Changes to Midwifery Training: The growth of "normal birth" ideology

With evolving challenges in the UK's maternity care system, including low moral, depleting staffing levels, poor recruitment and retention, budget cuts for training, and increasing safety concerns, is it time to re-evaluate policies that rely on the relevance and reliability of normal birth ideology tools such as the Pinard stethoscope within contemporary practice?

The Advance of the Normal Birth Campaign

The House of Commons Select Committee 2nd Report on Maternity Services (1992) aka The Winterton Review, provides recommendations to the future structure of Maternity Services. The distinct messages provided by this report indicate that services should be woman centred, placing the Midwife as the Central Care Provider. Politically, this placed midwives in a strong position to lead future maternity services. This led to the well referenced, Changing Childbirth Report, published in 1993, and recognised as a significant milestone in driving maternity framework and policy.

The report echoed The Winterton Review, to increase normal births and reduce the rates of caesarean sections. It advocated for personalised and woman-centred care, which included promoting the role of midwives and reducing unnecessary medical interventions during childbirth.

 One of the key recommendations was to empower women with more choice and control over their birthing experiences. This involved encouraging practices that supported normal childbirth and minimising interventions, unless the midwife assessed this to be medically necessary. The report highlighted the importance of providing care that respected the natural process of birth, which often aligned with the use of simple and non-invasive tools like the Pinard stethoscope.  This model of care, originally derived from the The Short Report (1980), is that of a minimum of one-to-one care from a midwife throughout labour for all women was recommended as best practice. This is currently reflected in the Continuity of Care model.

The National Institute for Health and Care Excellence (NICE) recognised the importance of intermittent auscultation for fetal heart monitoring. The Pinard stethoscope was officially introduced into the NICE guidelines in 2001 as a recommended tool for intermittent auscultation during labour. This endorsement reinforced the stethoscope’s value in routine maternity care, particularly in low-risk pregnancy and birth.

 Today the use of the Pinard is seen by many midwives as the 1st choice method of fetal surveillance. Often these are midwives, who predominantly promote the natural birth experience or support women and families who want a physiological birth. Sometimes this is because of birth trauma from previous experience or there are risk factors present that make them feel they have no say or control over the type of birth they want to experience (this is a whole other blog).

The Changing Childbirth Report's influence on maternity care:

Promotion of Normal Birth: It reinforced the use of intermittent auscultation with tools like the Pinard as a way to support normal birth ideology, environments and processes.

Reduction in Caesarean Sections: Advocating for fewer interventions, the report aimed to lower caesarean section rates, promoting the Pinard as a tool that could be effectively used in low-risk pregnancies.

Empowerment of Midwives: The report emphasised the critical role of midwives, whose skills in using the Pinard stethoscope for intermittent fetal monitoring was pivotal in providing woman-centred care and this evolved into the 'rebranded' current ideology of Continuity of Care (COC)

Several other reports also recommended that birth and care be less medicalised, and midwifery led such as:

2003 House of Commons Health Select Committee Inquiry into Maternity Services: The House of Commons Health Select Committee set up a sub-committee to look into maternity services in England. They took written and oral evidence from a wide range of health professionals, user groups and academics and produced three reports making recommendations to the Government.

"Making Normal Birth a Reality" a “joint” report, published in 2007 by the NCT (National Childbirth Trust), Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, was built upon the principles of the Changing Childbirth Report (1994). It provided further guidance on promoting normal birth and reducing unnecessary interventions. The report emphasized:

Normalizing Birth: Encouraging practices and policies that support the physiological process of childbirth.

Reducing Interventions: Limiting the use of medical interventions to cases where they are clinically justified.

Midwifery-Led Care: Promoting midwifery-led care units as a safe and effective option for low-risk pregnancies.

"Safer Childbirth" report, published in 2007 by the Royal College of Obstetricians and Gynaecologists, focused on safety and quality in maternity services and the importance of:

Staffing Levels: Adequate staffing of midwives and obstetricians to ensure safe and effective care.

Training and Competency: Continuous professional development and training for all maternity care providers.

