There is nothing so profound or influential in human life as the birth of a baby. The start to life, people becoming parents, the family forming or reforming, will affect not only the individuals concerned but will reverberate through life and down generations, and ripple into society. Midwives are central to the support of this new life and the promise it holds, and have the potential to enhance the beginning of life, or to harm it.
As President of the Royal College of Midwives (RCM) for more than 5 years, I travelled the UK from top to toe. I also visited many other parts of the world, meeting midwives, students, doctors, policy makers, government leaders, members of the public, and activists. I have seen many maternity services in many different countries and have met countless midwives who are passionate about giving high quality care. Some are supported in achieving these high aspirations, and others are impeded or even stopped by failure of leadership, limited services, inadequate resources or destructive political forces.
During my 5 years as President, I have also seen profound changes in our society. Not only a revolution in democracy and attitudes, seen in the results of referendums and elections, or migration at its highest levels since the second world war, but also new science and shifting or world views, particularly in regard to maternity care.
The intense experience of this immersion in world midwifery and maternity care has, for me, brought achievements in midwifery into sharp relief—and I see green shoots of change as well as the considerable challenges we face if we are to ensure that every woman, newborn and family around the world is to get the best start in life.
‘Midwives are central to the support of new life and the promise it holds’
Too much, too little
While a large number of women lack access to health services or a skilled birth attendant, over-intervention in birth or the medicalisation of birth is increasing. These are not two parallel problems, separated between high resource countries and low resource countries, but two extremes that often overlap. The Lancet classes these two approaches (Miller et al, 2016) as ‘too little too late’ (TLTL) and ‘too much too soon’ (TMTS). TLTL is described as ‘care with inadequate resources, below evidence based standards, or care withheld or unavailable until too late to help’ and TMTS is described as the ‘routine over-medicalisation of normal pregnancy and birth’.
I have witnessed not only the coexistence of these two extremes, but also a failure to provide appropriate care to women with multiple vulnerabilities, such as women living in poverty, women living in slums, or women who are refugees, where health care does not respond to their circumstances. Over-medicalisation, often associated with abusive systems, adds to their life trauma and to the sequelae of unnecessary intervention, including caesarean section, and psychological trauma.
For example, women living in refugee camps in Greece received good pregnancy care in the camps, but were admitted to hospitals to give birth; here, women had no companion, no interpreter, and hospitals' caesarean section rates were often around 60%. In India, I knew what it would be like for the women I met who were living alongside the railway tracks, when they were admitted to hospital to have their babies: overcrowded, no privacy, lying unclothed and flat on their backs for second stage of labour, with no sheet on the table, no pain relief or support, no companion and with their legs in stirrups towards the centre of the room so the doctor could ‘watch’ what was going on.
Women in India are paid to go to hospital, although they do not see the money. It is difficult to understand a policy of institutional birth when the quality of care is so poor. Midwives in India want to do more and the doctors I met wanted to change the system and see midwifery integrated into the health systems.
Harmful practices, such as shaving and enemas in labour, lying flat (often in lithotomy position, even for ‘normal’ birth), the routine use of electronic fetal monitoring, use of the Kristeller manoeuvre, routine episiotomy, liberal use of uterine stimulants such as oxytocin, and separation of mother and baby, are common in much of the world, including high resource countries, emerging economies and parts of Europe. These are abusive systems of care. Around the globe, many of the world's women have their babies in such systems.
Humanising midwifery care
The emerging movement of humanisation aims to provide maternity care that is human rights and evidence based, respectful, responsive to the life circumstances of women and their families and oriented to optimal wellbeing rather than focused on risk, pathology and fear. Humanised midwifery provides appropriate health care and access to skilled, knowledgeable and compassionate midwives, as well as other professionals and carers. The movement to humanise maternity is particularly important given the profound effect of care—or lack of care—on birth, physical and psychological outcomes, and the long-term security of mother, baby and family relationships.
Midwives have a crucial part to play in this global movement. The Lancet midwifery series (Renfrew et al, 2014) provided an evidence based quality framework, focused on the needs of women and their babies. The series estimated the potential for lives saved by the implementation of skilled, knowledgeable midwifery, particularly when combined with provision of contraception. Most of the care needed by women, babies and families around childbirth can be offered by midwives working in safe systems.
Building on developments
Midwives have been central to the evolution of effective, safe maternity care. Since the 1980s, advances in midwifery in many parts of the world have been exponential. Evaluations of midwifery development, research and collaboration have helped to identify successful and compassionate practice and the importance of access to midwifery led, relationship based care in and for communities. These new or renewed services should be evaluated in low and medium resource countries and emerging economies.
The question is, how should services be spread and built around health systems that understand the value of midwives, so that the full potential of midwifery is realised? Midwives want to do their best; to give more and to have their voices heard so they may contribute to the highest standard of care for women and babies everywhere (World Health Organization, 2016). Even in countries with highly developed services, the potential of midwifery is not fully realised. In addition, there are the countries where midwifery has been eradicated, limited, suppressed or severely restricted. It is a tragedy.
Advances in midwifery research
Growing scientific understanding of the impact of birth on long term health, wellbeing and relationships represents a shift in our worldview, giving us a new perspective. This makes it clearer than ever that we can no longer focus solely a live mother and baby. Survival is not enough: women, their babies, parents and families should be supported to thrive—and not only in the short term.
Research that has emerged over recent years has influenced understanding of the microbiome and how the human immune system is influenced by birth. This raises awareness of how the type of birth, vaginal or caesarean section, impacts on the long term health of the baby.
The physiology of birth, breastfeeding and skin-to-skin contact is understood more fully, as well as the importance of this biological foundation to the mother's wellbeing, the baby's emotional health, and the development of the mother-baby bond.
The interweaving of psychological support and help to maintain this physiology by avoiding unnecessary interventions (caesarean section, epidurals and inductions), reducing fear, and giving warmth, appropriate touch, and supportive interactions, will have a long term effect on the life of the baby and the family—one that lays a foundation for future relationships and a productive life. The birth of the baby is the birth of humanity, and also, through skilled knowledgeable compassionate midwifery, the birth of our humanity to each other.
Global unity and inspiration
At the end of my two terms in office I attended the International Confederation of Midwives (ICM) congress in Toronto. More than 4000 midwives and partner organisations from around the world attended, working to achieve solidarity and share knowledge and understanding. Delegates represented the extremes of inequality of resources and outcomes, both between and within countries, yet were united by a love of midwifery, and an awareness of their potential to improve the start of life. It was clear that midwives do make a difference, and want to do more.
I have been inspired by so many people working to make the world a better place through improvements in midwifery and maternity care. I know one thing for certain: it is critical to ensure that we build on midwives' potential to support every mother, baby and family to have a safe, life affirming start—this is, after all, the birth of our humanity.