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Mother and Baby

What’s the right choice of midwifery care for me?

So you’ve stared agog at the little blue line on your pregnancy test strip and swung fast and furiously from “Wow!” to “Oh, no!” and back again. Now you’re thinking, “What next?”

In the UK, the vast majority of women are cared for throughout their pregnancy, labour and postnatal period by a midwife. Even when complications dictate that doctors are involved along the journey, midwives still have a very large role to play.

The news has been full lately of stories about shortages of midwives and how many women are struggling to get the continuity of care and regular visits that their mothers expected as standard. Promises have been made in parliament about increasing the number of midwives by the year 2021... but you’re pregnant now!

So, what *is* a midwife and what do they do?

Midwife in an Anglo-Saxon word meaning “with woman” but, in the UK, the regulation and legal framework governing their training and practice only came into force in 1902. Until then, literally anyone could assist a women giving birth. Nowadays it takes a 3 year degree course in order to practice as a midwife. Many midwives having already trained as a nurse but this is not compulsory. Midwives are autonomous practitioners so, if all is well, they do not need to involve doctors in the care of the women in their caseload at any time.

A midwife can give a woman all her antenatal, labour, birth, and postnatal care, visiting the new mother for as long after birth as is felt necessary. Many midwives also teach birth preparartion to their clients as well as how to feed, change, bath and soothe the new baby. They can take blood, prescribe some drugs and do a range of screening tests. Some midwives are trained to scan and some to carry out the examination of the newborn check which, for decades, was only ever done by paediatricians.

Who looks after me, a GP or a Midwife?

The NICE (National Institute for Health and Care Excellence) guidelines recommend that the antenatal care of pregnant women is shared between her GP and midwife, alternating from one to the other as the weeks go on. This is simply a guideline (seeing your GP can be useful if you need a prescription for heartburn medicine) and is not compulsory so, if you only want to see a midwife throughout your experience, you can ask. Remember that, within the current constraints of the NHS, you might not see the same midwife at each clinic visit but all the tests and checks you need will still be done so you do not need to worry as long as you keep your appointments as planned.

What are the pros and cons of having a Midwife on the NHS?

The benefits of having all your care through the NHS is that it will be completely free of charge if you are a British citizen. You can have your booking and all your antenatal care in one region of the country and then, if you go into labour whilst on holiday in another part of the country, you can have your baby in the local hospital, again without incurring any charge. You can opt to have your baby in hospital, in a midwife-led birth centre or at home, knowing that a midwife will be available any time, day or night. Every test, scan and check you need will be done, when needed, and any emergency will be dealt with without you having to pay one single bill. We just don’t know how lucky we are!

The downside to the NHS system is that you might have to contend with seeing a new face at every clinic visit, a few different midwives during the labour and birth and only have very few midwife checks postnatally (many areas now have an army of care workers doing many of the postnatal visits whilst midwives are busy running antenatal clinics and working in labour wards). Some women feel that they are just a number in the system and that their care is not individualised enough. They might also feel that there is never quite enough time, in a busy system, to ask all the questions they have and get full answers, and they might find it difficult to get hold of a midwife for a quick worry-chat in the evenings or at weekends - all hospitals run a 24 hour service but midwives are busy and under pressure and it can seem as if the phone just rings forever!

Whay other midwifery options are there?

Happily, there are options outside the NHS for those who feel they want or need the certainty of seeing the same person each time or who want care of a type or standard which simply cannot easily be found within the NHS. Let’s explore the options ...

Choosing a midwife from a private hospital

If you’d like to have all your care privately and plan to birth in hospital, you could look at booking into one of the many private hospital across the UK. Some hospitals, such as the Portland in London, are completely separate from NHS hospitals whilst others, such as The Lindo Wing (made famous as the place of birth for the babies of Princess Katherine and Prince William) are set within NHS hospitals. Although most private maternity hospitals offer obstetric consultant-led care, some also offer midwife-led packages for those who are fit and well and do not want automatic input from the medical profession.

The pros of going private

The benefit of booking into a private hospital for midwife-led care is that you will be under a small, named team of midwives so that you can really get to know each other. You might feel less rushed and more able to get hold of someone outside of normal office hours. You will get all the necessary tests and checks, your birth preparation classes, and you might strike lucky and see the same midwife at your birth as you have done during pregnancy. For many women who choose this route, the security of being cared for by a hospital-based team is hugely reassuring. Of course, you will also be buying that little bit extra luxury in terms of good food and surroundings.

The cons...

The downside to booking into a private hospital is, first and foremost, the cost. Every test, every scan, every tablet and every intervention will be costed and added into your bill. You should be able to pick from a selection of packages but, ultimately, you will only get what you pay for. The cost of your hoped-for midwife-led birth might sky rocket if you suddenly need a Caesarian so check the hospital statistics as well as their fees before signing on the dotted line! Many women find that they have to travel a long distance to reach their chosen private hospital and this can cause worry as the due date approaches. Furthermore, depending on which hospital you choose, if you become very ill, you might need to be transferred to an NHS hospital for treatment. Don’t be afraid to ask lots of questions and really shop around to find a hospital which can offer you what you are looking for.

What's an independent midwife?

