Hypothetical question re ELCS and case-loading care

[Shagmundfreud]

...is it as reasonable to expect the NHS to provide case-loading care on request as it is to provide c/s on maternal request given that:

• case loading care costs for a pregnancy and birth would surely be roughly similar to the cost of an ELCS (in London £3200 buys you a very full package of care: antenatal and postnatal, plus birth - this could easily be trimmed to £2500 I reckon by using existing NHS staff)

• some women find the idea of giving birth with stranger caring for them very distressing and worrying. This was the case for me and I had to pay to go private to the ensure continuity of care I needed to feel psychologically comfortable about the birth.

• the outcomes for case loading care are better, particularly in relation to mental health and breastfeeding.

In other words - the NHS should pay for whatever pattern of care women need to feel OK about giving birth, as long as it is roughly equal and the clinical outcomes are good.

Because I would really put my name behind any campaign to increase access to case- loading care. I really think for many women it's the best possible way of doing things, even thought I appreciate that many midwives wouldn't want to work in this way.

In an ideal world, yes, it's a fabulous system. Over and over again we hear that women want a known midwife and one to one care but successive governments have not put money in to support their rhetoric.
I personally would not want that level of on call commitment. It is difficult without supportive family/partner and yet it works for Independent Midwives. I do know a few IM's who have become burnt out but that has as much to do with the number of clients who are desperate for their service and nobody else to refer them to. And there are areas in the UK and overseas where these services are standard, it takes commitment from all parties involved to keep it functioning.

"I personally would not want that level of on call commitment"

I appreciate it would be extremely difficult for anyone with young family.

You can bet that if they do introduce it in the NHS they'd overload midwives with a huge caseload, and it would become really stressful.

It would only work from the midwive's point of view if they didn't try to do it on the cheap.

I understand that this is a hypothetical question - but it's worth flagging up that we don't have maternal request c/s on the NHS. Whatever the NICE guidelines say (and they don't support straightforward maternal request for CS), you only have to glance at these boards to see how hard many women have to fight to get an ELCS, for phobia and after traumatic birth, and how some of them are denied it. We are a long, long way from 'maternal request CS', whatever the Daily Mail would have you believe.

Re: caseloading. In Wales a couple of years ago, there were lots of complaints about lack of continuity of care, through antenatal care to birth to postnatal care.

So they restructured services so that MWs only worked EITHER in antenatal care OR to cover birth. So there was absolutely no way you would get to meet the MWs looking after your birth before you were in labour.

To me this seemed not to be fixing the problem, but rather formalising the lack of continuity of care. Making it official, if you like.

The few MWs I spoke to about this were mostly against this, but not all. It looks to me like it was an attempt to address problems in antenatal care only (women more likely to see the same MW at antenatal appts if they don't attend births and so have a more predictable and standard work pattern). Mothers I have spoken to have various attitudes - most seem resigned from the outset that they will not know the MW who attends their birth.

I agree that more MWs would be a good idea.I think it's a false argument to set up 'maternal CS' versus 'more MWs'. At my local A & E, over 70 percent of admissions at weekends are for alcohol related injuries. Those patients get treated for free. We also have very high A & E admissions in Wales as a whole - and the lowest number of GPs per head in the UK. Again, anecdotally, HCPs say they are seeing a lot of admissions which they feel are caused by patients not getting access to a GP when they need it. This is all costing us millions in avoidable expenditure - millions that could go into better care in so many areas, maternity services included.

Any question of NHS care and provision needs us to take a holistic view of services and resources. Unfortunately for the tabloids, it's a complicated picture and few people want to grasp that problem.