AIBU to think that NHS maternity care is only sustainable with these kind of changes?

[Dragonflyby]

I've been asked to take part in a focus group looking at potential changes to maternity care, where more things that are currently done by midwives will be done instead by maternity support workers or other trained non-midwives. So things like breastfeeding support, antenatal classes, smoking cessation/weight management advice; the non-clinical stuff, basically.

I've got some mixed feelings about it - on the one hand I know there's a staffing/financial crisis in the NHS and there have got to be changes and finding new ways of working, on the other hand, I wonder how midwives will feel about their roles being pared down like that, and whether it's what women actually want.

So is it reasonable to delegate more of midwives' current duties to trained laypeople? Has it worked/failed already with MSWs, and with nursing and HCAs? Or do they just need a lot more midwives instead?

I had fantastic antenatal care, saw the same midwife every time except when she was on holiday. She sorted out follow up for me when I came back from a hospital scan with a plan to leave things be but no plan for if I went post dates, she texted me in the evening to make sure I was happy with the new plan. She clocked when I hadn’t come home after delivery because DS was in NICU and came to see me in hospital as she was at the hospital for something else. It meant I did feel more comfortable with her and able to be honest.

I work in a different area of healthcare but again we are getting more and more of the routine stuff done by pharmacists and nurses. They are excellent and we are short of doctors and it is more efficient in terms of money but often means I am only seeing people to break bad news or sporadically for results. You do clock if something isn’t right much more easily if you know them and it’s a bit more satisfying for patient and HCP.

But then I can’t see why smoking cessation and weight management couldn’t be done by someone else. So on the fence. Ideally no but in the real world it might be sensible!

And yes agree more staff etc for things like helping folk to the loo and shower etc and that doesn’t necessarily need to be a midwife.

I think there should be a charge for seeing a midwife as well as towards the birth. Nobody has to have children, it’s a choice. That way we could sustain the services, ensure enough staff etc. Not on a sliding scale though, a set charge for all as much fairer.

How is a set charge for all fairer? For some people £1,000 is loose change, for others it's an unimaginable amount to save up. What you are really saying is that poor people shouldn't have children and should be, as far as possible, priced out of having them.

The problem then becomes under resourcing of the maternity support workers. I was asked to drive an hour to a clinic for day 5 weigh in and heel prick test as they're only done by the maternity support worker and the local one is on holiday so no local clinic running. I'm more than happy with all the services on the list being provided by other trained professionals but I suspect it won't be well resourced.

Apart from the antenatal classes I don’t really see a need for midwives at all

Have you any idea what a midwife actually does?

In an average week.......

Antenatal checks on - screening for life threatening conditions for women and babies.
Information giving regarding choices around life changing experiences.
Referrals to doctors if someone is at risk of life threatening conditions.
Spotting signs of domestic abuse and empowering women to make decisions to escape.
Antenatal education.
Liaising with social workers. Safeguarding. Sifting out the vulnerable from those in actual danger. Attending case reviews to plan for safety for mothers and children.
Mental health screening and support.
Counselling women regarding screening choices and results.
Planning births that will be safe and acceptable.
Triaging women with any symptoms related to pregnancy, birth and postnatal and advising and referring on if necessary.
Labour care - this isn’t just catching, its all the way through. Pain relief, massaging backs, making tea, talking, making decisions about whether that woman and that baby are safe and healthy.
Clinical skills. - bloods, cannulating, giving medication safely, assisting in theatre, interpreting results, monitoring,

Managing emergencies. Saving lives.
Feeding support. Newborn screening. Changing nappies, teaching parents.
Emotional support. Mopping up tears, laughing, holding a woman whose baby has died.
Covering a front line service 24 hours a day., frequently with no break, because a woman needs something.

Absolutely no problem with support roles being taken by people other than midwives.

Absolutely not to charging, or even making it an option within the NHS - that's a very slippery road.

