found many units are at 100% capacity too much of the time. The most recent NHS Staff Survey found nearly 50% of midwives were stressed because they couldn't give the care they wanted to.

This desperately needs addressing, as the birth rate isn't set to fall until 2030, and women are continuing to present with more complex needs like obesity, diabetes, and also are choosing to have their babies at an older age. I want to be totally clear here, midwives don't blame women for any of this, it's just the demographics of England currently!

It does mean though that care is more demanding and there's more paperwork.

There's also the fear of litigation, which the National Maternity Review concentrates on quite a bit.

Obstetrics and gynaecology are the areas where the NHS pays out the most and this makes for a difficult working environment.

If you're working in an area of high litigation, your documentation becomes a way of protecting yourself. No midwife I know wants to think this way when spending time with women, but many of my old colleagues did feel like there was a potential court case hiding behind every door. So stressful.

The review also recognises that midwives need to be properly paid and incentivised for the work they do. Hopefully, the government will make note of this.

Midwives do what they do because they love it, but it's stupid to think they're not incentivised by better pay - it's a way of recognising and honouring them (and letting them look after their families).

Which leads me to question what the flip does the government thinks it's doing taking student midwife bursaries and course fees away....

Culture has also been recognised as fundamental to good care. At Morecambe Bay, a toxic culture was one of the main issues identified. If members of the team don't get along it directly translates to poor care for women. It's exciting that this point is being put into a formal government recommendation - no room for bullying.

What they're saying in this review is that for women and families to be treated with dignity, respect and compassion, staff must be treated that way too.

 

Solutions

The review calls for excellent leadership and 'inspirational vision and narrative' within trusts.

I especially like the emphasis on 'collective leadership', which means working in partnership with midwives and other staff rather than trying to control or dominate them.

Sounds like an excellent way to prevent the kind of culture where bullying occurs.

We're still not quite sure what form supervision is going to take - supervisors of midwives were one of the areas of concern from the Morecambe Bay events.

The National Maternity Review does acknowledge that many midwives say they'd be 'vulnerable and unsupported' without supervisors. It's going to be the trusts themselves which will train and sort out supervisors of midwives - and investigations into practice will now be through government structures. It's good that supervision is being identified as important, but as far as I can see there are no clear ideas about what supervision will be like in practice yet.

When I do practice interviews with aspiring midwives, the changes to supervision is often something they're confused and worried about and I can see why - it's complicated and not defined yet.

Continuity of care is something women want but there's lots of evidence to say midwives find it satisfying too.

The review calls for small groups of  4-6 midwives working together, still NHS funded, but able to get to know women and families as individuals over the course of pregnancy.

The ideas in this continuity model will mean less burn-out and better 'staff retention', i.e. midwives will stay in the same job longer. This should also mean less agency staff, who are cripplingly expensive for trusts to hire.

Caseloading can be an intense way to work - most independent midwives I know who work this way can be up for 48 hours+ at a time. But then there will be some days when they just have a 15-minute postnatal check to do.

In the review, this 'ebb and flow' is mentioned, and caseloading midwives are supposed to be 'ringfenced' so they can manage their own diary.

But, a big problem is caseloading midwives might be pinched for labour ward when it gets really busy. This isn't supposed to happen, but if there's an unsafe situation on labour ward because there's not enough staff, how can you justify not calling for midwives that are available....?

These are the logistics that need to be sorted out.

The continuity of care model should improve culture too, as each small group of midwives will have a named obstetrician that they can get to know and consult with. It's starting to sound a lot like New Zealand care.

There are also lots of suggestions for making labour wards less busy - like 'labour line' for women to call early in labour, to prevent assessments that don't need to happen.

I think the most exciting idea in the review so far is that midwives should be able to set up their own NHS funded services. 

It's not said in so many words, but I believe this means you get to play to your strengths. So if you love breastfeeding support, you could set up a service for this. Or if you're into support for pregnant teenagers, you could sort specialist services independently.

I truly believe that one of the things the business world has known for a long time, but the NHS still has to catch up with, is this concept of doing what you love.

Honestly, it's best for midwives, and for women. It's win-win.

I'll round off by saying midwives do feel better supported by managers in recent years, which is incredible, considering the service has been so stretched and they've had so little ability to change things. Hopefully, his review will means the good stuff can be expanded on.

I'll just drop in here too that the CQC, which assesses these things, found the maternity services came second in quality out of all acute hospital service areas. Second! Amazing - and down to the commitment and passion of staff.

 

Now I'd love to hear from you.

What are three areas you'd consider working in, as part of a small NHS funded midwifery service?

Especially if you're an aspiring midwife, is this something you'd be interested in, when you're a midwife of the future?

Or do you think these changes to the maternity services can't be done - why?

And, is 27 too old for a tattoo or should I get one now before it's too late?

 

Once again, thank you so much for reading Midwife Diaries. If you have any suggestions or you'd like me to write about something for you, leave me a comment or email me on ellie@midwifediaries.com

Whether you are an aspiring, student, newly qualified, or very qualified midwife, the culture you're within matters enormously - YOU matter enormously.

I'll be sending good thoughts your way this week,

Ellie x