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?