And, yes, I too, would like a 3rd trimester scan. So many potential issues could be identified.

I’m currently 31+4 with DC2 and would say the maternity service has changed since having dc1 less than 2 years ago. I’m under the aegis of Imperial College Healthcare Trust.

Firstly; being asked to bring a passport with me to my first booking in appt. (a good thing, IMO!)

Second; despite having low Papp-A in first pregnancy, and flagging this up to ensure it was tested for second time around, the test was ‘forgotten’.

Third; midwife appts moved from elected hospital to another (despite my clearly and repeatedly saying that I didn’t want to be seen there).

I understand the system is under great pressure. I’m not ‘entitled’, try to be as understanding as possible, but I do worry that if something should go wrong, there may not be a safety net in place.

Midwives did nothing for me in hospital, whereas the Maternity Care Assistants were absolutely amazing. Jobs like emptying my catheter and changing the pad on the bed which was soaking wet with blood were seen as beneath the MW's (their words) so they just left me. I know the roles differ, but honestly if more was invested in MCA's the experience would probably be better for many people. After birth the community midwives were also horrible, to the point I left in tears every appointment and I never want to go through pregnancy and birth again. I say invest more in other staff and leave the midwives to tend to things above the needs of the women and babies they are allegedly looking after. My experience may make my view jaded of course, but honestly, any change would be good.

As long as they are well trained

Breastfeeding support (in my experience) has been woeful. I've witnessed so much incorrect advice and seen so many women give up.

In our area the 'lactation advisers' are barely trained and very unavailable.

Sorry posted before I'd finished...

I don't see any massive issues if there is extensive training provided as you cannot expect an unqualified person to take on all these issues.
It should be a band 4 role which covers one specialism only. So smoking cessation only, or breastfeeding support only as they cannot be expected to know it all and the role would be massively watered down.

It would be a shame for midwives to lose out on these roles though as it's all part of the care they provide to women.

I'm thinking of getting a doula for my pregnancy at the moment. I want to do a VBAC but I'm scared of being left on my own.

Anyways, it shouldn't really matter if it's a midwife that helps with nutrition or smoking cessation. At one point, weren't nurses trained completely on the ward? They seem to get things done and the experience is the really valuable asset imo.

I see no problem with other trained people taking over some of the things a midwife does. For one thing my midwives struggle with drawing blood from me, and its much quicker and less painful for me if I see a phlebotomist and get them to do it. Also our antenatal classes were a mix of health visitor and midwife led, depending on whether it was about the run up and birth, or what happens after and caring for baby. As others have said, smoking cessation and weight management are other areas where an expert doesn't necessarily have to be a midwife. Antenatal mental health support is another that springs to mind. However what is important to me is continuity of care. I dont care if I have one person or three people caring for me and baby, as long as they know me, and I know them. Seeing a different person every time is frustrating and causes delays, means people miss things etc. And the relationship between midwife and pregnant woman is a really important part of the woman having a positive pregnancy and birth experience.

Sorry to vanish from the thread - busy day.

Really interesting and thought provoking replies, which I’ll reply to properly tomorrow.

This is being tried in lots of areas of the NHS- when well trained and with a very clear idea of role these kind of practitioners can be invaluable.

However in the NHS, in my personal experience, people in these roles take on more and more responsibilities which they lack the knowledge and training for. In the NHS service I work for we have a physicians associate and he is plain dangerous, he is treated as a substitute doctor but when you scratch the surface there is a complete dearth of knowledge and experience. I have mixed experiences of nursing assistants and the problem with these ‘support’ roles is that sometimes they don’t know what they don’t know- and vital things get missed. For example record observations but cannot interpret them and so don’t pass on vital ones, or reassure patients wrongly when the patient is actually reporting something which is a red flag.

The flip side for the midwifery team is that the ‘nice’ part of their jobs, gets taken away, so all they do is high risk and high intensity, and they have to supervise others. Hence faster burn out and fewer midwives.

