Midwifery in Britain in the 20th Century
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 timescale 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 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). I
t became very clear the sphere of a midwife was to support a normal pregnancy, birth and postnatal period and set an expectation of moral good character.
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.
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 commonplace in the late 1960’s and early 1970’s (induction, use of hormone drips, 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 midwife’s 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 health care 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.
It is without a doubt that a midwife requires a catalogue of attributes in order to provide a sensitive supportive journey for her clients. Here at Miracle In Progress it goes without saying, our years of experience, exposure to the forever challenging role of the midwife and access to only the best methods of assessment we pride ourselves at being a ‘Twentieth Century midwife, accessible, approachable and devoted to providing world-class care.