Watching choice disappear

It was only about eight weeks ago that I was writing up good news. NICE (The National Institute for Health and Care Excellence) confirmed that it’s safer for around half of women to give birth at home or in a midwife led unit.
Hooray, we thought… the evidence is out there, the cautious and well respected NICE is reinforcing the benefits and better outcomes found in a natural birth.
Since then, Calderdale Hospital Trust has failed to renew their consultant midwife’s contract and closed the long standing birth centre “temporarily” due to sickness rates. Also, the MAMs service in Airedale is shutting (this is breaking news so we have few details yet). And GPs have been sent a letter scaring them with unfounded concerns about local midwifery service 1-2-1, leading many to refuse to refer women wanting to use their services.
The debate about the guidelines was how we could increase access to natural birth to let everyone have the chance. But here in Yorkshire right now, women are being left without choices, without certainty and with the higher risks associated with hospital births: more interventions, much higher chances of a C-section, stressful environments that interrupt Oxytocin production and so on.
There are many complex reasons why any of these things are happening, but what I think links them is a clear lack of commitment to natural birth in commissioning, despite the guidelines.
Natural birth services are being seen as an ‘add on’ that can be dropped, because they aren’t closing labour wards! So can we hold commissioners to the guidelines? While health professionals get to make the final decision, “Healthcare and other professionals in the NHS are expected to take our clinical guidelines fully into account when exercising their professional judgement.” (NICE website) Therefore, we can argue that they aren’t taking guidelines fully into account if that’s what we believe, but we don’t have the right to overrule the commissioning judgement automatically.
When the future’s uncertain, one of the best things we can do is to keep sharing our experiences. The other thing we can all do is “ROAR”, as Sheena Byrom puts it. We’re organising petitions to make sure the health professionals making these decisions know that we care what happens to women during a very vulnerable experience. Here’s the link to the Calderdale petition.
Things we start to take for granted can disappear if we don’t roar.

A Midwife I know and Trust: Why I campaign for one mother one midwife care

Over many months I have been thinking a great deal about the importance of one to one midwifery care  or personalised care as the Government calls it.  Why am I so passionate and committed to seeing one to one midwifery happening in Bradford?

I am passionate about one to one midwifery care because I know what an enormous difference it can make to the experience women have during the childbearing weeks and months.  I really don’t think it is good enough for health services to say to a woman: ‘There you are!  You and your baby are alive and reasonably  well’.  And send them off to an unsupported home environment traumatised, exhausted, barely breastfeeding and with the minimum NICE visits to look forward to.  Similarly, it is unfair to expect that many women in the deprived areas of our city and district will be able to turn up to hospital to birth a baby, maintaining the best health and wellbeing of themselves and their baby and their wider family, on the minimum and fragmented care offered by the medical led NICE guidelines.

The evidence shows us that women supported by one to one care of a midwife, are more likely to have a normal birth, experience less pain in childbirth, are more likely to breastfeeding and continue to breastfeed and are less likely to have post natal depression.  Breastfeeding babies are 5 times less likely to be hospitalised for gastroenteritis, are less likely to be obese, less likley to suffer eczema,  less likely to have heart disease or diabetes.  Not breastfeeding a baby starts cost the NHS money from 8 weeks old, and new evidence shows that cutting the investment in maternity increases drop off rates for breastfeeding.  Moreover, we now know that personalised maternity care significantly reduces the risk of premature labour, miscarriage before 24 weeks and still birth.  Having a midwife you know and trust can save your baby’s life.

My Story:

I would not class myself as a vulnerable woman but I lived for 9 years in the deprived community of Girlington and 10 years on the Allerton council estate, my husband worked away and was on a minuscule salary as an archaeology PhD student(!) and so for most of this period I was having to manage a home, up to three small children, and a baby  –  all on a very low income.  Unsurprisingly I suffered from post natal depression and so I know the difference one to one care made for me.

