Here is what happens when an American midwife walks into a British labour ward– she is astonished.
Last week, while visiting my Father in London, I dropped by a local hospital, the Chelsea & Westminster. As a midwife, I was naturally curious about how my profession looked on the other side of the Atlantic. Midwifery is more common in Britain, and Prince William’s children were delivered by midwives. A 2014 official report by the British National Institute for Health Care Excellence (their governmental health policy agency) stated that women with low-risk pregnancies should be offered the option of home births with National Health Service (NHS) midwives. In Britain where per capita health care expenditures are less than half that in the States, perinatal mortality is lower. These things I knew. But, by the end of this adventure, I was going to be stunned by what I discovered.
It was a lovely day, so I chose to walk Fulham Road instead of taking one of the many buses. A trip to the Chelsea library had told me to walk past two other hospitals to this one where babies were born. After some minutes of passing shops and restaurants, I noticed a grimacing young woman holding her gravid belly with her left hand, walking with a solemn man, who paused whenever she paused to lean on a shop wall with her right hand. I slowed, wondering if I should offer assistance. But the couple did not seem in any hurry, so I concluded that she had probably been sent walking by hospital staff, and this was part of the plan.
Passing under the words, “Chelsea & Westminster Hospital,” I entered the lobby, where there were young and old of all sorts, and I noticed a peculiar metal statue of a man, with a torso of glass, which contained bills and coins. Walking to the building directory next to this strange figure, I noted that “Maternity Reception,” “Birthing Centre” and “Labour Ward” were all listed for floor 3. Once up the elevator, I pushed a button outside a set of double doors, just like in the States, and walked through. Unlike my last hospital, here there were no chatting nurses. Every person was engaged in a task. I mustered the boldness to present myself to the maternity reception desk where I was struck by the predominance of women with “Midwife” embroidered on their scrubs. A woman labeled “Senior Midwife” was typing at a computer when I walked up to her. She looked up from her work, and I came directly to the point, explaining that I was an American nurse midwife visiting the area, and was hoping to schedule an appointment with one of the midwives to learn about what it is like to be a practicing midwife in England. Her face did not reveal any emotion as she listened. She took up a pen and paper and stood to lean toward me over the desk. As she began to write, she said that I should call Pippa Nightingale (“Pippa” is the name of Kate Middleton’s sister, who nearly stole the show at the royal wedding with her clingy dress, and Nightingale is the surname of the world’s most renowned nurse of all, Florence) or a guy named Simon somebody. Her accent was a mixture of British and, perhaps, Swahili, and I strained to follow her words. While she did so, a gurney wheeled by with a smiling woman holding her newborn on her chest. Without further explanation, she handed me the slip. After thanking her, I passed back through the locked double doors, down the elevator, out the door, and walked back to Dad’s flat.
As soon as I got there, I called the first of the numbers and, after a bit of struggle figuring out which of the many digits to actually dial, I reached Simon Nehigan. Simon Nehigan is the Deputy Director of Midwifery, he told me, and he agreed to meet me the following Wednesday, in the lobby by the coin-man statue.
I arrived early, by bus this time, and sat across from the statue watching. At precisely 10:00, a mid-40’s fellow with a badge on a lanyard and a slightly graying beard on his chin appeared and looked at his cellphone. As I walked up, he smiled. His nametag confirmed he was indeed named Simon, and I showed him my nurse-midwife license to assure him I was legitimate.
As we climbed the stairs, I explained that I was particularly interested in the relationship between midwives and physicians, because we have some tension in this where I am from. In Britain as well, he was quick to reply. One of the main problems they have is that the “consultants” (which is what they call fully-trained obstetric “physicians” vs “registrars,” whom we call “residents”) are just not interested in birth, because it does not pay much. Thus, by the top of the stairs we had already come around to the subject of money. In my own experience, although obstetrics is not considered profitable in the States, physicians are often threatened by the presence of the competition of midwives for patient volume. In Britain, Simon explained, the consultants have little interest in births to women in the National Health Service (NHS), but will take on “private women.”