Monitoring and Evaluation: Implementing robust systems for monitoring outcomes and evaluating the quality of care.

These reports influenced maternity care by reinforcing the need for skilled midwives and appropriate monitoring tools, including the Pinard stethoscope, to ensure safe and effective care during childbirth. Before this, midwives many were being trained solely using the handheld doppler for IHA.

The National Childbirth Trust (NCT)

The National Childbirth Trust has played a crucial role in influencing the drive to promote ‘normal’ or ‘physiological’ birth within the UK. Its collaboration and procured contracts with the NHS have provided a great deal of financial benefit to the company and yet little work seems to be done to challenge the efficacy of its services, when reading the overview below, one has to question firstly, why this element was privatised in the first instance and secondly, if there truly is a fair tendring system within NHS procurement to allow other companies to also bid for contracts.

A brief overview of NCT's revenue from NHS contracts:

 2000: The NCT's revenue from NHS contracts was modest, as the organization was primarily funded through member subscriptions, donations, and sales of educational materials.

2010: By 2010, the NCT had seen a significant increase in revenue from NHS contracts, estimated at approximately £3 million. This increase was due to the growing recognition of the NCT's role in providing antenatal education and support services.

2022: By 2022, the NCT's revenue from NHS contracts had further increased to an estimated £5 million. This growth reflected the NCT's expanded role in supporting NHS initiatives to improve maternity care, particularly through educational programs and support services for expectant and new parents.

2023/2024: Recent reports indicate that NCT's revenue from NHS contracts has continued to grow, reaching approximately £6 million. This increase highlights the ongoing reliance on the NCT in delivering maternity education services.

Challenges in the Current Maternity Climate:

In recent years, the UK’s maternity care system has faced numerous challenges:

Low Staffing Levels: A chronic shortage of midwives has strained the system, making 1to1 care increasingly difficult to achieve.

Poor Recruitment and Retention: The healthcare sector, particularly maternity care, struggles to attract and retain qualified professionals, exacerbating staffing issues and ability to provide safe care.

Budget Cuts for Training: Financial constraints have led to reduced investment in training and professional development for midwives, impacting the ability to provide high-quality care.

Increasing Safety Investigations: There has been a rise in investigations into maternity care failures, highlighting the need for improved practices and tools to ensure safety.

Poor Identification of Fetal Distress: Challenges in accurately identifying fetal distress have contributed to adverse outcomes, necessitating reliable monitoring tools and ongoing training.

Increasing Fetal and Maternal Mortality Rates: Rising mortality rates underscore the urgency of identifying and addressing systemic issues in maternity care.

Increasing Fetal and Maternal Morbidity Rates: Rising claims suggest systemic trends, but these are only the claims that meet the legal threshold.

Negative stereotype of Midwives: Most media coverage over the last 10 years has been predominantly negative towards midwives and maternity carers. Also, there appears to be a wide held perception within the wider NHS community that midwives are elitist.

This is something that is openly encouraged at university, where student midwives are taught to see themselves as being ‘autonomous’ and very different to nurses. Should this model continue, or do we need to re-think our approach and consider the negative impact on both our colleagues and our service users, any #psychologists or image consultants out there please feel free to advise?

Changes to Midwifery Training; The introduction of Direct Entry Midwives

Simultaneously with the calls to decrease the medicalization of childbirth, midwifery training underwent significant changes. Traditionally, midwives were required to have a background in nursing before specializing in midwifery. However, in response to the evolving demands of maternity care and the emphasis on promoting normal birth, universities began to offer direct entry midwifery places. These programs allowed individuals to enter midwifery training directly without prior nursing experience. This change aimed to attract a more diverse range of candidates into the profession, addressing the shortage of midwives and supporting the goals of the Changing Childbirth Report.

Key Aspects of Direct Entry Midwifery Training:

Curriculum: Direct entry programs typically last three years and provide comprehensive education in midwifery care, including both theoretical knowledge and practical skills. These programs focus on all aspects of midwifery, from antenatal to postnatal care, emphasising normal childbirth and minimising interventions.