I am up for support staff in general but it is a slippery slope.

Yesterday 15:22 BogglesGoggles

‘Apart from the antenatal classes I don’t really see a need for midwives at all.’

Could not disagree more.

My first pregnancy was ‘normal’ - as the majority are. I gave birth in a stand-alone MLU, staffed by midwives. Quite aside from the very reassuring experience of getting to know the whole (small) team of midwives during ante natal checks, I was superbly supported during the birth by practitioners who were doing exactly what they were trained to do - ie: support labouring women and deliver babies. I had a long labour, and yes, it was pain like I’d never thought possible, specially as this was my first baby, but I got through it on gas and air and by being brilliantly supported and encouraged that I could do it.

I’ve had experience of both sides because I also needed a subsequent hospital birth for medical reasons. The birth was satisfactory, and of course the most important thing was the baby being safely delivered, but this time I didn’t know any of the midwives and they very much took a back seat with doctors rushing around in charge.

I had a very enlightening chat with one of the midwives at the MLU who told me how much more rewarding her job was than her previous one in a big hospital. She said she felt able to properly use her specialist skills of supporting women and delivering babies.

Personally I think things like advising about smoking cessation etc could be passed to well trained non midwives.

But my main point is that there is VERY much a point to having midwives and allowing them to get on and do the job they’re trained for.

Doctors and consultants have their place too- of course they do. But lets face it, the majority of pregnancies are ‘normal’ with the potential to give birth ‘normally’ without lots of intervention and this is where a good midwife is the gold standard imo

Midwives are low-paid professionals already. In my opinion, the only thing needed to improve maternity care is to employ enough midwives so every ward is fully staffed. The reason behind all the problems I hear about is, there are not enough midwives in the ward, so they are overworked and stressed. Midwives are the experts in normal, it is not fair to expect them to only work with "the most complicated cases". in fact, the place a midwife is best utilised is in normal pregnancy, birth and postnatal, promoting normality and helping mothers breastfeed and care for their babies.

Employ more midwives, and magically all problems will disappear.

Aurynne- yes to more midwives. You’re absolutely right: midwives are the experts in ‘normal’

Birth has become so medicalised now (and of course in certain situations that’s a good thing) but imo something that’s been lost along the way is the fact that most births (not all, but most) have the potential to be managed by midwives only, without doctors or anaesthetists. Feeling safe and supported by a familiar midwife goes a long way to reducing fear which in turn makes you better able to manage pain. Of course it doesn’t take the pain away, and there will always be some women who prefer to have a more medicalised birth with epidural which of course necessitates an anaesthetist and that’s their choice. But most births can be managed by midwives, and they are the experts in this.

"To be honest, I was thinking more of the really practical stuff that midwives don’t seem to have time for like helping someone to the loo/shower, bringing food - the things that used to be taken for granted on maternity wards that just don’t happen any more."

Agree that conditions on the wards are horrific. I was denied painkillers for hours on the morning after a c-section because apparently nobody could be spared to bring them, and then I got yelled at for begging for help walking to the loo (it was only 3 or 4 paces but I was scared of passing out due to the lack of pain relief). That's very mild compared to some of the stories I've read.

More midwives would be ideal. For things like breastfeeding support, I'd have taken support from a trained person who wasn't a midwife over having a midwife telling me "don't be ridiculous, I haven't got time for this".

I think we need more midwives for antenatal checks rather than trained support, although in my area some things like the whooping cough jab are done at the GP surgery by a nurse. It's good to have a midwife spotting potential mental health or domestic issues. However I think postnatal teams on the ward could definitely benefit from practical support. My DS was sicky so I had to keep buzzing for a new cot liner, for example, and a midwife ran me a bath after birth.

I’m 39 weeks pregnant into my 1st pregnancy and I agree more midwifes are needed.

