FOCUS: LABOUR PAINS: Midwives:

an endangered species?

After the birth of her second child, Julia Guy, a 31-year-old midwife, realised she could no longer work for the National Health Service. She had been a midwife for eight years, but had become increasingly frustrated by the lack of time and energy she could give to the mothers going through labour.

"I had my second child at home with the community midwife. It was such a wonderful experience I thought this is what every woman should be able to have," she said.

"I was a hospital midwife and often used to look after more than one woman going through labour. It's very difficult as you can't give anyone 100 per cent attention because you are thinking about the others at the same time. The way the system was set up meant that I had no time to build up a relationship with my patients. This, coupled with staff shortages, meant that I could not give the kind of care that I wanted to."

Mrs Guy moved to the Wessex Maternity Centre, in Southampton, a private centre which offers pregnant women a "one-stop shop" of maternity care. Now she can offer women individual care, emotionally and physically, throughout their pregnancy and early motherhood, and is on call 24 hours a day.

Her concerns about midwifery in the NHS were echoed in a report by the English National Board of Nursing, Midwifery and Health Visiting, released last week. In an analysis of 124 maternity units in the country, nearly a quarter had a severe shortage of midwives, a third were unable to provide one-to-one care and many women were being left unsupervised in the final stages of labour. Virtually none of the maternity services in the country could recruit the number of midwives it needed and 15 per cent of all vacancies were unfilled. "There are very few midwife units in the country that have a full quota of midwives," said Tony Smith, chief executive for the board.

Official figures show that since 1988 the number of midwives working full time has dropped by 15 per cent, from 20,567 to 17,396 in 1999. Although many more midwives are working part time compared with 10 years ago - 48 per cent rather than 33 per cent - the number leaving the profession is increasing.

Between 1998 and 1999 the number of midwives working part time increased by 331, but the number working full time dropped by 845, a shortfall of more than 500 midwives.

New research to be published shortly, conducted by the Centre for Business Research at the University of Cambridge, has found that low morale, poor pay, lack of flexibility and staff working under extreme pressure are having a devastating effect on the profession.

"The widespread feeling among midwives was that excessive hours and more intensive work are causing stress and have detrimental effects on both the quality of their work and on their families. Midwives are leaving the service in ever greater numbers, while new recruits are proving more difficult to attract and retain," said Frank Wilkinson, author of the report.

The report was based on questionnaire responses from midwives from 120 maternity units, and face-to-face interviews with nearly 100 midwives in six different maternity units. It found there was also a widespread difference in pay. Two midwives doing the same job and carrying out the same responsibilities could be on two different grades of pay.

"Many health authorities, when a midwife leaves, have seized the opportunity to cut costs and get a new recruit in on a lower rate of pay," said Mr Wilkinson.

The report shows that only a handful of hospital trusts have implemented the officially recommended new minimum grade of pay for midwives giving the full range of midwifery care.

"Midwifery is not just a job; it is a vocation. Midwives feel called to perform to the best of their abilities regardless of poor morale because of their obligation to women and to their babies. However, it remains an open question as to how long the NHS can continue to rely on midwives voluntarily making special efforts in the face of low morale and deep dissatisfaction with pay and conditions," he said.

Overall, two-thirds of midwives said that the pay structure did not reward their level of training, their commitment or their role as autonomous practitioners. Three-quarters felt they receive little or no reward for their accountability and additional responsibility.

Louise Silverton, deputy general secretary of the Royal College of Midwives, believes the Government is letting midwives down. "We feel that the contribution of midwives to the health of the nation is not valued by the Government because they have not encouraged the widespread introduction of models of care that allow midwives to use their full skills," she said.

"They have not implemented the agreement we had with them about pay, that midwives should be paid a minimum of pounds 17,000, which is the equivalent of a junior sister level in nursing."

Ms Silverton said that midwifery was "not seen as very sexy because it is women with women". "We are not using fancy machinery and interventions. We are talking to women, supporting and helping them through their pregnancy. Future mothers want midwives and we want to help women.

"Midwives are not nurses. It is a separate profession and it is time it was treated as such in both pay and conditions."

Experts believe that the increasing shortage of midwives could have a devastating effect on future mothers, both physically and emotionally. Judy Perry of Full-Time Mothers, a support group for women who stay at home with their children, said that all women wanted to have a midwife with them during labour.

Mrs Perry, from west London, is the mother of two young children, George, seven, and Lucy, four. She had a midwife present at both her births. "It would have been awful if I had been left in the hands of the hospital doctors," she said. "They are so busy and pressurised with emergencies and trying to do 10 things at once.

"I was over 40 when I had my first child and having a midwife was very reassuring. You know they have seen lots of births before and have experienced nearly every eventuality. Although they don't sit with you the whole time during labour, they are just outside the door," she said.

The rise in caesarean sections has also been blamed on the lack of one- to-one dedicated care during labour, coupled with the increasing use of medical intervention during childbirth. Official figures show a rise in the frequency of caesarean sections - operations in which a doctor is the key medical practitioner, rather than the midwife - between 1996 and 1998. In 1996, 84 maternity units performed caesareans in 10 to 20 per cent of cases, and nine units carried them out even more frequently.

Last year, there were 68 units in the 10 to 20 per cent bracket, with 25 in the 20 to 30 per cent bracket. A further two units were carrying out caesareans in more than 30 per cent of cases, compared to none in 1996.

Overall, caesarean sections accounted for 17 per cent of the births in England, 18.5 per cent in Scotland, 18.1 per cent in Wales, and 19 per cent in Northern Ireland.

Professor Lesley Page, of Queen Charlotte's Maternity Hospital in London, said: "We have known for some time that caesarean section rates are now quite astronomical and I think it is a problem of things not being done properly in labour. If a woman is left alone in labour, then she is much more likely to need an epidural, pain-killing injection, which in itself leads to an increase in the need for caesarean sections."