Published on the British Medical Journal Guest Blog, 29 March 2012

Earlier this year we received news of a social enterprise, Neighbourhood Midwives, providing midwifery services in the community in London, and a private company providing midwifery services for NHS Wirral Primary Care Trust. One to One, in the Wirral, promotes itself as offering the kind of continuity of care in pregnancy and maternity that midwives have wanted to provide but have often been unable to, for decades. It heralds its high rates of home births—part of which it, bizarrely, appears to attribute to the launch of the BBC drama Call the Midwife set in the East End of London in the 1950s. Of course women would prefer a single familiar and friendly midwife to see them through pregnancy and labour, instead of a roll call of harassed and overworked ones who they may only meet once, or one who barks commands as she flits between different women on the labour ward (a la real life in One Born Every Minute, Channel Four). Of course what women most want is a safe delivery and a healthy baby.

It is hardly necessary to revisit all the ways in which midwifery is failing women and midwives are being failed in turn by the health system. The Royal College of Midwives has long been calling for the urgent recruitment of 5,000 more midwives to deal with a spiralling birth rate amid great uncertainty about future resourcing in the wake of cuts and NHS reforms. In this context it is certainly worth considering the opportunities and pitfalls presented by independent organisations of midwives providing services to exploit the new liberalised health commissioning environment.

Different questions arise:

Will midwives be attracted to leave the NHS and join groups of independent providers? Which ones? Will they be those who are highly motivated to provide a good quality of service for women, continuity of care, and women-centred midwifery; or those who are unhappy or ill equipped for providing the spectrum of care women need including support through complex or high risk pregnancies and obstetric emergencies (which happen in some 15% of all pregnancies); or those who seek better or easier working conditions. This is strongly related to the question about why there is such a shortfall of midwives in the NHS, where independent organisations will find the midwives to staff their services, and—if they can find them—why the NHS can’t recruit and retain them instead?

How will these services be linked in, and relate to, services in NHS settings? It is clear that such services will be set up to support women only through low-risk pregnancies, but inevitably a proportion of those women will end up in NHS maternity units through choice or necessity. What will the impact be on NHS service planning for emergency and unplanned admissions from independent providers?

How will the comparative effectiveness and efficiency of these services be assessed when they, by their nature, will cream off the low-risk cases and have greater capacity to provide home-births which are less costly? It is not hard to see how attractive this kind of low-risk provision might be to the private sector and how essential it would be for them to return women back to the NHS as soon as it might cost them a penny more than expected.

Will the NHS—as in so many areas of care—be expected to treat only the complex and expensive cases, or handle the mistakes of the private sector? If so, what are the implications for NHS midwives who also need to look after low risk cases as part of the spectrum of care they offer, and enjoy doing so? If private provision leads to even more medicalisation of NHS services could it result in a further haemorrhaging of good midwives from the NHS?

If NHS maternity services are at risk of becoming a dumping ground for complex cases and obstetric emergency, how will this impact on options for those women who may want a more low-intervention approach, but with the safety net of doing so in a hospital setting?

Will the independent, community-based service be open to and promoted to all women, or will we end up with two tiers of provision? Will women who are well-versed in what they want get shiny new community services, while everyone else—including teenagers, those with language or learning difficulties, the poor, and those simply lacking in knowledge and confidence—is expected to “like it or lump it” in the local hospital?

How have these new groups managed to organise NHS support to arrange professional insurance when this is something independent midwives have often struggled or failed to do?

Finally, the question we are asking about all NHS services: is it just a matter of time before we are expected to pay fees for some services, and could privately provided midwifery be one of these?

We would all like to see services providing continuity of care for pregnant women in the community. If this is to be provided by independent organisations it must be freely available, and must not be provided at the expense of good quality, comprehensive NHS maternity provision by midwife-led units, whether within or attached to NHS hospitals.

A guest blog by Lisa Hallgarten: social media manager at Reproductive Health Matters; sexual health trainer, educator, and blogger at Education For Choice; and advocate for better sex education for all young people.