A baby boy is held by a midwife after being born in an NHS maternity unit in Manchester. Photo: Christopher Furlong/Getty
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The battle for better maternity care shows the limits of the Amazon warehouse approach to medicine

The issues around maternity care are a microcosm of the bigger battles in the NHS – centralisation, protocols and “efficiency savings” v making a space for common sense, professional judgement and personal relationships.

What is the most common reason for a hospital admission in Britain? Not heart attacks, not strokes, nor even ingrown toenails. It’s having a baby. Giving birth is an everyday miracle and its relative safety in the developed world is perhaps the greatest triumph of modern medicine. In Britain, eight women die per 100,000 live births – against 980 in Chad or 28 in America. Childbirth is still one of the most dangerous things a woman can face: 35 per cent of all NHS clinical negligence claims last year, by value, were for obstetrics.

I have been thinking about this because, at the time of writing, the Duchess of Cambridge is due any day. Although she will get a “second baby discount” at the Lindo Wing of St Mary’s Hospital in London, the cost of going private is roughly £12,000 for a – what’s the delicate word here? – no-frills, Tesco Value birth without use of forceps or the need for an anaesthetist. The cost to the NHS of such a birth is less than £2,000.

For her money, the duchess gets the services of the Queen’s surgeon-gynaecologist, Alan Farthing (what a business card that is), who helped deliver Prince George, and the obstetric specialist Guy Thorpe-Beeston. Of the latter, the Daily Mail notes: “He has cleared his diary so he can be solely on call.”

Cor. That’s fancy, isn’t it? Kate’s experience will clearly be far removed from that of most women who give birth in Britain but it is an interesting study of what the health service might do if money was no object. So what can we learn from it?

The first lesson is a counterintuitive one: the doctors sound impressive but might well be superfluous. Cathy Warwick, chief executive of the Royal College of Midwives, tells me: “A lot of women assume they are safest where there are doctors, and yet the evidence suggests that for women who are suitable – meaning low-risk – they are probably as safe, in terms of their baby, and safer, in terms of themselves, out of obstetric units.” Only a quarter of women want to give birth in a hospital obstetric unit, according to research by the Women’s Institute, although 85 per cent end up in one.

Where the duchess really lucks out, however, is in having medical staff present whom she already knows. The coalition tried to implement this in 2012 with a “named midwife” policy – with the same person seeing mothers through from early pregnancy to the challenge of breastfeeding and beyond – but it has been difficult to deliver. “In the last survey we did on this, one in four women reported being left alone and worried during labour,” Warwick says. “That’s just not good enough. In addition, if you don’t have enough midwives, post-natal care tends to suffer quite badly, with midwives being pulled from less safety-critical areas to the labour ward.”

Abi Wood, public affairs manager at the National Childbirth Trust, says a midwife who has got to know a mother can judge better how seriously to take her anxieties. “It helps an awful lot because then that midwife can make much more accurate judgements. Also, if there’s anything in your past they need to know about – if you’ve experienced sexual violence or if you’re in an abusive relationship – if you have to explain that to a new person every time, it may prove a difficult experience.” Similarly, a midwife or health visitor who has been able to build a rapport with a mother is better placed to look out for mental health problems, such as post-natal depression.

Could any of this be achieved within the NHS? People are trying to find out: in London and the south-east, a social enterprise called Neighbourhood Midwives aims to repopularise the idea of “caseload midwifery”, where one worker takes on 30 or so expectant mothers, and is available to them 24/7 in pregnancy and for six weeks after delivery. The midwives plan their own working week, in contrast to the NHS model, where they work shifts and see whoever walks through the door. Annie Francis, who works for the scheme, had always wanted to integrate it into the NHS, but that is proving hard. “The system is so enormous and unwieldy, so mechanistic . . . it costs a fortune because women end up with more and more interventions, and they don’t have the relationship of trust.” She is adamant: “We need to start again from the beginning.”

Why does all this matter so much? Because it’s a microcosm of the bigger battles in the NHS – centralisation, protocols and “efficiency savings” v making a space for common sense, professional judgement and personal relationships. As Wood says of the caseload approach, “It does require a certain amount of trust in midwives just to get on with working in that way, and taking a more long-term view.”

At the Cambridge Literary Festival, I interviewed the neurosurgeon Henry Marsh, profiled in this magazine in 2014, and he offered a compelling argument against what you might call the “Amazon warehouse” model of health care. He described moving from the Atkinson Morley, a small hospital where all the medical staff knew the porters by name, to a vast PFI-funded building with miles of echoing corridor. Turning a bedbound patient was once a matter of calling a porter; now it requires all the nurses on shift to give up whatever they’re doing. He reminded me of Dunbar’s number – a concept popularised by the anthropologist Robin Dunbar, which suggests that the optimum size for a group of human beings is 150 – and suggested that any future reorganisation of the NHS should bear this in mind.

