Sheila Kitzinger’s Letter from Europe:
What’s Happening to Midwives in Europe?
Published March 2004. BIRTH, 31:1:68-70.
The whole system of maternity care in Britain is based on midwifery. Because obstetricians are specialists in pathology, without midwives care in childbirth would collapse, and most women have to give birth attended only by family and friends.
Throughout Western European countries midwives are the main caregivers. What doctors learn about normal birth they acquire largely from midwives. On the whole, women don’t need obstetricians, but there is no question that they need midwives.
Wherever autonomous midwifery exists—in the Scandinavian countries, the Netherlands, where one third of births take place at home, and New Zealand—perinatal mortality rates are the lowest in the world.
Although midwives are qualified to provide total care in pregnancy, birth, and afterwards, they have had little influence on formulating public health policies, and institutions representing obstetricians speak with a louder and more authoritative voice.
In Germany and Italy, maternity clinics are similar to the United States model. When I observed births in hospitals in Northern Italy, for example, I witnessed women waiting to give birth until the obstetrician put in an appearance. They were ordered not to push, however much they wanted to. Midwives were not supposed to deliver, except in an emergency. The obstetrician enters, performs an episiotomy, and delivers, often employing fundal pressure and using a manoeuvre that entails sticking a finger in the woman’s anus and forcing the baby’s chin up over the perineum.
In Eastern Europe Communism introduced totalitarian and highly bureaucratic medical control of childbirth. It is still the norm. Zuzana Stromerova, of the Czech Association of Midwives, says: “ Under the Communist regime midwives were a small body of professionals who had little power and had to do as they were told” (1). There is no midwifery legislation or laws referring to midwifery in the Czech Republic. Midwives are not recognized legally as an autonomous profession…and are called “women’s nurses.” She went on to say that doctors “view a normal birth as a potential crisis, not a normal event in life, and it is doctors who are considered the experts.…Hospitals are not paid by health insurance companies unless there is a signature from the doctor on duty or chief doctor.” So an independent midwife, if it were possible for her to exist, would get paid nothing. Birth is the responsibility of obstetricians.
Out-of-hospital births are forbidden by law, and a midwife can be punished for helping a women
have a planned home birth, as can the mother.
World Health Organization (WHO) report (2) on midwifery in Central and Eastern European countries states “Doctors are the lead professionals in birth…Midwives hold the position of doctor’s assistant and are often not advocates of women. Home birth is neither attended by midwives nor supported.… Midwives provide care immediately following the birth but not in the postnatal period.… Midwifery practise is not based on the latest evidence and research… Legislation states that ‘Midwives work under the authority/direction of a doctor.’ There is no register for practising midwives…Midwives have little influence in the setting of national policies…No local structures exist which monitor standards of midwifery practice.” Commenting on midwifery education, the WHO report observed that up to 65 percent of time is spent on theory and never more than 40 percent on practice. “There are no midwifery training establishments. There are no nursing establishments affiliated with institutes of higher education” (2).
The situation is particularly bad in Hungary.
Maternal and child health nurses, not midwives, are the primary caregivers for pregnant women. Midwives work under the supervision of doctors and, according to WHO, although midwifery practice is claimed to be evidence-based, it “is dependent on the physician’s practice and philosophy of the institution” (3). Home births are banned. The Board of Obstetricians and Gynecologists has issued two statements about home birth (3):
· First, “Pregnancy is a biological process that has several special patho-physiological features even in ‘normal’ cases. Pregnant women must not endanger the health or life of their fetuses/new-born babies by rejecting birth in a clinic/hospital.”
· Second, “The restoration of home births would, even after significant investments, endanger the safety of child-births, and put the health and lives of mothers and new-born babies at risk.” Section 17(2)a) of the Health Care Act proclaims that “pregnant women do not have the right to autonomously decide in this issue, and thus cannot reject maternity treatment in hospital.…The outstanding results of Hungary’s obstetrics in reducing perinatal mortality have always been accreditable to institutional births.… Women about to give birth need the constant availability of emergency service” (4). The Health Care Act rules, “a pregnant woman must not reject life-saving or life-maintaining intervention. Pregnancy is not among the exceptional situations when a patient is legally allowed to reject health-care provisions” (4). That includes delivery in hospital and compliance with any obstetric interventions that are considered necessary by the professionals in charge.
Ten new members are joining the European Community in 2004, including these Eastern European nations. They are required to change their maternity care systems to meet the European Community standard, and will have to give midwives professional and autonomous status, although they are allowed 2 years in which to make these adjustments. It will be a huge challenge.
Meanwhile a new restlessness is occurring among midwives in the United Kingdom, with lively debate about how to promote normal childbirth, really listen to women, and work with those who want to avoid obstetric interventions and high-tech management. Midwifery is also being examined in terms of the needs of a society in which deprivation starts, for many people, at birth.
