 to you, Katherine Hale, who is a very good friend of mine anyway. Katherine is an NHS midwife in the north of England in a place called Hexham. She also practices as an independent midwife, but she's speaking to us today as the national coordinator of the Association of Radical Midwives. So over to you, Katherine. Thank you, Linda. I'm going to talk today about the new vision, which the Association of Radical Midwives has just published in 2013. The Association of Radical Midwives was an organisation formed in 1976, which was started by student midwives who were alarmed by the increasing medicalisation of childbirth. They used the acronym ARM because they felt that their practice was very much dominated by the requirement to artificially rupture membranes, abbreviated as ARM, in order to induce labour. At the time in the 1970s it may have been similar in other countries, too. There was a very great preponderance of induced labour, sometimes not very long after the due date, and people felt that it was really due to hospitals wanting more women to give birth to their babies during office hours and weekdays. The student midwives feared that they were becoming less midwives and more obstetric nurses and that they wished to return to the original profession of midwifery or the traditional profession of midwifery. They used the word radical, meaning roots and origins from Latin original, as an indication of that, that they were returning to the basics of fundamentals of midwifery practice. The Association of Radical Midwives is an organisation which anyone can join. There are a lot of midwives who are members, but also women who have interest in childbirth and anybody else who is interested. We aim to improve care to become more women-centred. We hold study days and conferences. We've had for the past few years a national conference which has been very successful each year, and we have a national meeting quarterly. We try to have these in different parts of the UK so that all members may have an opportunity to attend. We contribute to national consultations into midwifery and obstetric practice and provide sports to mothers and to midwives and information through a helpline and advice newsletter. We have a UK midwifery discussion list and helpline which has been much contributed to over the years from people all around the world. We're members of the International Confederation of Midwives and the European Midwives Association. We produce a quarterly magazine called Midwifery Matters. One of our quarterly meetings extends into a gathering or a holiday or retreat for as many of us as we are able to go. We try to hold those in different parts of the countries as well so that more people may attend. In the last few years we bought a Yurt, a Mongolian style framed tent that we take to festivals to provide space for pregnant women and their families and we are involved in social media as are most people. We have charitable status and most of us are volunteers and our biggest income through subscriptions. Although we do sell a range of midwifery goods and occasionally we do make profits from conferences and awful meetings and also retreats. In 1986 the members of ALM decided that they wished to promote women-centered care by producing a document which they called the vision of how they would like maternity services to develop. This was very much based on the idea of caseload midwifery and of continuity of care for women by their midwives throughout the whole of the childbirth period. It was later taken up by initiatives such as Changing Childbirth in 1993 and Maternity Matters in 2006 and has had a lot of support generally in government documents. The difficulty has been that although government policy and various policy documents that have come out have supported the philosophy of ALM and the vision, it has proved much, much more difficult to put those policies into practice. In 2013, many years later, care for women in childbirth remains dominated by acute hospital services. The birth rate has gone up as well in recent years which has sort of made things more difficult in that respect. Many midwives work in places where there aren't really sufficient staff to give women one-to-one care. Obstetrics staff and midwives are under a lot of pressure to process women through a system that is very overloaded, especially in the big cities. Midwives perhaps feel that they have become more obstetric nurses rather than midwives. Birth centers where they exist are often under threat because they are seen as a luxury service and it is felt that it's more cost-effective to centralise care in the big nursery centers where there is a full special care baby service and neonatal intensive care service and where a number of staff can be concentrated on a single site. Birth centers are often closed for short periods as well when events occur such as understaffing or an incident has occurred to reassess. So in some cases it's quite difficult to be certain of the number of birth centers that may be available to women. When this happens or when a previous obstetric unit becomes a birth center or a midwife-led unit it's often portrayed in the media as a downgrading as the word often used or a second-grade service and obstetrics is looked on as an emergency service rather like an emergency department or a casualty department. This existence of birth centers across the country is very, very variable and very patchy. In some parts of the country there are a number of standalone