Key learning points:
– Detrimental advice in 1970 suggested all births should take place in the hospital
– Setting up and an independent midwife has financial implications but allows one-to-one care
– The government could change financial structures so maternity services money follows the women
Pregnancy and birth used to be a family affair in the UK and the midwife was a familiar face in the community. The default place of birth was the home with hospital beds reserved for the complicated cases. The homebirth rate began to fall in the 1960s and 1970s and the domino system of birthing became common practice, with the GP and midwife caring for women in cottage style hospitals.1
While unrelated, the maternal and neonatal death rate also began to fall in the second half of the 20th century, mirroring the gradual change in place of birth and leading to the assumption that hospital was the safest place for birth to occur. In 1970 The Peel Report2 had a totally detrimental effect on the homebirth movement when it called for 100% hospital delivery rate.
This report was not underpinned by reliable evidence, nor were women consulted. The following decade saw birth continue to evolve into a medical event and the role of the community midwife go backwards to focus on antenatal and postnatal care. Recent evidence has demonstrated that the reducing mortality had less to do with hospital care than improved medical knowledge concerning general health, the rare complications of pregnancy and birth and overall social and economic reform following World War Two.3
Several generations of babies were born in hospital before any radical change emerged. Midwives and women began to question why the birth culture for was so firmly set with the medical model and fragmented delivery of care, when relationship building is known to produce better outcomes both physically and emotionally for mother and baby.4 Birth out of hospital, either at home or in midwife-led unit has been demonstrated to be safe with added benefits to mother and baby and indeed to society due to its cost effectiveness.5
Most women want to build a relationship with a known and trusted midwife,6 instinctively knowing that it will help them to cope with the challenges of pregnancy, labour and the transition to parenthood. Unfortunately, despite evidence to support one-to-one care as the safest and most economical, it is well documented that midwifery services in the NHS have an ever-increasing workload yet a decreasing workforce, and therefore this continuity of care is often not available in the NHS.7
Some midwives are frustrated with not being able to offer individualised care and so choose to work independently outside of the NHS, setting up in practice either solely or in groups. All student midwives follow an approved programme of education, leading to eligibility to register as a midwife with the regulatory body, The Nursing and Midwifery Council (NMC).8 Within the regulations all midwives, independent midwives included, are supported by supervision in practice, a process which focuses on the protection of the public.9
Unlike community midwifery, self-employed midwives can choose their caseload and workload and make changes to those in order to suit the circumstances of their lives. With no set hours, they can run their own diaries and only work when necessary. They are not bound by an employer’s policies or guidelines and can adapt a woman’s care to her individual needs in accordance with available evidence and the NMC’s ‘The Code: Standards of conduct, performance and ethics for nurses and midwives’.10 Furthermore both the women and the midwife have a vested interest in the relationship as they have chosen to work with each other.
This pattern of care has demonstrated less issues concerning burnout for the individual midwife and a reduced loss of workforce for the profession.
The independent midwife must take on the dual role of midwife and businesswoman. She has to market herself, stock and finance her business, register for tax purposes and ensure any money earned will cover not only her salary, but all financial outgoings, professional insurances, a pension and sick pay. Setting up as an independent midwife is a big step, just as it is for any other business venture, unless the midwife joins an already established practice which may reduce some of the set up considerations.11
Previous experience in the NHS can help transfer practical and clinical experience to her new role but working independently calls for a high level of autonomous decision-making. This could be daunting if she has become reliant on, and comfortable with, working with organisational regimes and foreknowledge may be difficult to discard. However, she will usually be able to adapt to this new way of working (and thinking) slowly as her case load and practice develops.
The newly-qualified independent midwife may have had less exposure to, or been influenced by, the large organisational structures of the NHS or the medical model of care delivery. With the correct tools to care for a woman who is experiencing a normal pregnancy and birth, the newly-qualified independent midwife can seek support and advice from her independent colleagues.12 As her caseload increases she will develop her art and science in a different clinical setting.
I worked for two years as an NHS hospital midwife but my heart was in the community. I was unable to secure a community post and came to the conclusion that independence was the only way I could continue as a midwife. Now approaching my 15th year my commitment to women is intransigent. Although on call 24/7 for a small caseload it is spread out throughout the year to give me around three month’s holiday. Night births are easy when it is for a woman with whom I have developed a relationship.
Having had previous business experience I am attuned to marketing my practice. Initially, in order to find clients I offered my free services to speak at yoga classes or educational antenatal groups.
The popularity and development of social media such as Facebook and Twitter has helped to inform women about their choices including independent midwifery however there are still women who are unaware that the choice exists.
Women are not widely informed about or offered independent midwifery as a mainstream choice yet evidence suggests it is the best care and is available.
Excellent relationships with NHS midwives, mainly those who practice and promote the same physiological model of care, compensate for others who make working relationships challenging. Despite excellent statistics and outcomes some maternity service professionals appear to take a poor view of independent midwifery. Most independent midwives are members of an organisation, Independent Midwives UK (IMUK), which was initially set up as a support system in the 1980s by a small group of midwives but was formalised into a social enterprise in 2008. IMUK has written guidelines for practice for its members which are evidence-based and underpinned by the Midwives Rules and Standards. The organisational philosophy has a focus on true informed choice.
A widely held misconception is that that only affluent women can afford this service. The majority of women who employ an independent midwife are on a budget and plan for this care in the same way they do for a wedding, car or holiday.
Working independently as a mainstream choice for midwives with improved job satisfaction and reduced burnout could increase the numbers of midwives in the UK.
In order to achieve this the government could change financial structures so the money allocated to maternity services follows the women, thereby widening the choice structures for midwives and women and making independent midwifery free at the point of delivery. One-to-one midwifery and continuity of care with a known and trusted midwife should be the minimum default choice for all women.
1. Flint C, Midwifery Teams & Caseloads. Oxford: Butterworth
2. Department of Health and Social Security, Peel Report. Domiciliary midwifery and maternity bed needs. London: HMSO; 1970
3. Journal of the Royal Society of Medicine, British maternal mortality in the 19th and early 20th centuries. 99(11): 559–563; 2006
4. McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, Albers L, Flood M, Oats J, Waldenström U. ‘Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. British Journal of Obstetrics and Gynaecology; 2012; DOI: 10.1111/j.1471-0528.2012.03446.x.
5. National Perinatal Epidemiology Unit (NPEU) Place of birth Stud; 2011 Available from https://www.npeu.ox.ac.uk/birthplace
6. Department of Health. Midwifery 2020: Delivering Expectations; 2010 Available from:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216029/dh_119470.pdf
7. Royal College of Midwives, The Contribution of Continuity of
Midwifery Care to high quality maternity care Available from:
8. Nursing and Midwifery Council Rules and Standards. London:
9. Nursing and Midwifery Council Modern Supervision in Action.
London: NMC; 2009
10. Nursing and Midwifery Council The Code: Standards of conduct, Performance and Ethics for nurses and midwives. London: NMC; 2008
11. Hobbs L. The Independent Midwife Second Edition. Hale: Books for Midwives; 1997
12. Independent Midwives UK. The Home of Independent Midwifery;
2014 Available from: http://www.imuk.org.uk/
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