With my first child, 19 years ago I was not referred to midwifery care by my GP and only found a midwife late in pregnancy.  Case loading was in operation then in the local teams and so not only did I  have continuity of care from my midwife, it was likely she or a midwife I knew and knew me would be attending my birth at home.  My birth was a long and difficult one and although I had a dream baby I was traumatised by the birth, regularly having flashbacks.  I remember with gratitude the care I received from this midwifery team – but most of all the couple of hours I was able to spend with my midwife 4 weeks after the birth going through what happened and why – debriefing we would call it today.  I had a lot of emotional work to do after that – not least because I was still struggling with loss of a previous child, but it helped move me forward: I did not get stuck at the birth.

Contrast this with another difficult birth – my fourth child.  I had a midwife who did not really support my choice of homebirth ( when I saw her which was not often), I had one in sixty midwives on call so had to accept a complete stranger into my home and birth, there was a fiasco because I was having a water birth and she did not know  how to deal with this.  I was transferred in for bleeding with another set of midwives.  I returned home that evening unbelievably exhausted. Within a week my husband was back at work ( no paternity leave in those days) I had 2-3 perfunctory visits from 2 different midwives ( I remember just 2 visits but cannot believe this is all I had but it could have been) I was discharged at 10 days.  I had no opportunity to debrief or  talk through what had happened with the midwife who attended the birth which I desperately wanted/needed to do.  My husband started working away again at 4 weeks.  At 8 weeks both he and I were utterly exhausted and depressed.

Because of that experience, with our fifth child we took the advice of the supervisor of midwives to whom I had complained during the pregnancy of my fourth child, when I realised the level of the fragmented care that I was supposed to accept for my fourth child: we booked an independent midwife.  Better late than never! My husband was training to be a teacher at the time, the cost represented 20% of our then income and it took us 2 years to pay it off but it was worth every penny.  We were given timely information, the birth went smoothly because there was no interference.  The difference in postnatal care was enormous:  Our independent midwife kept us in check, visiting us daily until I begged her not to because I did not need it.  We were not discharged for over 2 months because they wanted to ensure we did not suffer postnatal depression – she had the knack of ringing me on the day I had done too much so she could gently remind me of my priorities and I would go to my bed and leave my job.  Michelle always said self employed women were the worst for taking too little time off around the baby!

I tell my story because I want to demonstrate in my own life – as much as others – why personalised care is so important and why I am so passionate and committed to seeing it happen on the NHS before my daughters have children.  Not every woman needs the kind of care I needed.  Different women have different social and emotional needs.  BUT women and babies NEED the investment of one to one midwifery care in order to remain healthy, to care and guide them when they are not, and to help us pick up the pieces and to carry on if it all goes horribly wrong.

Up until now whenever I have raised the possibility of case loading in Bradford I have been told it is impossible, too expensive, too difficult for midwives, women will just have to live with the (unacceptable) levels of care I faced for my fourth child.  But now we have a practising NHS midwifery team with a solid  business plan who can do it and are doing it to Tariff; and making a difference to the lives of ordinary women living at the rougher end of the Wirral.  I want this to happen for women in Bradford, especially for the women living in Girlington, Manningham, Little Horton, Barkerend where rates of infant mortality are high and many women struggle as I did to make ends meet..  It makes such a difference, SUCH A DIFFERENCE.

I know that midwives cannot wave a magic wand and give us the money to fix the car and pay the bills, they could not give my husband paternity leave or bring him home from working away.  But what they did was bridge the gaps  – of the understanding and skills I needed, give me some social and moral support so I could keep going, get me to a place where my social network could take over.

If we invest in this one mother one midwife project, if the CCGs take the needs of women seriously enough to ensure it happens, we will be investing in the health and wellbeing of not just women and babies but their families and their communities.  It makes that much of a difference.  19 years ago I was a young traumatised mum living in Girlington and my midwife was Julie Walker. Julie Walker is head of midwifery.  I have just stepped down after four years as chair the MSLC and I own an international birthpool business.  It really does make that much of a difference.Image

Find out what YOU can do to make a difference:

Birth is a human rights issue

Birth is a human rights issue! 

Here is the powerpoint presentation I am going to deliver to the 3rd year midwifery students at the end of my seminar on women-centred care tomorrow, Friday 17th January 2014.

Be part of making change happen, help us to change the way the wind blows!

