By: 1 September 2008


As the National Health Service (NHS) celebrates its sixtieth year, this offers a good opportunity to reflect on how the birth of the NHS has influenced and shaped midwifery practice since its introduction. In post war Britain, General Practitioners were offered financial incentives to develop antenatal care, whilst providing this service independent of a midwife or obstetrician (Stewart, 2004). It is interesting to note, that in the 1950’s all medical students be it hospital based or in general practice, were trained in clinical skills by midwifery tutors (Worth, 2002). As the socio-economic status of many women and their families was precarious at this time, it was perceived that the women would have access to expert services which previously they could not have afforded. Promoting this model of care, resulted in the General Practitioners not only being the sole identified point of contact for pregnant women but also being the principal decision makers in defining normality (Dingwall et al, 1988 & Reid, 2005). Statistically, this led to a drop in the number of home confinements as women were offered the availability of intrapartum care in a hospital setting. Women perceived doctors as being the most knowledgeable profession in regards to expertise on childbirth and as such, accepted without question their recommendations (Jomeen, 2007).

Following publication in the 1970’s of the Standing Midwifery and Maternity Advisory Committee report, commonly referred to as the Peel Report, hospital based deliveries were observed to be at an almost 100% rate (HMSO, 1970). The justification for such a recommendation amongst practitioners, of hospital based deliveries was primarily marketed as being the safest option for mothers and infants in relation to maternal and perinatal mortality. However, as Cochrane (1972) highlighted in criticisms of the report, this recommendation was not based on evidence, nor had any innovative research taken place to compare the safety of childbirth in a variety of settings.

Fundamentally, the Peel Report facilitated the medicalisation of childbirth with a high intervention rate being regarded as acceptable and normal for example, continuous electronic fetal monitoring and active management of labour. This ideology correlated to O’Driscoll’s promise to women that labour would be conducted in an intensive manner, in an environment which was controlled by the obstetrician and lasting no longer than twelve hours for a primigravida (Bates, 1993 & O’Driscoll, 1973). Midwives wholeheartedly embraced the technological approach to childbirth and perceived many interventions positively, as an enhancement to their midwifery skills. However, in adopting this approach to women’s care, midwives did not consider the fact that they would become de-skilled in basic midwifery tasks and renounced the concept of autonomy by handing over the responsibility and accountability for women to obstetricians.

The publication of Changing Childbirth ( Department of Health, 1993) refocuses midwifery care essentially back into the hands of midwives whilst offering women choices regarding the entire childbirth experience. The timing of this report co-incided with a re-evaluation surrounding midwifery education which recognised that in order to be a midwife, it was not a pre-requisite to have completed a nursing qualification (Kent et al, 1994).

With this change to midwifery education, the concept of a reflective practitioner was introduced which attempted to correlate the relationship between theoretical practice and experiential learning (Philips et al, 2008). Prior to this, midwifery practice was primarily based on ritualistic and traditional methodologies. However, midwives could no longer justify practices as being acceptable simply because they had always done so. Consumers were becoming involved in the provision of services such as the Association for Improvements in Maternity Services and the National Childbirth Trust who guided midwifery research to focus on the experience and expectations of women (Lavender et al, 2003).

Professionally, the United Kingdom Central Council (UKCC, 1986) stipulated that midwives should be involved in recognising the relevance of evidence based practice in relation to education, a statement which is further endorsed the Council’s successors, the Nursing and Midwifery Council (NMC) which emphasises that all midwives should deliver care which is of the highest standard, due to the best available evidence (NMC, 2008).

The introduction of Clinical Governance in 2000 within NHS Trusts further actuated the opportunity of midwives to become involved in research by challenging them to not only question, but to improve the care which they provided through research and evaluation (Hundley et al, 2000).

Despite the drive to promote evidence based care within midwifery practice, midwives themselves faced some barriers to implementing this within their sphere of clinical practice. Midwives cite some of these reasons as being a lack of resources and research accessibility, difficulties in changing existing policies and procedures and a resistance to breaking down well established hierarchical systems (Richens, 2002). Thankfully, strong leadership within midwifery has enabled us to overcome these issues in order to provide true women centred care. The establishment of Professors of midwifery has raised the professionalism of midwifery whilst demonstrating the level of commitment in producing high quality research (Lavender, et al, 2003).

Midwives have been afforded the opportunity to influence national and regional policy at strategic levels by their involvement in many organisations. The contribution of midwives as Cochrane reviewers, members of ethics committees and multidisciplinary development groups which include NICE and SIGN have provided them with a voice and an appreciation of how their involvement at such levels directly impacts on individual maternity care.

More midwives than ever are motivated to become educated to masters level and beyond which facilitates the critical analysis of research based evidence in relation to providing the highest possible level of women’s care. The establishment of Consultant Midwives further promotes the commitment to support ongoing research awareness and encourage midwives to generate their own research. Within Lanarkshire this has been demonstrated by midwives promoting a “stand and deliver” approach to the second stage of labour in relation to mobility. This research based hypothesis resulted in recognition by the Royal College of Midwives as innovative practice and was commended with an award from the College for promoting normal birth (RCM, 2005).

As skilled practitioners, midwives have continuously striven to offer a high level of care to the women who we are responsible for, even throughout the early days of 1948 when we were unsure where our niche was in a fragmented new NHS. In order to do this and meet the needs of the woman in our care, it is essential that midwives are involved in the research process and are at the forefront of change and innovation. The involvement of midwives in advocating an environment of evidence based practice not only benefits the consumer by facilitating choice and empowerment; this enhances the midwives professional autonomy and produces a workforce who is fit-for-practice within today’s modern NHS.


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