birth centers and alongside obstetric unit birth centers and in other places there are none. So it's difficult for women all over the country to have complete freedom of choice. We brought out and devised a new vision for maternity care in response to the birth space study of 2011. Professor Leslie Page, president of the Royal College of Midwives kindly wrote our preface and she says the new vision for maternity care will be of importance to all of us as we set out to improve the start of life for babies and their families not only midwives and all those providing care but also policy makers, leaders, managers and commissioners all will find in it a way to more life affirming, more humane, more effective and cost effective maternity services. The basic principles are I guess the basic principles that should inform all maternity care if we're truthful around the world. Care should promote the health and well-being of the woman and her baby primarily and the mother is the central person in the process of care. The relationship between the mother and the midwife is fundamental to good midwifely care. All childbearing women should have access to their own personal midwife throughout the childbearing period. All women should exercise fully informed choice in childbirth including the right to decline treatment. Choices would include the type of care and carer, the place and manner of birth which includes home birth now enshrined in European law. A recent case in Hungary under the argument of allowing that women have a right to privacy made it mandatory that women should be entitled to home birth. In the future we feel that that could be best effected by midwives being based in the community. Perhaps under the kind of settings that general practitioners are presently placed. Midwives do work in the community in this country at the moment but they often work in conjunction to general practitioners surgeries and are employed by acute hospital trust which means that the continuity of care is variable and they can often be pulled into the big obstetric hospitals to provide assistance when there are staff shortages or there is a huge number of people attending those centres. We feel that birth centres should be promoted and that there should be more of them, that there should be more availability for all women in the country. There is a good deal of evidence that birth centres have very good and very safe outcomes and that they reduce interventions in labour and women's satisfaction with their labours and their births is higher in those centres. That there should be one-to-one women-in-centred care. That a woman should feel that she is cared for by her midwife and others if necessary but that she has that continuity with one known person. Hospitals and birth centres should be staffed to support women not to support an institution, not to provide support for an institution. More midwives should be appropriately trained for providing low-risk care as well as high-risk. These are some of our publications, a new vision and the old vision in one of the magazines. That's just a short presentation about our new vision for maternity care. I'd like to answer any questions please. Thank you very much then Catherine. That's very interesting. Can we have some questions please in the chat room? I haven't noticed any so far. It's been mostly discussion about how to keep in touch which is an important aspect of meeting in such an environment as this. Did I notice any mention of case load holding? Could I ask about case load holding Catherine? Yes, in the vision we feel that the ideal would be that midwives would carry a case load of women each, not too large to allow them to provide continuity of care. Perhaps by a system in which they could work with a partner or a buddy or perhaps two or three midwives together depending on how many hours they wish to work up to full time. In that way they could share their on-call, they could cover each other for holidays and women would have continuity of care. We feel that if that case load care was based in the community and midwives would have the opportunity to discuss cases to debrief among themselves, it would give them control over their work and job satisfaction. Case load projects in the past have sometimes been difficult to implement because the case loads have been too large. The vision recommends that full case load midwives would have 28 cases a year. Have we lost you Catherine? No, I was just wondering if you were going to speak, Linda, but it had difficulty with your microphone. I'm just reading about the case loading in New Zealand, which I've heard about. Ideally we feel that this would be good for us in the UK that midwives could choose to do case loading as they can in New Zealand and that would be paid on the basis of a per case basis, a per woman basis. I imagine that's how it works in New Zealand. I think somebody is saying that... Yes, indeed. Sorry, Linda. Go on, Catherine. No, Catherine, if you're reading the chat box, please just go ahead and answer the questions. Yes. I'm not sure about Germany. I see somebody is asking about Germany. I don't know if anybody can comment on that. I think from contact with the International Confederation of Midwives, I think they do have that degree of independence, but I can't recall asking or hearing exactly how they did that. Yes, it's very difficult for people not to get burnt out if midwives are holding case loads which are too large. And it would still be perfectly