 If you are hoping to birth at home and want to see the same midwife throughout pregnancy, labour, birth and postnatally, without ever needing to step foot inside a hospital or GP’s surgery, then an independent midwife might be just the ticket. As long as they have adequate insurance, an independent midwife can take on any client they choose for total midwife-led care in the true sense of the word. Working completely outside of the hospital setting, an independent midwife works for them self and deals directly with their client when it comes to making appointments and charging fees. Some independent midwives will take on clients with pre-existing risk factors such as a breech lie or twins who might otherwise find it almost impossible to birth at home or journey through pregnancy without lots of medical intervention.

What are benefits of a independent midwife?

The benefits of using an independent midwife are that you will see the same midwife right the way through your pregnancy, birth and postnatal time and never, unless it becomes essential, have to visit a hospital or GP clinic. You will also have someone at the end of a phone morning and night, with most independent midwives being very handy with texts and WhatsApp if all you need is a moment of their time. You will be offered all the tests and checks that you need, should you want them, and may also find it easier to refuse checks and tests that you and your midwife deem not strictly necessary. Most independent midwives will offer one to one birth preparation as part of the whole package so that you can have truly individualised care. Some also offer additional services such as massage and fitness classes. You will know who will be present at your birth and this, alone, might be the thing that swings you in favour of finding the money and employing an independent midwife.

What about the downside?

There are a few downsides. Although not anywhere near as expensive as a private hospital, you should expect to pay well to have the undivided attention of an experienced independent midwife. You can negotiate payment terms to spread the cost and there might be some wriggle room for those on reduced income so remember to ask. If you cannot birth at home as planned, unless your independent midwife has a contract with the local hospital they will not be able to help you birth your baby. Your independent midwife will stay with you but will hand over care to the hospital midwives whilst they takes off the midwife “hat” and puts on a doula “hat” instead. This enables you to have the continuity you want at a time of high anxiety and stress. Finally, recent changes to the way non-NHS midwives must insure themselves means that there are very many fewer independent midwives currently available in the UK than before 2017 so finding one local to you might be tricky. Be sure to ask about your chosen midwife’s insurance provision and what it covers, and don’t be afraid to be specific. Independent midwives are currently working to improve their insurance cover and so this really is a case of watch this space ...

Okay, so what's a freelance midwife?

Many women are actually fairly happy with their NHS care or, if not, are unable to pay for either a private hospital birth or an independent midwife. Freelance midwives can provide the answer for these women and their families. Most women think that they must choose between NHS and private care. One or the other, no middle ground. This simply is not true! In the UK, it is perfectly ok to mix and match to your heart’s content. You can blend your NHS care with as little or as much input from a freelance midwife as you wish. Like an independent midwife, a freelance midwife generally works outside of either an NHS or private hospital and deals directly with the client when it comes to making appointments and invoicing. Because they offer a blended style of care, freelance midwives will work with women who plan to birth in a hospital setting or a home birth.

The benefits of a freelance midwife?

The benefits of using a freelance midwifery service are that you can have the best of both worlds. In the same way as you might see an NHS physiotherapist for that ongoing back problem and then have a one-off session with a private physio when you’ve cricked your neck and can’t wait six weeks for a referral, you can see your regular midwife according to your schedule and then call up a freelance midwife for a home visit or Skype call at a weekend when you need reassurance and your local midwifery service is too stretched to give enough time. If your nearest freelance midwife is a long way away, you should still be able to use the service for reassurance calls via FaceTime or Skype. Although able, just like an independent midwife, to provide total care and support throughout your pregnancy, birth and beyond, a freelance midwife can also simply fill in the gaps left by the NHS so that you can dip in and out of the services on offer as suits you. You only pay for what you need and want. Freelance midwives generally also offer add-on specialist services such as birth preparation, massage, and pregnancy fitness classes, so do ask to see a full list of services so that you can choose exactly what services you want without having to pay for those you don’t need.

The downsides?

There are a couple of downsides to using a freelance midwife. As with all the other private options, you will need to pay but, according to what you want, this might be quite minimal and you will only pay for what you want. As with independent midwives, because of the law governing midwifery practice, unless your freelance midwife has a contract with the hospital where you plan to birth your baby, they will not be able to help you birth your baby in hospital. They should, however, be able to offer doula care and some freelance midwifery practices have experienced, specialist doulas working alongside them. Freelance midwives must be fully insured for the services they offer so, as with independent midwives, finding one to birth you at home might be trickier than a year or so ago. However, the provision of a good doula service either at home or in hospital should be well within their insurance provision so don’t be put off contacting a freelance midwife if you’re planning a home birth, are happy to use NHS midwives for the big day and simply want the additional time, care and support that the private sector can offer.

So now that you’ve shown the pregnancy strip to the whole world before binning it, start thinking about what you really want and need from your midwifery care and, if you want more than the NHS can offer but money is tight, why not ask friends and family to hold back on buying endless pairs of scratch mitts and baby-gros and, instead, club together for that baby shower and help you to buy a different sort of present for yourself.

Written by Rachel Fitz-Desorgher

Rachel Fitz-Desorgher is a specialist freelance midwife with Henley Birthcare (www.rachelfitzd.com & www.henleybirthcare.com) and the author of “Your Baby Skin To Skin” published by White Ladder

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