Midwifery became legally recognised in Britain in 1902 with the first Midwives Act. Despite this, there continued to be a large proportion of women who were supported by midwives who had not been formally trained. “Before the First World War and, in some areas, until the mid-1930’s, the majority of working-class women in Britain were attended in childbirth not by a professional but by a local woman” (Leap and Hunter 1993:1). The Midwives Act allowed for lay midwives to continue practising, as there were so few trained midwives at the time (Heagerty 1997). However, there was a time scale attached to this; by 1905, all midwives had to register as ‘bona fide’ or they could not call themselves midwives (Heagerty 1997). After 1910, bona fide midwives could no longer legally attend births without being under the supervision of a certified midwife or physician.
The Central Midwives Board and Legislation
The Central Midwives Board (CMB) was established as part of the Midwives Act. Its function was to approve training programmes, define ‘Rules of Practice’ (which clearly identified the sphere of the midwife as normal pregnancy, birth and puerperium) and set an expectation of moral good character, which was to be demonstrated in written proof submitted by individuals considered acceptable to the Board (Heagerty 1997). It also set up Local Supervising Authorities that provided routine supervision of midwives by non-midwife, middle-class lady inspectors (Duerden 2002). The CMB initially had no midwife members, as this was not considered acceptable until 1920 and even then it was statutorily forbidden that midwives form a majority (Drury & Staples 2000), with an obstetrician as its Chair. Midwifery was legitimated through the Midwives Act but the control of midwifery practice remained largely in the hands of other groups.
The developments in midwifery within the twentieth century are a reflection of the continued battle for recognised status. There was a series of additional Midwives Acts- in 1918, 1926 and 1936- which provided stricter guidance in assuring that only qualified midwives were able to attend births; many women continued to seek unqualified midwives as they were less expensive. One of the outcomes of the fourth Act in 1936 was to lay a foundation for a significant change to the working lives of midwives. The Local Supervising Authorities in England and Wales became responsible for providing a salaried domiciliary midwifery service (Towler & Bramall 1986). For the first time, midwives supporting women in their homes received a regular income, planned off duty, annual leave and financial security (although the norm was only one day off per month at the time and the salary relatively low).
The National Health Service (NHS) Act in 1946 provided free access for all women to doctors as well as midwives; it was at this point that general practitioners began to regularly see women through pregnancy in order to get the fee available to them from the NHS. As they were not required to attend the birth in order to be paid, this role was frequently left to the midwife who may not have had the opportunity to meet the woman through the pregnancy. Continuity of support suffered as a result of these changes (Towler & Bramall 1986); total responsibility by the midwife for the pregnancy, birth and postnatal period was also affected.
Changes took place in the CMB through the century; the numbers of members increased but the proportion of midwives continued to be in the minority. The most significant change took place in 1973 when, for the first time, the Chair of the CMB was a midwife. This was short lived, however, as the Nurses, Midwives and Health Visitors Act (1979) ended the CMB, moving the locus of control of midwifery from doctors to nurses. A Statutory Midwifery Committee within the UKCC was established, with some effect, following pressure from midwives (Thomas 2002) to ensure midwifery regulatory issues were not subsumed within the broader nursing agenda. This remained a vexatious point for midwives throughout the life of the UKCC as the Midwifery Committee was not autonomous and the work was controlled by Council with its majority of nurses. There has been little change in this since the Nursing and Midwifery Council was established in 2002.
Supervision of midwives altered through the century as well. Following the initial introduction of supervision by non-midwives (the middle-class lady inspectors), in 1936, two types of supervisors were recognised- medical and non-medical. The non-medical supervisors were expected to be senior, experienced domiciliary midwives but they were responsible to the medical supervisors, maintaining legitimate control by the medical establishment. In 1974, with the reorganisation of the NHS, the Regional Health Authorities became responsible for midwives, delegating the Local Supervising Authority (LSA) function to District Health Authorities. In 1977, it was agreed for the first time that supervisors must be midwives (Towler & Bramall 1986) and the words ‘non-medical’ were removed from the title of ‘supervisor of midwives’ (Drury & Staples 2000). It was very unlikely, however, that these midwife supervisors would be responsible to midwives in the District Health Authority; therefore ultimate control of midwifery practice was still not in the hands of midwives.