possible, as I'm sure it is in New Zealand, for midwives who felt that it suited their circumstances better to continue to work as core hospital midwives. They would still be needed to do that, I imagine. I think there has to be an element of choice for the midwives when case loading because it could be more difficult for some midwives at certain times of their life with on-call or birth when perhaps they have small children themselves. The British new NHS bill works on a system described as payment by results. They still have modular payments, as Cheryl Joy Christian from New Zealand says, for antenatal, post-natal labor and birth, but there are certain difficulties with it. It is felt by some midwives because if women have a high risk of transferring to obstetric care, for instance a woman having a first baby may have about a 45% risk of transfer to obstetric care, then there will be a lot of additional costs for the individual midwife or the group that she's working with when they transfer that woman. And it might be in those cases that a situation would arise where midwives have done an awful lot of work at antenatal and labor work with a woman, but because the woman transferred a large amount of the fee would then go to the obstetric hospital and possibly also to the ambulance service who might have performed the transfer. I don't think that our system has been set up with this in mind because these sort of difficulties also arise when women transfer from one hospital trust to another. I'm just reading questions here. I was told by a midwife who worked in New Zealand that it can sometimes be a little bit difficult because women, of course, are quite entitled to change their care provider in sort of pregnancy or maybe write up to the time of the birth. And this also can be a problem for some midwives as regards their fee. Again, they may have given quite a lot of care and yet lose the main part of the fee. But I guess no system can be without its drawbacks. Yes, independent midwives have been working in the UK over the last many years and have had many satisfied clients and provided a good standard of care with very good outcomes. We've been collecting statistics for that effect for these last nine or 10 years. And we are at the moment under a certain amount of pressure because in October of this year it becomes mandatory to have indemnity insurance and that insurance has not been available to individual midwives in this country and I'm sure in other countries for many, many years now, really since the 1990s. This is because of the large risks involved in having a claim against the midwife. Claims themselves would be extremely rare but if there was a claim that was found in favour of the claim and the payout could be £6 million and it is said by insurance specialists that this could go up to £10 million in the near future. So understandably insurance companies feel that even a risk of one such claim happening to any one midwife would wipe out most insurance payments that have been made. The independent midwife UK and other people are at the moment, the Royal College of Midwives and many others are campaigning on this subject now. It may be possible for groups of midwives to contract into the NHS through social enterprise schemes and so on but it's not really clear at the moment how this is going to be after 26 October when this law becomes live in. Just reading down the questions. Yes I found as an independent midwife when I've worked independently I'm reading about relationships. It is a huge luxury and a privilege to be able to have a very developing and a close relationship with an individual woman because I think it's rewarding for both. I hope as Jo Lundman says yes if people feel that they're not having a rewarding relationship then they ought to change to another midwife indeed because you can't get on with everybody and it is really really important. It is very rewarding because in that situation even if the outcome isn't exactly as the woman would choose the relationship and the belief and feeling that she has, that she's had control over what happened to her that she's made choices that weren't in any way made under pressure it generally seems to me that people feel that this is very rewarding for them and even as I say if the birth doesn't go as well as they expected or in the way that they expected they generally feel at peace with their care and with what's happened around the birth. It's very difficult to read down the questions on Paul can think at the same time. I apologize for that. You're allowed to have thinking time don't worry. Oh thank you Linda. Can you see or throw out anything else from the chat that's going on Linda that we ought to comment on? There's been several questions about how the vision can be incorporated into the institutional support or political environment. Can we answer that one at all? Yes, yes I see that, yes. We have just all in the last week circulated the vision around all the newly set up clinical commissioning groups which exist in the UK. They exist to buy services for the NHS effectively. They are finding their feet at the moment but I think perhaps we have an opportunity to interest people who aren't set in their idea of how things should be or indeed set in the way of having purchased services already. It might be a window of opportunity to be able to promote the vision and to see if we can influence some of the clinical commissioning groups to set up the kind of maternity services that we