Applied to childbirth, the conclusions are obvious: we need enough midwives to provide one-to-one care throughout labour but then it’s time to think bigger. Or, rather, think smaller: how can the NHS give personalised support to mothers, rather than making them feel like the latest item on a maternity conveyor belt? 

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.

This article first appeared in the 24 April 2015 issue of the New Statesman, What does England want?

Photo: Getty Images
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I'm far from convinced by Cameron's plans for Syria

The Prime Minister has a plan for when the bombs drop. But what about after?

In the House of Commons today, the Prime Minister set out a powerful case for Britain to join air strikes against Isil in Syria.  Isil, he argued, poses a direct threat to Britain and its people, and Britain should not be in the business of “outsourcing our security to our allies”. And while he conceded that further airstrikes alone would not be sufficient to beat Isil, he made the case for an “Isil first” strategy – attacking Isil now, while continuing to do what we can diplomatically to help secure a lasting settlement for Syria in which Assad (eventually) plays no part.

I agreed with much of David Cameron’s analysis. And no-one should doubt either the murderous barbarism of Isil in the region, or the barbarism they foment and inspire in others across the world.  But at the end of his lengthy Q&A session with MPs, I remained unconvinced that UK involvement in airstrikes in Syria was the right option. Because the case for action has to be a case for action that has a chance of succeeding.  And David Cameron’s case contained neither a plan for winning the war, nor a plan for winning the peace.

The Prime Minister, along with military experts and analysts across the world, concedes that air strikes alone will not defeat Isil, and that (as in Iraq) ground forces are essential if we want to rid Syria of Isil. But what is the plan to assemble these ground forces so necessary for a successful mission?  David Cameron’s answer today was more a hope than a plan. He referred to “70,000 Syrian opposition fighters - principally the Free Syrian Army (FSA) – with whom we can co-ordinate attacks on Isil”.

But it is an illusion to think that these fighters can provide the ground forces needed to complement aerial bombardment of Isil.  Many commentators have begun to doubt whether the FSA continues to exist as a coherent operational entity over the past few months. Coralling the myriad rebel groups into a disciplined force capable of fighting and occupying Isil territory is a heroic ambition, not a plan. And previous efforts to mobilize the rebels against Isil have been utter failures. Last month the Americans abandoned a $500m programme to train and turn 5,400 rebel fighters into a disciplined force to fight Isil. They succeeded in training just 60 fighters. And there have been incidents of American-trained fighters giving some of their US-provided equipment to the Nusra Front, an affiliate of Al Qaeda.

Why has it proven so hard to co-opt rebel forces in the fight against Isil? Because most of the various rebel groups are fighting a war against Assad, not against Isil.  Syria’s civil war is gruesome and complex, but it is fundamentally a Civil War between Assad’s forces and a variety of opponents of Assad’s regime. It would be a mistake for Britain to base a case for military action against Isil on the hope that thousands of disparate rebel forces can be persuaded to change their enemy – especially when the evidence so far is that they won’t.

This is a plan for military action that, at present, looks highly unlikely to succeed.  But what of the plan for peace? David Cameron today argued for the separation of the immediate task at hand - to strike against Isil in Syria – from the longer-term ambition of achieving a settlement in Syria and removing Assad.  But for Isil to be beaten, the two cannot be separated. Because it is only by making progress in developing a credible and internationally-backed plan for a post-Assad Syria that we will persuade Syrian Sunnis that fighting Isil will not end up helping Assad win the Civil War.  If we want not only to rely on rebel Sunnis to provide ground troops against Isil, but also provide stable governance in Isil-occupied areas when the bombing stops, progress on a settlement to Syria’s Civil War is more not less urgent.  Without it, the reluctance of Syrian Sunnis to think that our fight is their fight will undermine the chances of military efforts to beat Isil and bring basic order to the regions they control. 

This points us towards doubling down on the progress that has already been made in Vienna: working with the USA, France, Syria’s neighbours and the Gulf states, as well as Russia and Iran. We need not just a combined approach to ending the conflict, but the prospect of a post-war Syria that offers a place for those whose cooperation we seek to defeat Isil. No doubt this will strike some as insufficient in the face of the horrors perpetrated by Isil. But I fear that if we want not just to take action against Isil but to defeat them and prevent their return, it offers a better chance of succeeding than David Cameron’s proposal today. 

Stewart Wood is a former Shadow Cabinet minister and adviser to Ed Miliband. He tweets as @StewartWood.