The news and social media have been ablaze with debate and comments since the new (non-coalition) Government has been elected, many suggesting it will lead to further privatisation of the NHS as well as other public services. Some have suggested staff will become demotivated, which may lead to more shortages of personnel directly affecting patient care. As we know, there is already a national shortage of midwives. This, together with changes to supervision and other challenges, might have adverse effects on staff and the services we can provide.
Things do not appear to have improved since Ball et al's (2003) study reviewing why midwives leave the profession. I recently supervised a return to midwifery ‘student’ who left around 15 years ago. Her reason for leaving then was a perceived lack of support and burn-out leading her to pursue a career outside of midwifery. On her return she still sees the tell-tale signs of midwives suffering from stress at work, noting the lack of breaks, increasing workloads and ever-changing roles. So without generating a political debate, what can we do as teams or individuals to ease the burden on maternity services and make the most of the valuable resources we do retain?
You may argue that change is nothing new and midwives will rise to these challenges, providing the best woman-centred care they can. But at what cost? Can we simply carry on and hope for the best? Some Trusts are looking to make long shifts compulsory and introducing mixed day and night shifts in a week. Although there is a dearth of literature in relation to this, Hunter and Warren (2013), determined that shift-working, adverse incidents and staff shortages affected midwives' resilience. Midwives' welfare has to be considered and given last year's decision to take strike action, perhaps the time is right to address the concerns.
In leadership ‘speak’ this might be classed as a ‘wicked problem’—one that is complex, multi-faceted, and not resolvable by any one individual or group (Grint, 2008). Therefore, midwives need to work not only with other health professionals, but also with members of the community to look for long-term solutions.
Can midwives continue to work with increasingly complex case loads and support women's choice without some compromise? Women might be integral in easing the burden on stretched resources. While for a number of years, at least since the introduction of ‘choice, continuity and control’ in the Department of Health 1993 Changing Childbirth report, women have seemingly had all options open to them. Leaders in midwifery have strived to ensure that women have access to services as required, even if their choices are ‘outside of conventional advice’. But can we continue to offer care, which is essentially ‘against policy’ all of which should be evidence-based? Of course, women should be at the centre of care and encouraged to participate in making decisions, but in these times of austerity can or should this always be supported?
One recent ‘story’ led me to consider this dilemma. A woman wanted a home birth but due to a previous complicated obstetric history she was discouraged by the midwife carrying out the booking interview. She contacted the supervisor of midwives (SoM) for support who, appropriately visited the woman to negotiate a plan that met her needs and also considered her wellbeing. After numerous meetings, a plan was agreed and two midwives attended the birth at home. The midwives became concerned about progress in labour and once again contacted the SoM (who had made herself available for advice and support). Eventually, the woman was transferred into the consultant unit and requested the continued support of the original midwives who were familiar to her along with the care from the core midwife used to working in the hospital environment. A safe and happy outcome was achieved. However, does it follow that there was a woman in labour somewhere that was not getting one-to-one care as three midwives were supporting one woman? Is this something we can continue to offer and should the woman have been informed this was not an option?
There is much debate at present about ‘patient leaders’—those service users working at a strategic level using their experiences to influence care and contribute to change. Would this concept work at an individual level? A humanistic and informed discussion about realistic options and professionals not being afraid to say that some choices cannot be resourced. Women might then chose to look outside the NHS in some cases. Although some midwives are sceptical of the increasing number of non-NHS services providing maternity care, perhaps they can meet the needs of some women. The concern is that women might decide to ‘go it alone’, feeling that they have been deserted by midwives, but hopefully if they have been part of the decision-making process all realistic options have been explored.
These are difficult decisions and there may be no definitive answer but perhaps the time has arrived to have the debate?