would like. We've also sent copies to heads of midwifery and supervisors of midwifery where we can access them and indeed to some members of parliament and to anybody else that we thought might be influential in this area. I think that, yes, as somebody is saying, we do need to follow this now. Having sent the vision out just this week in time we hope for International Day of the Midway. As many of us as possible are going to try and get along to board meetings of the clinical commissioning groups and try to influence what they do in that sort of way. I believe that some of us did try to be elected on to some of the boards but I don't think we've had much success with that at the moment but to be truthful it seems that the new groups are finding their own feet in regard to how they're going to go forward anyway. So I do think we have an opportunity to do that. Can you still hear me Linda? Yes indeed, I'm just letting you speak because you were doing so well. Yes, no I just lost the screen for some reason just brimming it there and I thought maybe I'd lost everything. No, no you're still here. I'm just asking how they can get to see the vision. I lost you again Linda. I'm here, I'm here. Can you hear me? We have a link on the website. Yes, I can hear you. Can you hear me? Right, so somebody's asking. Yes, I can indeed. Someone's asking about getting hold of the vision. I can't lose you Linda. There's a link on the WW. Yes, can you hear me? Yes I can. Yes. You can find a link to it on our website which is on the screen at the moment. You're still there Linda. Have we got any more questions? We've still got time to ask you more questions. Yes I'm still here. Just asking if anybody else has got any more questions. You may be ones that we've missed or any comments. Captain Lorraine's pointed out an excellent question from Maureen Wahidi a little, not very far ago I think. Yes, so I see that, yes I see that higher up there. Yes, I absolutely agree Maureen that the relationship is free and very difficult to develop within the present UK system. I've rarely had people disclose that they were a survivor of sexual abuse to me as a midwife in the NHS. And of course on very short acquaintanceship when you just meet somebody in labour they're very unlikely to do so although sometimes one does suspect that that may be the case by other things that occur during the midwistly care. So obviously one tries to be careful to treat everybody with that degree of care that they might be feeling some difficulties due to that past experience. When you know people well as a midwife you usually find out if there is anything of that kind in their past. It may be not straight away, or not straight away but usually after you've known them for a time. And I have found that women who use independent midwives and wanting to pay for independent midwistly care which they would have to do at the moment in this country they often have got a very strong reason to want to be in control of what happens to them in the sense that they want to know that the person who's caring for them is somebody who has formed a relationship with them. It is very difficult in the present system as I say even our community midwives often are not having very good continuity of care with women and even where they have reasonable continuity of care for the antenatal and post-natal period their time for appointments and chats with women antenatal is often very restricted to just a few minutes. I'm just trying to find the question in blue that somebody's mentioned. I can't find the moment. Yes, community midwives. Yes, I'll scroll back. I found it for you Catherine. What might the ideal increased midwistly training in low risk as well as high risk look like? I think more time spent actually working with the midwife in perhaps an apprenticeship style of care. One of my colleagues is very keen to promote an apprenticeship style of mentorship where an individual student would work closely with a midwife's case loading for a reasonable length of time in her training. At the moment our students here, Linda will confirm this, perhaps only spend about 50% of their time in clinical care. There's been some pressure in some countries for that to be even less. I do feel that midwistly is a very, very practical discipline. A high level of education is of course important and the ability to analyse different areas is important. But I think students, they learn by role models and it's learning how you communicate with a woman who is in different situations, whether in labour and maternity or post-maternity. That is what you learn by observation with a good role model. It also helps students to build up their confidence in the normality of birth. I think that that's the thing that midwives, student midwives need to learn fundamentally. They may then go on at a later time to develop their knowledge and skills in the high risk and the intensive care areas. But the fundamental midwistly is normal midwistly and based in the community. I can see somebody, Shelly, saying she spent the whole of her first year with the Short Start case load team. I think you were lucky, Shelly. I didn't know this but I was quite shocked when I had some mentorship training recently to find that the practical components of the midwistly course was relatively small or smaller than I expected it to be. Linda's saying there's a lot of emphasis on high risk. It is important of course for women who are high risk and having medical and health problems