This year the Government will publish a National Service Framework for children, young people, and the maternity services, and midwives are in the forefront of initiatives to identify how they can serve the most vulnerable in our society. Sure Start projects have begun to address drug and alcohol addiction in pregnancy, and the needs of teenage pregnant women, ethnic minority families, and travellers. More options for home birth are opening up, together with birthing units run by midwives.
Meryl Thomas, Vice President of the Royal College of Midwives, says: “There is evidence that women wish to have, and improved outcomes are more assured by, one-to-one care by a midwife for a woman throughout labour” (5,6). “There is also a significant number of women who would like to have a non-interventionist, normal childbirth experience and the option to give birth in a midwifery-led environment, or in a purpose designed birthing centre” (5,7). She stresses that midwifery is an autonomous profession, and that capitulation to the views of other professionals is not appropriate, whereas reasoned argument is.
On the other hand, midwives are leaving midwifery in droves. Of the 43,590 registered midwives, 32,190 are practicing (data for March 31, 2003) and 11,400 qualified midwives are not practicing. In statistics soon to be published, around 4,000 left in 2003. For some this is because they simply wanted a midwifery qualification in order to get a senior post as a health care professional. Policy makers often discuss the midwife shortage as if it were solely a matter of low pay and working conditions that are incompatible with family life. Both of these may be true, but there is more to it. Many are dissatisfied because they did not go into midwifery to spend their time filling in forms, manipulating machinery, and having to switch their attention between 3 or 4 women in labor at the same time, leaving them supervised only by continuous electronic fetal monitors and rendered compliant with epidurals. They entered midwifery to give woman-to-woman care.
Not only do mothers often not receive this quality of care, but midwives are denied the opportunity to give it. National statistics prepared by the United Kingdom Government Statistical Service reveal that the proportion of births conducted by midwives in the year 2001/2002 fell to 65 percent from 1989/1990, when it was 76 percent. Only 45 percent of women gave birth “without intervention” (i.e., no induction, spinal, epidural, or general anesthesia, and no instrumental delivery or cesarean section) compared with 56 percent in 1991/1992; 21 percent of labors were induced, and the cesarean rate increased from 21.5 percent to 22.3 percent. The proportion of hospital deliveries that occurred spontaneously is approximately 67 percent, having fallen steadily from 78 percent in 1989 (8).
With increasing dependence on technology and more obstetric intervention, midwifery skills are eroded. At the same time, midwifery education has improved. Although more and more graduate midwives are entering the profession, many find that they are unable to have some control over their work, use their skills, and make decisions. They encounter a working environment that is hostile and blame seeking. Midwives are set against midwives, and intimidation and “horizontal violence” is prevalent (2–11). It is very difficult for midwives to continue to give supportive care to women when they themselves feel unsupported.
But this is not all. Mavis Kirkham, Professor of Midwifery at Sheffield University, tells me: “The problem with midwifery is bureaucracy. Midwives get totally disillusioned and leave as practice gets rule-driven. We are all policing each other. It is not medical oppression. It is bureaucratic oppression. Midwives are supposed to be autonomous. But we are caught in a bureaucratic trap.”
The depressing conclusion may be drawn that, rather than Eastern European midwifery being transformed to the standard of midwifery accepted in Western European countries, in Britain midwifery is at risk of being degraded to conform with the totalitarian East European model.
1. Stromerova Z. Royal College of Midwives International Conference, Vienna, Oct, 2002.
2. World Health Organisation. Profiling Midwifery in Newly Independent States and Countries of Central and Eastern Europe. Geneva: Author, 2003.
3. PappZ, ed. Statement of the Board of Hungarian Obstetricians and Gynaecologists on Home Birth, Budapest, Hungary, Jan 18, 2002.
4. Statement of the Board of Hungarian Obstetricians and Gynaecologists on Home Birth, Budapest, Hungary, Feb 26, 1999.
5. Thomas M. The crest of the wave—will midwives ride it? MIDIRS Midwifery Digest 2003;13:3.
6. Page L, Beake S, Viaol A. Clinical outcomes of one-to-one midwifery practice. Br J Midwifery 2001;9:700–706.
7. Boulton M, Chapple J, Saunder D. Evaluating a new service: Clinical outcomes in women’s assessment of the Edgware
Birth Centre. In: Kirkham M, Ed. Birth Centres: A Social Model for Maternity Care. Oxford: Elsevier Science, 2003.
8. National Health Service. Maternity Statistics, England: 2001/2002. Bulletin 2003/09, 2003.
9. Fanon F. The Wretched of the Earth. New York: Grove Press, 1963.
10. Leap N. Making sense of “horizontal violence” in midwifery. Br J Midwifery 1997;5:689.
11. Ball L, Curtis P, Kirkham M. Why Do Midwives Leave? London: The Royal College of Midwives, April 2002.