My experience clearly tells me resources are stretched and struggling. For me it’s little things such as having a consistent midwife throughout, which I’ve not had. I’ve passed between midwifes and apparently was assigned to one who I never even met.

I’m now under consultant care due to GD. Again I’ve been seen by a merry go round of midwifes.

I just would like to say I really respect all occupations and do agree generally that nurses and midwifes are under paid imo. But I do feel there is a massive lack of midwifes and The wards don’t have the best reputation from when I’ve read up and asked people their experiences. Like every service more money Is needed to cope with the demand.

I’m not planning to breastfeed so can’t comment on who should run those sessions.

I've strong feelings on this actually. I'm not a midwife but I am a registered health care professional. When I had my last miscarriage I was "triaged" by an auxiliary who clearly was working on parameters of observations deemed "normal". She couldn't fathom that some people have baselines outside these parameters which for "normal" people these numbers are OK, but meant I was infact very sick. Too sick to argue.
I certainly think the voluntary sector, and non registered staff are important for extra care for multiple births, and premies and home visits, but I think its an insult to both patients and registered midwives being fobbed off to non qualified personnel for clinical issues.

Apologies for the rant. The current health service is certainly unsustainable, and there are certainly things that can be outsourced to admin or unregistered staff, but I think it's vital that clinical issues are still addressed and recognised by actual clinical staff.

Student midwife here.

I think it’s a good idea for maternity support workers to do the non clinical aspects such as breastfeeding support, as it helps the midwife to focus on the clinical aspects of the job.

In today’s society high risk pregnancies are the norm, and looking after high risk women takes up a lot of time both during and after labour. Then theres paperwork to do on top of all that, then medication rounds, emergencies to deal with the list is endless!

Breastfeeding support for example takes up a lot of the midwives time, it can take up to an hour or more to sit with a woman to help them feed their baby, unfortunately with the workload and often shortage of staff women don’t get the support they need which is a known issue as breastfeeding rates in the UK aren’t great and this is attributed to lack of support to establish breastfeeding. So ideally there needs to be someone available to provide 1-2-1 breastfeeding support in hospital both after labour and once the woman is on the postnatal ward.

Also things like providing refreshments, changing beds, emptying catheters ect takes the midwife away from providing 1-2-1 care to women in labour as the midwife will have more than one woman to care for. These things of course are not beneath the midwife, we just have so much to do, so often the non essential things may be left as there’s other priorities to deal with.

So from my perspective ideally there needs to be;

• More midwives - so 1-2-1 care can be provided throughout labour. More midwives are also needed in the community so that 1-2-1 care can be provided there too.
• a team of breastfeeding support workers working both in hospitals and in the community.
• more midwife support workers, to do the non clinical things (change beds/clean the rooms after a discharge/provide refreshments ect) and the basic clinical aspects of the job (take bloods/empty catheters

But this comes down to money and unless money is ploughed into the system nothing will change as these are well known issues....

My midwifes at hospital were amazing, they spotted depression and potential pre clampsia early and offered support.
My local community midwife was appalling. I'd have rather seen a layperson. But that being said my hv arnt great so it depends on the person.
I'd be happy to see tadined laypeople and midwifes for regular checks etc.
I was terrified due to complications in labour. The midwife team at hospital are my hero's and looked after my baby and me. Without them I doubt we would both be here still

Midwifes aren’t currently doing any of these things though? better to have somebody do them than nobody! my prenatal midwife appointment took maximum 5 minutes - come in , fond notes, measure blood pressure, out. A triage system might make sense, meassuring blood pressure doesn’t need a midwife. so, you see the midwife is you need to/have something to discuss, otherwise not

I don’t see the problem. Surely this is no different to a Health Care Assistant, Assistant Radiography Practioner, Emergency Care Assistant, Community Support Officer etc.

All doing roles previously done by nurse, radiographer, paramedic or police officer.

All less skilled but very important roles leaving the professional to be more hands on in clinical or law enforcement or whatever.