There has been a tension within the role of Supervisor since the early days of the twentieth century when they were known as Inspectors and their function was to investigate cases of misconduct, negligence and malpractice. Despite the ‘Ministry of Health Letter’ in 1937 stating that the newly titled ‘supervisor’ should be ‘regarded as a counsellor and friend to midwives rather than as a relentless critic’ (Drury & Staples 2000:160), the role remained largely a ‘policing’ one (Halksworth, Bale & James 2000), with little evidence of close support for the midwives being supervised. Possibly the most significant change in the quality of supervision was brought about in 1993 when it became a requirement that new supervisors undertake an educational programme of preparation for the role (Mayes 2000). Following this development, from 1996, for the first time all Local Supervising Authority Responsible Officer posts were taken by midwives (Duerden 2000). These two developments ensured that supervision was in the hands of midwives and that there was a consistent understanding of the remit of and positive potential of the role.
The effectiveness of the supervision function as a support to midwives, rather than as a policing role, was explored in a study reported in 1998 (Stapleton, Duerden & Kirkham 1998). The key results of this study demonstrated variable quality of supervision, some supervisors being perceived as helpful and supportive and others as intimidating and undermining. Power was an important theme in this study; the supervisor was perceived as relatively powerful especially if the supervision role was alongside a management one. The vast majority of midwives supported supervision, however, and wanted to see the model of support continue as they felt it had a direct impact on their professional wellbeing and the service they were able to give to clients. Therefore, it would seem that supervision did offer support for many midwives but, in cases, it can be controlling and disempowering. Some midwives appeared to be constrained rather than enabled through this mechanism of professional support.
Despite supervision having been a function unique to midwifery practice (it is not replicated in any other health professional group), changes planned for midwifery supervision in 2017 may significantly change or remove this important and distinctive feature of professional midwifery support and regulation.
Patterns of Care
The changing patterns of maternity care over the twentieth century have provided another challenge for midwives. Increasing rates of hospital births supported by successive government reports (Cranbook Report 1956 recommended 70% hospital birth, Peel Report 1970 recommended 100% hospital birth), the technologies and interventions which became much more common place in the late 1960’s and early 1970’s (induction, use of Syntocinon for augmentation, electronic fetal heart rate monitoring, episiotomies) and the increased proportion of obstetricians employed within maternity services, all impacted on the autonomy of the midwives’ role (Towler & Bramall 1986). The increasingly technological approach to birth has largely followed the pattern of change in the U.S. where intervention in birth became the norm in advance of it happening in Britain.
In the 1980’s there was a continued emphasis on hospital birth supported by the Short Report in 1980 but, as a result of criticism by women of the impersonal service this provided, there was a move to make hospitals a nicer place in which to give birth. The change in the 1990’s instigated by Changing Childbirth (DOH 1993) was potentially the most significant in the last century in terms of the midwives role in the UK. It promoted midwives as the ideal supporter in cases of normal childbirth and identified the importance of women being able to have choice, continuity and control of their childbirth experience. However, despite this report being an ideal tool for midwives to use in increasing their autonomy, there has been little significant progress in consistently adopting the principles of Changing Childbirth across Britain since that time, as Sandall (2014) highlighted in her research report for the Royal College of Midwives. Resourcing teams of midwives undertaking caseload practice in order to provide continuity of care may be seen as resource intensive by NHS maternity services, despite many projects having demonstrated positive outcomes (for example Page et al 1999, Benjamin et al 2001). Being able to deliver high quality, safe and compassionate care continues to be an NHS priority but the cost of socialised healthcare since the inception of the NHS escalates as technologies and treatments become increasingly expensive over time. The introduction and acceptance of maternity support workers as an important part of the maternity services (RCM 2010) has offered one solution in respect of resourcing demands and has increased the role of the midwife as one of overseer of care rather than delivering it directly throughout pregnancy, labour and the postnatal period.
There is considerable evidence of the positive impact of midwifery care on outcomes for women having babies (Cochrane Review, Sandall 2015). However the future of midwifery practice will need to continue to change as resources, expectations and opportunities do, as it has throughout history.
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