Birth as Human Rights Issue

Infant Loss, Inequality and why things should change

I went to a workshop  a couple of weeks ago about ‘Inequality and Infant Loss: Identifying the gaps in women’s networks’.

I learnt that the UK rate for infant mortality is 4.1 per thousand. But for Caribbean Women it is 9.7 per thousand, for Pakistani women it is 7.4 per thousand, for African women 7.4 per thousand and for teen mothers 5.4 per thousand births.

I also learnt that in Bradford and Airedale the only risk group that get caseloaded midwifery are the teen parents.  Their normal birth rate is 94%.

The highest risk groups in our city do not get caseloaded midwifery and we know this is affecting outcomes.  And outcomes are not just statistics but human beings lost and unnecessary grief and suffering.

One to One Midwifery came to Bradford and Airedale offering women caseloading care on the NHS with evidence of great outcomes elsewhere. They are being prevented from operating in our area because our local CCGs are both refusing to commission them or pay the invoices on non contracted activity.

At the same time local Trusts tell us that they cannot at this time deliver one to one midwifery care even to the most vulnerable and at risk groups in our city – except teen parents – who need it most.

These UK infant mortality rates reflect our experience in Bradford district over several years and I am saddened and disappointed that the people who have the power to make a difference – without paying extra  – are currently choosing not to do so.

Is there any one there who will answer?  Who will do something that will make a difference?

One to One Midwifery: How things can change

Belinda Phipps CEO of the biggest UK wide charity for parents NCT sets out the barriers to achieving one to one midwifery care on the NHS and how it can change to enable the maternity care we all want.

The question is:  why is it proving so difficult for CCGs and Providers to deliver one to one care, and why is there so much opposition to commissioning other providers to deliver the care?

In addition to the answer given below she has offered to work with CCG commissioners here and in other parts of the country because she says there are ways and means of working within the NHS rules, inappropriate as they are at the moment, to give acute hospital providers the flexibility they need to deliver one to one/personalised, continuity of CARER.

Belinda Phipps, CEO of NCT over to you:

I think you know that it is proving difficult for the NHS itself to offer or to buy in proper one to one care with a midwife you know and trust because

1)      The health service including commissioners don’t accept/understand how important continuity of carer is to women and what health benefit/cost reductions this can bring over all to the NHS. If you want to help them understand add your voice to this campaign

2)      The heath service cannot, with in its current system rules accommodate case-loading in a sustainable way that is acceptable to most midwives

3)      Fairness is an important NHS value and a service that is “unfairly” better and reaches only a minority of women is difficult for commissioners to take on.

I think first we need to change NHS rules:-

In England the new risk based PbR (Payment by Results) will not work any better than the old activity based one.  We need a system that is truly based  on results ie outcomes for the woman and her baby.  We need to pay when women are satisfied with their care and when babies and mothers come through pregnancy and labour whole and healthy with the mother feeling ready to start her role as mother.

The old PbR (Payment by Results) system paid by activity.  The more activity you did as a hospital, the more you got paid, the more complex activity you did the more you got paid. It was based on the principle that C-Section costs more than a normal birth so the payment for this would be higher, using the principle that the price of an activity is the same as costs, because the NHS is non profit making.  However the actual cost of a C-section for instance is not known and the payment for it does not necessarily bear any resemblance to what the procedure actually costs in reality.

However, in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost as above does not work because the building, equipment and staff need to be available even if the C-Section is not done.  So there maybe little difference in cost for a Trust between a 15% C Section rate and 25% C- Section rate in terms of costs to them.  But they rely on the income often to fund the fixed costs for other services and so any fall in the election rate means they cannot cut costs because so much of it is fixed so start to have financial problems

This means a ratchet mechanism operates which drives the C-section rate up irrespective of clinical need.

The new PbR system allocates women at booking to a risk category ( low medium and high) of course there is now an incentive in monetary terms to allocate women to a higher risk category to  raise income levels delivering more women into the Consultant led system.