in pregnancy to have equally good care. But I think that a student midwife needs to learn the basics first and then add on the layers thereafter because that is the basic midwistly which will serve her well in all settings really. I can see somebody saying they are second into midwitest. I see what Maureen says as regards women who have had problems with sexual abuse in their past. It's a very moving thing to see the transformation that can occur in somebody who has felt such terrible trauma and how it can just help them move on and develop in their lives and transfer that confidence onto their children and become a positive process as Maureen said. There's a nice point there being made by Fiona, Catherine, about having case load within their training. Oh, that's very good. Where are you Fiona? Yes, I do say that again, in Preston. Oh, that's great. I'm not far from there. I know it well. I'm just asking about non-independence midwistly care. What I would call the mainstream NHS care or perhaps what has been the recent tradition in NHS midwistly has been that women visit their community midwife who is generally based at the GP's general practitioner's surgery. She would book for her care there and she would tell the midwife where she wished to have a baby in the local area. Although, as we said before, the choice can be restricted depending on what part of the country you live. Ideally, she should ask women if they would like a home birth or if they wish to give birth in a birth centre or an obstetric unit. Most women will have most of their anti-native care from the community midwife although usually there's more than one community midwife that they will see through their pregnancy. And then when they go into labour, they will go to the hospital or birth centre where they are to give birth and be cared for by a midwife that they don't know usually and possibly a number of midwives depending on how long their labour is and whether the shift change happens during their labour. And then they would have perhaps a very short postnatal stay in the hospital or birth centre and then be discharged home to be visited again by hopefully the same community midwife but sometimes a number of different community midwives, some of whom they may have met and others not. The postnatal visiting in a lot of parts of the country is now extremely restricted. I believe down in the south-east in the London area where there's a lot of pressure on services women may get a visit on the first day home and perhaps the fifth day and maybe that's it. In a lot of areas women are expected to attend a postnatal clinic for their checks and some breastfeeding support can be very limited as well. Sometimes in some areas healthcare assistants and maternity assistants are used to provide breastfeeding support but again that's very patchy. I think a lot of community midwives in the NHS are sorry that they aren't able to give longer to their caseload and to their postnatal women that they have to visit. That's been cut down often to a very large extent compared to you. There's a lot of lovely discussion going on here but I just have to warn you that we're almost at the end of our time. We've just got a few more minutes left. There was one person who asked a question that I thought was very pertinent and that was Gamed Wife further up saying should a woman who has been deemed to be high risk for home birth prefer to stay at home, what are our options, can the midwife stay with her? Yes, they can. Easily speaking in the UK if a woman chooses to have a home birth, whatever her situation the service ought to be provided for her. In reality there is often a great deal of pressure put on that woman to go into hospital either because she is told that the community midwives may have too many other home births to attend at that time or that she is risking her life or the baby's life. Sometimes this can be dealt with by the intervention of the supervisors midwives which is a legal position in the UK enshrined in the 1902 midwives act. A lot of women aren't aware that they may have the course to a supervisor of midwives to discuss their care and indeed to help facilitate their midwifery care. In reality many high risk women who wish to have a home birth end up booking with an independent midwife because there is often so much pressure although it may be covert rather than overt upon her to go into hospital. Occasionally hospital trusts have employed independent midwives to provide high risk home birth care to women whose requirements are quite specialised and most community midwives and most midwives in general wouldn't feel confident in providing such as in cases where there are twins or a breach baby. That again is extremely patchy and valid it really depends on the situation in individual areas. I feel that with ARM's vision we could provide better continuity as well for high risk women who do go into hospital too and of course this is important as well. I'm trying to read down. I think we'll have to leave it there Catherine and you've likely brought the discussion back round to the vision which was the purpose of this presentation anyway. So I want to thank you Catherine very much for talking us through the dream really of the ARM and all midwives really as they look at it and also thank you very much for having a very good discussion using the questions that have come from the delegates in the chat box. So thank you very much Catherine. Thank you Linda, thank you for helping me with that.