We have long known that there is a significant problem in the maternity services, and it’s not the one that you read about in the press.
The real problem is the systematic devaluing and disintegration of models of care that follow the evidence, support female physiology, and promote autonomous midwifery practice.
I wrote those lines a few weeks ago, when I was lucky enough to read an advance copy of Closure: How the flagship Albany Midwifery Practice, at the heart of its South London community, was demonised and dismantled.
Closure was written by Becky Reed and Nadine Edwards, and it’s about the flagship Albany Midwifery practice which in 1997 negotiated a pioneering NHS contract with King’s College Hospital Trust.
As the authors explain,
“The Albany model of midwifery care was loved and respected not only by those who experienced it first-hand, but also by the wider midwifery profession. Founded to serve one of the most disadvantaged populations in London, its innovative approach led to improved outcomes for mothers and their babies. Why, then, was the practice suddenly shut down in 2009?
Although it was widely acknowledged that the Albany model offered gold-standard care, the hospital trust claimed that since March 2006 this care had been ‘unsafe’. But both the data and the methodology used to condemn the practice were flawed, and the real reasons for the closure remained obscure. Despite extensive protests by mothers and families, midwives, and many high-profile supporters, the Albany was forced to close its doors and one of the midwives was subjected to a punitive investigation by the Nursing and Midwifery Council, which eventually found that there was no case to answer.
Midwives and campaigners have long pushed for answers about what really happened to this flagship midwifery practice. In this damning assessment, based on years of careful research and interviews, the authors reveal how a hugely successful healthcare project was undermined and dismantled, to the detriment of mothers and babies, the wider community and the midwifery profession as a whole.”
Closure is now available, and I’m writing this blog post because I think it’s so important that those who are working in the field of birth understand the history, the herstory, and the deeper issues that influence what is happening today.
Here’s the rest of what I wrote:
“This book is important because it doesn’t just tell us that this happens: it shows us how it happened to one group of midwives and the women and families they were caring for. I desperately wish that Closure had never needed to be written, but it is really important that it has been. We have much to learn from it.“
Secret decisions and bad data
Nick Wallis, author of The Great Post Office Scandal, had this to say about the book.
“Closure highlights the social and professional harm caused by decisions made in secret with bad data. The lack of transparency, the dissembling and the vindictiveness is here in all its ugly predictability. I hope this is not the end of the story.” Nick Wallis.
It is both striking and distressing that we seem to be living in a time of secret decisions and bad data. Like Nick, I hope that this is not the end of the story, and I hope that you will take a look at the book and see for yourself.
Celebrating the Albany Practice Outcomes
An important paper on the Albany Midwifery Practice was published in Midwifery in 2017.
Titled ‘Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997–2009)’, the freely available paper by Homer et al (2017) examined trends and outcomes for all mothers and babies who received care from the Albany Midwifery Practice from 1997–2009.
This was a total of 2568 women.
There are several reasons why this paper is important, but I am going to focus on just three of them.
First, this study further demonstrates the effectiveness and safety of woman-centred, individualised and choice-focused midwifery care.
It’s hard for many people to understand why governments aren’t doing more to promote and support midwives and ensure that midwifery is regulated by bodies that are fit for purpose. That’s because this and similar studies show time and time again that midwife-led care leads to lower intervention rates and safe, positive outcomes, even for women (like many of those in this study) who have complex pregnancies and perceived risk factors.
“Overall, 79.8% of women had a spontaneous birth with an overall caesarean section (CS) rate of 16%. Of the 84% of women who had a vaginal birth (spontaneous and instrumental), 78% had a physiological third stage of labour with 5.9% of these women having a postpartum haemorrhage (PPH) (blood loss >500 mL). The overall PPH rate for all births was 14% (2.3% had a blood loss of 1000 – 1500 mL and 0.5% had a blood loss of >1500 mL). Two thirds of women who had a vaginal birth had no perineal trauma (62.2%).” (Homer et al 2017).
The second key takeaway for me is that this analysis shows that midwifery care can make even more of a difference for women from Black, Asian and Minority Ethnic (BAME) communities, who comprised 57% of the women whose data were included in this study, as well as for single women. Both of these groups of women tend to have a higher perinatal mortality rate than average, and the data from this study shows that good midwifery care can make even more of a difference to these women.
“It has been shown that women from BAME groups and single women are at higher risk of adverse outcomes during pregnancy and after. For example, these women are more likely to experience complications during pregnancy, an unplanned caesarean section, and having their baby cared for in a neonatal unit than those from the White British group (Raleigh et al. 2010). Babies of Black or Black British and Asian or Asian British ethnicity have also been shown to have the highest risk of extended perinatal mortality with rates of 9.8 and 8.8 per 1,000 total births respectively (Manktelow et al. 2015). These rates are considerably higher than the Albany rate of less than 2.0 per 1000 births in women from BAME groups (Table 8). In addition, in a UK survey, women in all minority ethnic groups had a poorer experience of maternity services than White women (Henderson et al., 2013) and expressed more worries about labour and birth (Redshaw and Heikkilä 2011).“ (Homer et al 2017).
As Homer et al (2017) noted, those leading The Albany Practice, “…negotiated the first National Health Service (NHS) contract between a local health authority and self-employed midwives. They successfully applied for NHS funding to address inequalities in health and promote long term health gain through the provision of community based, continuity of midwifery carer throughout the childbearing period (caseload practice model) to groups of women known to have poor health outcomes due to various forms of disadvantage.” (Homer et al 2017).
But the practice was controversially closed by the Trust in 2009, in response to concerns about safety. The Homer et al (2017) study was carried out as an independent evaluation of the maternal and neonatal outcomes over its entire 12 and a half year span and it demonstrated that the Albany model offered safe and effective care.
Homer CSE, Leap N, Edwards N and Sandall J (2017). Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997–2009). Midwifery 48: 1-10. doi.org/10.1016/j.midw.2017.02.009
photo credit: Albany march banner modelled by Tigger Reed.
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