What would work is a payment of x per birth ( where x is total cost of maternity in UK minus necessary admin costs not borne by providers divided by number of births) with a deprivation payment per woman for those from the most deprived postcodes ( bit like the pupil premium).  This should be paid per birth and the provider take the risk.  Effective providers  would benefit by making sure they did all the preventative work they could to keep births simple.  There would have to be a rule that says the woman chooses the midwife and then irrespective the provider cannot refuse care (they would have to pay for others to provide complex care if that became necessary).  However this would require the NHS to break its mental rule of cost=price at a treatment level.

This would also work better than the block contract approach.

Another option is to give the woman the budget – and I like that option too.

In concert with this, the capital changes have to be changed from a charge on space (as now) to a charge on people (a capitation charge) so the payment has to be made irrespective of treatment location which would remove the drive to treat people inside buildings in acute trusts unless this was clinically necessary.

You know I think CNST (the NHS litigation insurance payment system) and its equivalents in other countries needs to change so that prevention and watchful waiting is rewarded with lower fees and that the focus is not only on being safe during intervention however necessary or unnecessary they are.

Then there is the whole business of care being carried out in organizations where the governance and the building is aligned. They don’t need to be and a system set up across trusts with the service and governance alighted rather like clinical networks with teeth would probably work better, certainly for maternity.

Case-loading without the rule changes above is only a  partial solution to this dilemma and is difficult to sustain because of the above.


It starts to address this problem of women being left alone in labour and stressed midwives caring for may women because the rostering pattern almost never matches the number of women in labour.  It can’t be done like this, so the system needs changing.

NCT 121 midwifey blog 2

I am happy to offer whatever support I can though I think NCTs optimum skill is getting attention paid to these rules so they change for the better and make it possible for women to have a midwife they can get to know and trust who is there fore the pregnancy, labour and birth and afterwards.   if you want to help join us

Best wishes


Belinda Phipps

Chief Executive

Thankyou Belinda!

And don’t forget the Airedale Mums Petition for One to One Midwifery

Why there has to be change

As we continue to sit in the maelstrom of the one to one midwifery storm.  I remember what this should be about: not the egos, not the posturing for postion not the covering of backs, but the women who day in day out, week in week in week out need the nurturing care of a midwife, but who continue not to get it.

The CCGs tell us women that the advent of a new provider in Bradford and Airedale is a surprise, that they have never heard of one to one until now.  Here below is one of many letters written to the Commissioners last year asking them to seriously consider delivery of this model of care.

I have called it  ‘there has to be change’ because after listening to these stories you would have to agree . . there has to be change. And we don’t want to wait any longer because too many lives are being broken and damaged whilst people argue instead of taking action.  A simple action for you to take is to sign Airedale Mums’ Petition:

From: []
Sent: 15 September 2012 10:21
To: ‘Rashid Rafaqut’
Cc: ‘Hayward Ruth’
Subject: RE: One to One documents

Dear Mr Rashid,

Thank you so much for meeting with us a couple of weeks ago.  Forgive my tardiness in getting back to you: I work full time and this is a busy time of year.

I hope you have had a chance to look through the information sent through by Joanne Parkington, it would be interesting to know your comments.

In the meantime I thought it may be helpful to you to make you aware of some of the recent feedback on service I have which gives cause for concern.

·         On Tuesday this week I learnt of the experience of a woman in Your CCG area who had sat in a GP waiting room for an hour and a half only to find the receptionist had given her the wrong Midwifery appointment time, the receptionist laughed it off and did not apologise for the mistake and inconvenience caused.

·         On a separate occasion the same woman had a suspected urine infection and was advised to have it checked out immediately – she went to A&E at Bradford, sat there for 5 hours had to leave to collect her children, the staff told her to contact her GP, which she did the following morning.  The surgery gave her an appointment in a week’s time.

·         Her companion at midwifery appointments commented that language was not a problem because  the midwife hardly had time to speak to her

·         The woman wanted a TENS machine and very nearly did not get one because she was not given the relevant information ( see point above – and there seemed to be an assumption that a woman like her would not want one)

·         On Thursday I sat with a young mother – a really competent mother, third child but breast feeding for the first time.  A lone mother through very difficult circumstances that had also made her homeless 5 months ago.   She also has high blood pressure ( and no wonder with all that she has to cope with).  This woman needs extra care and support, and certainly if she is going to successfully breastfeed. The support and compassion may also calm the cause of her blood pressure. But I know she won’t get that extra  preventative care – only her blood pressure will attract the attention of the medical professionals – not her social and emotional needs as a young Mum.