“Private women” are those who are paying cash out of pocket in an effort to receive a higher quality of care, or those who are from other countries with insurance that will pay more than the NHS. These patients deliver in a separate unit. Some of them request midwives, but most expect to be delivered by a consultant.
At the third floor, Simon directed me through a new set of doors and ushered me into an empty patient room. There was a large birthing tub, a large mat on the floor, like a gymnastics mat, and a stack of oversized pillows on the mat. “Where is the bed?” was my first question. He laughed. “Oh, we encourage our women to be up and mobile during labor,” he explained as he walked over to the far wall. “But afterward, there is a bed for her to rest,” he continued as he reached up and pulled the end of a murphy bed partly down from its hidden chamber.
He explained that about 20% of women are considered low-risk enough and want to use these designated rooms, where they have access to the tub, nitrous oxide and midwives specially trained in aromatherapy. There was a heavy hook on the ceiling to attach a rope or hammock as well. This natural birthing unit is staffed with 2 midwives, or more if volume is heavy. Home births are not common in this area, which he attributes to the midwives preferences. “It is all in how you talk about it.” Only about 1% of the area’s births occur at home, but when they do, they are attended by midwives from this hospital. Most of the hospital’s births happen in the standard Labour Ward, which appeared very much the same as our L&D rooms in the States.
We were joined by a lovely young midwife with a cheerful countenance, who told me that they work 12 and half hour shifts and always work hard while they are there. They do not have L&D nurses on the unit, so the midwives themselves do all of the documentation, fetching supplies, medications, etc. When a birth is imminent, a second midwife may be called, but only if trouble is anticipated. Usually, the only person in the room with the family is the one midwife. In the States, the last minutes before a baby is born is usually accompanied by the sudden arrival of at least 2 and sometimes as many as 6 nurses playing various roles, inevitably introducing strangers and an element of chaos at that climactic moment. I tried to imagine what it would be like to be alone with all the responsibility at that moment.
There is a shortage of midwives in Britain. The training is 3 years of exclusive midwifery school: no nursing degree is required. They can begin as early as age 18. A new midwife will be hired in at a “band 5” salary, the same as a nurse, but can expect to quickly move up to a “band 6” salary, and will have annual raises. Most midwifery administration is done by midwives themselves, and higher pay can be expected as a midwife gains management responsibilities. The NHS website states that the band 6 salary range is £26,041- £34,876 with a 15-20% augmentation due to the hospital’s location in central London. At a current exchange rate of £1/$1.3, a 1st year midwife in London would only earn $33,853-$45,339. This is half what a certified nurse midwife can expect to earn in the U.S. and may well be part of why they have a shortage in the profession.
Early in a woman’s pregnancy, she is assessed and given a risk level. Payment for her prenatal care and delivery is determined by this early assessment, and does not change if she has a Cesarean section or other expenses. This structure incentivizes the hospital staff to use fewer costly interventions. In the U.S., most payors reimburse health care providers more for Cesarean section, sometimes in excess of the increased costs. Follow the money, as they say.
Then came the biggest shocker of my visit. I asked Simon how many midwives and how many consultants work at the hospital. He thought for a moment, then said, about 450, but not all of them are full time. I asked for clarification, “450 what?” “Midwives,” was his answer. “You have 450 midwives working here?” was my stunned reply. “How many births per year do you do here?” He held up his fingers and thought out loud that there are 5 hospitals in their system, and they do 12,000 births per year in the 5, but at this particular hospital, he closed his eyes and was silent for moment, “About 6000, last year,” he concluded. “Wow. That’s a lot. And how many consultants do you have?” Here his reply was quick, “28.” “Wait a minute. You have 450 midwives and only 28 physicians?” He nodded. I still haven’t gotten over my amazement.
So an army of midwives, run by midwives, with layers of midwifery management, working in peaceful cooperation with their physician consultants, with lower costs and better outcomes actually can exist on this planet. I feel as if I’ve been to Narnia.
