Feature

Harder labour for midwives

Anthea Symonds analyses the events which have lead up to recent calls for strike action by midwives

When the result of the Royal College of Midwives ballot on rescinding its ‘no strike’ policy was announced recently, it received top coverage on TV and in the press. Midwives’ anger at the offer of a centrally-funded 1 per cent pay rise with an additional 2 per cent to be negotiated locally had prompted this ballot and the result.

The midwives are the first group within the nursing and healthcare professions to accept formally the option of strike tactics in pursuit of a pay claim. The general feeling engendered by this decision was one of amazement that a previously ‘conservative’ profession should adopt so radical an approach. Why are they so angry and what is it about midwifery itself that has engendered this intense reaction?

First, the idea that this almost exclusively female occupation is unused to political and professional activity of a vocal and assertive kind needs to be reviewed. A discernible feminist orientation has always existed within the profession, in that midwives have identified themselves with the interests of women and their babies. They have also resisted the entry of men into the profession for two main reasons: the articulated preference of women to be cared for in childbirth by women; and to ‘protect’ the occupation from male advancement. When one looks at what has happened within nursing as more and more men have entered the profession and gained a vastly disproportionate number of the management and tutor posts, the latter appears to have been a very sound tactical move.

Unlike nursing occupations, midwives have historically been in a competitive and sometimes antagonistic relationship to the medical profession. Midwives and GPs were market competitors before the advent of the NHS and subsequent hospitalisation of childbirth. This move was prompted by pre-war political concerns about the rate and causes of maternal mortality on which obstetricians, GPs and midwives conflicted. But the concern about ‘safety’ was used to move childbirth from home to hospital and remove it from the hands of midwives into the control of doctors. Since then midwives have been in a subordinate position to the overwhelmingly male obstetric profession, a position which continues to be fiercely resisted by them.

Midwifery was organised and has developed within a professional strategy of resistance to the power of the medical profession and a determination to preserve and extend the ‘autonomy’ of professional practice. But the reality of a professional ‘independence’ for the vast majority of midwives has always been questionable.

In recent years, both feminist and professional concerns within midwifery have become interlinked and have formed a foundation for the organisation of self-identified radical midwives within the mainstream of the Royal College of Midwives. Although relatively small in number (approximately 7 per cent of the total of practising midwives), the Association of Radical Midwives through the quarterly journal Midwives Information and Resource Services, has powerfully advocated change in both the role and responsibilities of midwives and the siting and methods of childbirth generally. This self-styled midwifery ‘think tank’ insists on the identification of a midwife as ‘an autonomous professional in her own right’ and rejects the role of midwives as salaried employees and maternity nurses working under medical control. Together with members of the consumer group, the National Childbirth Trust (NCT) it has also campaigned for less medical intervention in childbirth, more home births and the extension of ‘choice’ to women in the birth methods to be adopted. Many of these issues have become common currency in the larger field of midwifery education and among midwives’ representatives.

In 1992 it appeared that their combined demands had been heard and heeded by the government. The Health Committee chaired by Nicholas Winterton reported on the future of the maternity services.¹ Representatives of both the RCM and the Association of Radical Midwives (some being members of both) gave evidence on behalf of the profession. Evidence on ‘what women want’ was taken from many organisations, the voice of women users was represented by, among others, the NCT, the Association for Improvement in the Maternity Services (AIMS) and the Maternity Alliance. What they wanted was continuity of care during pregnancy and childbirth, choice of site and method of birth and control over the birth process. These demands formed the background for the subsequent proposals to move midwifery care into smaller midwifery-led units as an alternative to the large consultant-led institutions, to promote the midwife as the lead professional in 30 per cent of all births and to place antenatal care within the community for all women with normal pregnancies.

For the first time since the foundation of the NHS, the medical model of childbirth was formally questioned and the statement made that ‘the policy of encouraging all women to give birth in hospitals cannot be justified on the grounds of safety’. The new look maternity services were to focus upon reducing the use of high technology in childbirth where appropriate, and widening choice for women as to where to have their baby, including encouraging more home births in response to demand. It appeared that the important elements of the radical midwives’ agenda had in fact become accepted government policy. This was certainly the way in which many in the profession regarded the findings and proposals.

Following the Winterton report, an expert maternity group was set up under junior health minister Baroness Cumberlege ‘to review the policy on NHS maternity care’. This group published its first report in 1993 and made concrete many of the recommendations of the Winterton Committee in its proposals for action over the next five years.² The move to midwifery-led care was of paramount importance as was the freedom of choice to the mother. On the surface then, both these reports were an illustration of a massive government U-turn and a significant gain for the recognition of midwives as a professional group. But why did the government decide to move in this direction?

First, the Health Committee recommendations for more home or community-based births in small midwifery-led units and with ‘antenatal care to be firmly placed within the community’ are fully consistent with implementing policies of de-hospitalisation and community care. Likewise the ‘woman-centredness’ of the proposals and the identification of mothers as consumers of services whose satisfaction must be sought and who can exercise choice, are in line with The Health of the Nation (1990) and Working For Patients (1989) policy initiatives and the consumer-orientated market approach of the reformed NHS.

But when one looks at the actual proposals even more light can be shed on the reasons for the apparent U-turn in government thinking.

Midwifery care would obviously be cheaper than obstetrician-led care in large units. Even though the majority of hospital births have in fact been managed by midwives, officially recognised midwifery-led care could be costed at a lower overall rate. But would this shift to midwife-led care lead to redundancy among consultant obstetricians? On the contrary, evidence to the Health Committee showed that the specialty was suffering from a shortage of recruits, that there was a need to reduce the number of hours worked by junior medical staff and that new working practices should be introduced to reduce the drop out rate in the specialty. Obstetricians would, of course, remain primarily responsible for ‘complicated’ or ‘abnormal’ pregnancies and deliveries.

All these proposals meant that midwives would be required to take on more responsibility with the greater possibility of vulnerability to litigation, continue their present responsibilities (for instance conducting antenatal clinics within a GP practice for the remuneration of the practice) but with an increased workload, work in midwifery teams in order to give continuity of care, which could mean longer duty hours ‘on call’ and more restricted holidays, and yet still be employed within the NHS by trusts which were keen to lower labour costs.

The midwives were given a high ‘ideological’ status by the government reports and proposals for change but this was never to include higher financial rewards, in contrast to the GPs and obstetricians who would be contributing fewer hours for more money. This has also been the tactic employed against other groups of women, such as mothers and nurses, where the rhetoric of praise for their vital contribution substitutes for any financial reward.

By taking the decision to keep strike action as an option, have the majority of midwives defined themselves as skilled craft workers rather than as ‘autonomous professionals’? This could be a pragmatic move, as the present government has proved to be antagonistic towards the ‘independence’ of the professions.

The Health Committee report and the subsequent report of the DoH expert maternity group do not offer an unambiguous ‘way forward’ for this female occupation, they simply require hospital and community midwives to do more work for less money and to be satisfied with recognition and gratitude as a reward. It is sad that this was not apparent to some midwives when they embraced the Winterton report and subsequent proposals so uncritically but it does now throw some light on the reasons for the depth of midwives’ anger.