·         On Tuesday afternoon I was rung up by a support worker for a local refugee organisation – could I help an asylum seeker, 38 weeks pregnant . . . .

It is tempting to go on, for this is the bread and butter of the stories I listen to week in week out  – and over the last few years.  This is why there has to be change – the current level of care paid for by our taxes is not delivering the quality of care it should.  If a group of midwives have demonstrated that they can deliver that level of care to tariff,  for the sake of the many women whose stories I don’t hear as well as the ones I do, I think we are honour bound to commission the people who really deliver the goods for the women and children of our city.

Our approach to you was not done lightly, it was done after months of research and discussions, backed up with years of grassroots knowledge of the maternity care women are actually receiving in our city.  We know this to be a big problem endemic in our system  with consequences in terms of high infant mortality, low breastfeeding rates, postnatal trauma and depression. We therefore need a big solution.  I would be letting down the women  whose stories I was part of this week if I did not advocate for a proper standard of statutory care within the NHS – and offer a solution to the provision of it within a tight budget.

For your information I also enclose a personal statement reflecting on my own experience of having five children in 10 years in deprived urban Bradford.

Every good wish

Ruth Weston

Women are voting with their feet for one to one midwifery care

Midwife 4 ME:

Women in West Yorkshire choosing one to one midwifery care

Scores of women throughout West Yorkshire and beyond have been voting with their feet in the last few weeks as news got round that One to One midwifery (Northwest) Ltd had set up in West Yorkshire.  One woman said “I referred myself to them because I wanted to be guaranteed a homebirth without staffing issues”.  Another said she had seen four different midwives postnatally and had seen different midwives ante-natally and through her birth.  This time she wanted to have the support of the a midwife who knew her.

At present local Commissioners are not supportive of the choices these women are making:  saying “We are not commissioning One to One midwifery at present.  We recognize that caseloading midwifery is in the NHS mandate but although it is a commissioning stance, it is not a priority for the CCGs ( GP commissioning groups) amongst its wider commissioning priorities.”  The CCGs say that it’s patient engagement exercise last year did not reveal this as a priority for patients generally or the mothers they consulted.

Ruth Weston, Co- chair of the MSLC says:  “We do not know who the CCGs consulted with but we do know this did not include the MSLC, NCT or Airedale Mums.   More consumer and Voluntary sector groups are being contacted for whether they were consulted.”

In the meantime, several consumer organizations have been writing to the local CCG Commissioners requesting, in the light of medical evidence, that women’s healthy choice is respected and paid for when they seek a care provider offering one to one midwifery care.   Airedale Mums have also set up a petition at

Beverley Beech, Chair of AIMS ( www. wrote to the CCG Commissioners saying:

“The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:
 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”
The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.”

The full text of letter with 34 citations is given at the end of this blog.

Local Campaign Group Airedale Mums wrote:

” It has come to our attention that an amazing opportunity could be opened up for the women of the district through the commissioning of private care provider One to One Midwifery.  Airedale Mums have met and corresponded with One to One Midwifery and we were very impressed by their model of care and record of normal birth in the Wirral. Several of our members attended the Open Day in Bradford last month and were further enthused by the transparency of information and the excellent attitude of all the One to One representatives.

We have also been asking questions at the MSLC over recent months about how the Commissioners and Acute Trusts are going to handle the requests of women who would formerly have chosen Independent Midwifery care – no solutions have been put forward.

For this reason we have been utterly baffled to discover there is high level opposition to this service from the Area CCG’s.  Bradford may have taken steps to introduce Midwifery led intrapartum care, but our district is way behind the game when it comes to case-loaded antenatal and postnatal care.  Many of the women who engage with Airedale Mums have seen up to 12 midwives for antenatal care alone.

