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?

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The triumph of Misbah-ul-Haq, the quiet grafter

How Misbah redeemed Pakistani cricket.

It was an incongruous sight: the entire Pakistani cricket team doing press-ups on the revered pitch at Lord’s, led by its captain, Misbah-ul-Haq. This unusual celebration marked not merely a Test match victory over England on Sunday but something greater: the rehabilitation of Pakistani cricket.

Seven years earlier, the Sri Lankan team bus was en route to the cricket stadium in Lahore for the third day of a Test match against Pakistan when it was attacked by Islamist militants. Gunfire killed six police officers and a driver; several Sri Lankan cricketers were also injured. That was the last Test match played in Pakistan, which, despite protestations, opponents consider too dangerous to visit.

A year later, Pakistan toured England for a Test series. The News of the World alleged that in the final match at Lord’s three Pakistani cricketers had conspired to bowl no-balls in exchange for money. All three received bans of five years or more for corruption. The entire squad was lampooned; police had to shield its members from abuse as they arrived home.

Misbah was on the periphery of all of this. Aged 36 at the time, he was dropped from the squad before the English tour and seemed unlikely to play international cricket again. But the turbulence engulfing Pakistani cricket forced the selectors to reassess. Not only was Misbah recalled but he was made captain. “You have to ask yourself,” he later said: “‘Have I been the captain because they supported me, or because they had no alternatives?’”

Pakistani cricket prizes and mythologises teenage talent plucked from obscurity and brought into the international side. During his decade as captain, Imran Khan picked 11 teenagers to make their debuts, often simply on the basis of being wowed by their performance in the nets. Misbah shows that another way is possible. He grew up in Mianwali, a city that was so remote that: “The culture there wasn’t such that you thought about playing for Pakistan.”

At the behest of his parents, he devoted his early twenties not to his promising batting but to gaining an MBA. Only at 24 did he make his first-class debut, strikingly late in an age when professional sportsmen are expected to dedicate all their energy to the game from their teenage years.

Pakistani cricket has always been “a little blip of chaos to the straight lines of order”, Osman Samiuddin writes in The Unquiet Ones. Misbah has created order out of chaos. He is unflappable and methodical, both as a captain and as a batsman. His mood seems impervious to results. More than anything, he is resilient.

He has led Pakistan to 21 Test victories – seven more than any other captain. He has done this with a bowling attack ravaged by the 2010 corruption scandal and without playing a single match at home. Because of security concerns, Pakistan now play in the United Arab Emirates, sometimes in front of fewer than a hundred supporters.

Misbah has developed a team that marries professionalism with the self-expression and flair for which his country’s cricket is renowned. And he has scored runs – lots of them. Over his 43 Tests as captain, he has averaged at 56.68. Few have been so empowered by responsibility, or as selfless. He often fields at short leg, the most dangerous position in the game and one usually reserved for the team’s junior player.

Misbah has retained his capacity to surprise. As a batsman, he has a reputation for stoic defence. Yet, in November 2014 he reached a century against Australia in just 56 balls, equalling the previous record for the fastest ever Test innings, held by Viv Richards. The tuk-tuk had become a Ferrari.

Late in 2015, Misbah tried to retire. He was 41 and had helped to keep Pakistani cricket alive during some of its darkest days. But the selectors pressured him to stay on, arguing that the team would need him during its arduous tours to England and Australia.

They were right. His crowning glory was still to come. The team arrived in England following weeks of training with the national army in Abbottabad. “The army people are not getting much salaries, but for this flag and for the Pakistani nation, they want to sacrifice their lives,” Misbah said. “That’s a big motivation for all of us. Everyone is really putting effort in for that flag and the nation.”

Now 42, almost a decade older than any cricketer in England’s side, Misbah fulfilled a lifetime’s ambition by playing in a Test match at Lord’s. In Pakistan’s first innings, he scored a century and celebrated with push-ups on the outfield, in homage to the army’s fitness regime and those who had had the temerity to mock his age.

When Pakistan secured victory a little after 6pm on the fourth evening of the game, the entire team imitated the captain’s push-ups, then saluted the national flag. The applause for them reverberated far beyond St John’s Wood.

“It’s been a remarkable turnaround after the 2010 incident,” Misbah-ul-Haq said, ever undemonstrative.

He would never say as much, but he has done more than anyone else to lead Pakistan back to glory. 

Tim Wigmore is a contributing writer to the New Statesman and the author of Second XI: Cricket In Its Outposts.

This article first appeared in the 21 July 2016 issue of the New Statesman, The English Revolt