Feature

Whose baby is it anyway?

At a time when maternity care is being criticised increasingly for absence of choice and lack of involvement in decision-making, a number of practices in Sheffield are encouraging women to take greater control over their pregnancies. Fiona Brooks explains

Women’s criticisms of maternity care have developed an all too familiar ring over the last decade. Absence of choice, lack of involvement in decisions, unwarranted medical interventions, long waiting times at impersonal clinics — research studies and consumer movements have identified numerous causes of women’s dissatisfaction with their experience of care. Research has documented the desire of women across all social classes for more information and involvement in decisions made almost entirely by professionals.

Combined with growing consumer demands, the last 10 years have seen increasing levels of frustration among midwives. Many midwives, faced with the erosion of their role to that of an obstetric nurse, have voted with their feet and entered independent practice, or left the profession altogether.

But working alternatives for maternity care do exist. A number of general practices in Sheffield have attempted to face up to the issue of consumer dissatisfaction by encouraging women to make informed choices and take greater control over their care during pregnancy and labour. This article reports research findings on women’s experiences at two of these practices.

At these practices, both in predominantly working class areas, the midwives are responsible for providing all aspects of care to each woman throughout her pregnancy. The GPs act in an advisory capacity, and can be consulted by either the midwives or the women over any problems that might arise.

Both practices provide women with an open choice over the place of birth, with the majority of women choosing a midwife-attended GP unit delivery, or a home birth.

Antenatal clinics are unhurried and informal, with midwives providing 15 to 45 minutes at each appointment. All women carry their own notes, which are openly discussed. this is appreciated by the women, who particularly welcome the opportunity to talk with the midwife.

Sue, who is unemployed says: ‘Sometimes you would have to wait a while but I never minded because you knew that once you went in you would be given plenty of time. Some days I would be in there 40 minutes and she never hurried me or made me feel that I wasn’t the only person she had to see.’

The question of which health worker is the most appropriate for maternity care is hotly-debated among the professions, yet none of the women express any reservations over the adoption of the midwife as the main provider of care. In fact, the women without exception see the midwife as ‘the expert’ over issues concerned with pregnancy, delivery and childcare.

’I want the midwife, definitely’ says Sharon, a barworker. ‘The midwife is there to deliver babies, that is her only job. Whereas the doctor is just there to see that nothing goes wrong, the midwife is your best friend. She’s there to make sure that everything goes right.’

The women express a preference for the midwives, based not only on a perception of their superior clinical expertise, but also on a belief that the midwife identifies with them and values their needs in a way that even a supportive GP would to unable to.

One of the inadequacies with the current system is that providers cannot offer choice unless women have access to information about their rights and the options available. Many women, especially working class women, simply are not told. The role of the health worker in passing on information to the user may be of central importance in enabling her to exercise real choice.

At every stage of care the midwives at the practices provide detailed information and explanations to the women about their pregnancies and the different options available.

This is especially appreciated — the women feel the discussions enable them to choose a kind of care that they would not otherwise have known was available.

Karen says: ‘Just in talking to other people I feel very fortunate in the care that I have got. The midwife told us about things that I just wouldn’t have known about; she gave you the choice over things, like cutting the cord, things you would have wanted but wouldn’t have known to ask for until it was too late.’

The midwives are not only committed to providing information, but are also concerned to enable women to exercise greater choice and control. The simple question ‘what would you like?’ is, for many, unique experience in terms of their contact with health services. Previous encounters with health professionals had led them to believe that decisions were only made about them, not by them, as Sara and Margaret, both recently out of college, found.

’I am still surprised when it comes down to it, to have been asked,’ says Sara. ‘I though you just had to do what they said.’

Margaret agrees: ‘I was really amazed when I came here — they said to me: “Where would you like to have your baby?”. My own doctor told me to have it at the local maternity hospital. Here they actually asked me.’

Most women find continuity of care and the development of a one-to-one relationship with ‘their’ midwife the most important and positive aspects of their care. In particular they feel that safety and high standards equate with continuity of care.

’This practice gets you better care than at the hospital,’ argues Jean. ‘Here the slightest thing you have felt is noted down and remembered, because they know you. You really feel they care what happens to you — whereas in the hospital you are just one of the faceless thousands.’

As their pregnancies continue and they get to know the midwives better, many of the women feel their anxiety, especially over going into labour, is reduced. Karen’s comment is typical. ‘I found knowing who I was going to see and knowing that she was going to be there for me at the delivery was very reassuring. I felt really safe. I knew I could trust her.’

As a result of the support that the women get from the practices, many feel empowered to challenge and negotiate more effectively with doctors at the local hospital — as Margaret relates.

’When the consultant at the hospital said that I might not be able to have a GP unit booking because of my age, I told her I didn’t want to make any decision until I had discussed it with my midwife and my GP who knew all about me. She got really nasty and said: “Oh, its patients who make those decisions now!” I was really upset, but I knew they would back me up at the practice so I wouldn’t give in.’

Margaret ultimately delivered in the GP unit, as she had planned.

These women’s accounts show that a new kind of care, meeting physical and emotional needs and giving users a measure of control can exist within the constraints of our health service structures. The sad thing for midwives and users alike is that these practices are still very much the exception.