The prospect of a family being given named Midwife care throughout pregnancy, birth and the postnatal period (up to six weeks) is no longer a halcyon dream.  Not only that, but this care can, and IS being provided at the same tariff as comparably less successful models being used within the NHS.”

Women of Yorkshire and the UK in general it is time to vote with our feet, our pens and our voices for the care we need.  It is being offered to us here on a plate, but if we do not write those emails to our MPs  and local GP commissioners, if we do not sign the petitions, if we do not start voting with our feet and referring ourselves ( do we have to be pregnant to refer ourselves in?!) into to One to One Midwifery and Neighbourhood Midwives even if they cannot currently provide our care, then we will be doomed to suffer another generation of fragmented, factory, care leaving us and our daughters traumatised, alone and angry.

You can join the campaign by doing three easy things:

  1. Signing the petition:
  2. Writing to your local MP and your local CCG Commissioner. You can write to your MP asking her/him to forward your letter to the local commissioner.  A good framework for a letter is given above by Airedale Mums and Beverley Beech.
  3. You can go to and sign up to the national campaign which has a lovely postcard to save you the hassle of writing a long letter.

If you want to do more, contact me or Airedale Mums if you live in West Yorkshire, if you live elsewhere contact M4M (  Midwifery 4 Me) or AIMS.  Now is the time to act.

Full Text of Beverley Beech’s Letter complete with 34 citations:

Dear Mr Pue

I am dismayed to hear from our members the difficulties they have been having in being able to refer themselves to One to One midwifery practice, and very disturbed by the reluctance of your Commissioning Group to commission these services.

The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:

 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”

The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.

Yours sincerely
Beverley A Lawrence Beech
Hon Chair
Association for Improvements in the Maternity Services

The following documents support the statements that are made in this letter:

  1. Only 1 in 5 women will be attended at any point in their labour by a midwife they have met before:

Redshaw M, Heikkila K. Delivered with care: a national survey of women’s experience of maternity care 2010. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2010. Available from:

  1.  Only one in 10 will have a midwife they have met before, while in other places nearly 1000 of them will be left alone in labour or after the birth when they are frightened

Healthcare Commission. Maternity services review 2007 Data tables for 148 trusts in England. Available from:

3. Over 1 in 4 women will have a caesarean operation.NHS Information Centre. NHS maternity statistics, England: 2011-2012. Available from:;

  1. 8 in 1000 babies die at or around the time of birth.  Sands. Preventing babies’ deaths: what needs to be done. Sands; 2012. Available from:
  1. One in ten women will become depressed following the birth.  Just over 1 in 3 women will appraise their experience as ‘traumatic’ and 2 in 100 women will develop post tramatic stress disorder (PTSD).  Alder J, Stadlmayr W, Tschudin S, et al. Post-traumatic symptoms after childbirth: what should we offer? J Psychosom.Obstet Gynaecol. 2006;27(2):107-12.
  1. Tyler S. Commissioning maternity services. A resource pack to support Clinical Commissioning Groups. Available from:

The way a woman is supported and cared for during her pregnancy and birth, and in the days and weeks following, profoundly affects her and her partner’s ability to parent their baby

7.            Allen G. Early intervention: the next steps. London: The Early Intervention Review Team; 2011. Available from:

  1.   Odent M. The scientification of love. Free Association Books; 1999.

9.            Solter A. Tears for trauma: birth trauma, crying, and child abuse. 1996. Available from:

10.       The way that a baby develops in utero and in the weeks after birth is influenced by the quality of care that parents receive   Field F. The foundation years: preventing poor children becoming poor adults. The report of the Independent Review on Poverty and Life Chances . London: Independent Review on Poverty and Life Chances; 2010. Available from:

11.       Quality maternity services should be defined by the ability to provide a safe transition to parenthood and a positive and life enhancing experience.  Midwifery 2020 UK Programme. Midwifery 2020: delivering expectations. Edinburgh: Midwifery 2020 UK Programme; 2010. Available from:

  1. Providing a model which ensures that women can be seen in a community setting where appropriate and focuses on the needs of the woman and her baby and enhances the woman’s experience.  Royal College of Obstetricians and Gynaecologists EAG. High quality women’s health care: a proposal for change. London: RCOG; 2011.
  1. One in five women is left alone in labour.  Care Quality Commission. Maternity services 2010. Available from:
  1.   10-15% of women suffer from postnatal depression.  National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance. National Clinical Practice Guideline Number 45. London: The British Psychological Society and The Royal College of Psychiatrists; 2007. Available from:
  1. 8% of babies are born prematurely.  Office for National Statistics. Preterm births data (2007, Accessed 26 March 2013). Available from:

16.       69% of new mothers start breastfeeding exclusively, but a week after birth, only 46% are doing so.  Health and Social Care Information Centre. Infant feeding survey 2010. Health and Social Care Information Centre (IC); 2012. Available from:

17.   The birth rate increased by 22% between 2001 and 2011.  Royal College of Midwives. State of maternity services report 2012. London: RCM; 2012.

  1.  More older first-time mothers are giving birth.  HM Government. General Household Survey. Available from:
  1. There is an acute shortage of midwives.  Front Line Care: the future of nursing and midwifery in England. Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010. London: The Prime Minister’s Commission on the Future of Nursing and Midwifery in England; 2010. Available from:

20.       There is no financial incentive to provide continuity of midwifery care, but the improved outcomes demonstrated by this service generate significant savings.  van der Kooy B. Continuity of care: the elusive key to improved maternity outcomes . Pract Midwife 2013;16(4):16-7.

21. Centralisation of maternity care in fewer, very large impersonal obstetric units create increased travel time for women in labour.  NCT. Location, location, location: making choice of place of birth a reality. London: NCT; 2009.

22.  . Student midwives have a high drop out rate because after qualification they are unable to practise in the way that they wished.Centre for Workforce Intelligence. Workforce risks and opportunities: midwives. Education commissioning risks summary from 2012. Woking: Centre for Workforce Intelligence; 2012. Available from:

23.       Fewer women having the support they need to have straightforward births

Downe S, McCormick C, Beech BL. Labour interventions associated with normal birth. British Journal of Midwifery 2001;9(10):602-6.

24.       Fewer women having one-to-one midwifery care in labour in obstetric units. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.

25.       The required ratio of one midwife to 28 women is not being met.  Smith H. Daily Hansard debate 17 Jan 2012. Midwife and maternity services. Available from:

26.   Each woman should have a named midwife they can get to know and trust and who they will see during their pregnancy, birth and after their baby is born.  Association of Radical Midwives. New vision for maternity care. Hexham: The Association of Radical Midwives; 2013. Available from:

27.  To provide care in line with the evidence will require the establishment of maternity networks with most care based in the community.   NCT. Innovative, integrated and in the interest of families: the Maternity Network approach. London: NCT; 2010.

Good evidence demonstrates improved outcomes from midwifery case-loading models providing continuity of community-based care

28. McLachlan HL, Forster DA, Davey MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119(12):1483-92.

29. Milan M. Independent midwifery compared with other caseload practice. MIDIRS Midwifery Digest 2005;15(4):439-49.

30. Improved birth outcomes generate significant financial savings.  NHS Institute for Innovation and Improvement. Delivering quality and value. Focus on: caesarean section. Coventry: NHS Institute for Innovation and Improvement; 2006. Available from:

31. Increased breastfeeding rates have the potential to save the NHS £40m a year.  Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK; 2012. Available from:

32. Payment by Results is not well-suited to promoting continuity and co-ordination of care.  Appleby J, Harrison T, Hawkins L et al. Payment by Results: how can payment systems help to deliver better care? London: King’s Fund; 2012. Available from:

33.Independent midwives need to have insurance and guaranteed access rights to support women giving birth on NHS premises.   Independent Midwives UK. Current situation with regard to the forthcoming requirement for mandatory Professional Indemnity Insurance. 2012. Available from:

34.  Midwifery led care when compared with models of medical led care and shared care was associated with several benefits for mothers and babies, and had no identified adverse effects.  Hatem M, Sandall J, Devane D, Soltani H and Gates S.  Midwife-led versus other models of care for childbearing women, The Cochrane Collaboration,