Diverse Backgrounds: Many direct entry midwives come from various backgrounds, bringing a range of skills and perspectives to the profession, but many lack any previous healthcare experience.

Known Challenges: One significant challenge with direct entry training is the variability in the level of preparedness among graduates. Without a prior nursing background, some direct entry midwives initially struggle with the clinical demands and the adjustment to NHS culture in the role.

Dual Registered Nurse/ Midwives Completing an 18-Month Post-Registration Course:

Background: Nurses who enter midwifery through an 18-month post-registration course already possess substantial clinical experience and foundational nursing skills. This background can make the transition to midwifery more seamless, particularly in handling complex clinical scenarios and understanding the NHS structure as a whole.

Curriculum: The 18-month post-registration course builds on the nurses' existing knowledge, focusing specifically on midwifery skills and practices. This approach allows for a more in-depth and focused education in midwifery care.

Decline in Uptake: Over recent years, there has been a decline in the uptake of post-registration midwifery courses. Several factors contribute to this trend:

Financial Constraints: Many nurses face financial challenges in pursuing additional qualifications, especially with reduced funding and support for professional development.

Workforce Pressures: The demands on the nursing workforce have increased, making it difficult for nurses to take time off to pursue further studies.

Career Pathways: Direct entry midwifery programs have become more attractive due to their shorter duration and the ability to enter the profession directly, bypassing the need for prior nursing experience.

Negative stereotype of Midwives: Most media coverage over the last 10 years has been predominantly negative towards midwives and maternity care putting many nurses off from applying.

Comparing the Swedish Model of #MidwifeLed Care

The Swedish model of midwife-led care offers a distinct approach compared to the UK maternity system, particularly in terms of training, staffing, and the demographic and health profiles of the population.

Training and Education:

Sweden: Swedish midwives are all required to first qualify as registered nurses, which involves completing a three-year nursing degree. Following this, they undergo an additional 18 months of specialised midwifery training. This rigorous and sequential training ensures that Swedish midwives have a strong foundation in both general nursing and specialised midwifery care. The education is highly standardised and includes comprehensive training in normal and complex births. Continuous professional development is also emphasised and supported, ensuring midwives maintain high competency levels throughout their careers.

UK: Midwifery training includes both direct entry and post-nursing programs. Direct entry programs are generally three years long and focus on providing a solid foundation in midwifery practice, though they may not always include as extensive clinical exposure as Swedish programs. The diversity in educational backgrounds can lead to variability in the preparedness and ability of graduates.

Staffing Levels:

Sweden: Sweden has a higher midwife-to-patient ratio compared to the UK, allowing for more personalised and continuous care. Swedish midwives typically manage fewer births per year, enabling them to provide more individualised attention and better support to women throughout pregnancy and labour.

UK: The UK faces a chronic shortage of midwives, with high patient loads and overstretched services. The significant shortfall in midwives has been exacerbated over the years, making it challenging to provide one-to-one care during labour.

Diversity of Health / Epidemiology:

Sweden: The Swedish population is generally more homogenous with lower rates of conditions that can complicate pregnancy, such as obesity and diabetes. This demographic profile contributes to better overall maternal and neonatal outcomes and a lower incidence of high-risk pregnancies.

UK: The UK has a more diverse population with higher rates of high-risk conditions like obesity, diabetes, and hypertension, which increases the complexity and management of higher risk pregnancy and birth. The diversity and complexity of these health issues require UK midwives to be adept at managing a wide range of clinical scenarios, often under the strain of limited resources and working in high pressure environments.

Health Outcomes:

Sweden: Sweden consistently reports better maternal and neonatal outcomes compared to the UK. The well-resourced and midwife-led care model in Sweden contributes to lower rates of maternal and neonatal morbidity and mortality.

UK: The UK has faced challenges in improving maternal and neonatal outcomes, with many reports highlighting recent failures that demonstrate increasing rates of fetal and maternal mortality. These highlight the need for systemic improvements. The pressures of low staffing levels and the complexity of health issues in the UK contribute to these challenges.

Is The Pinard a reliable tool for safe maternity care?

Named after Dr Adolphe Pinard, a French obstetrician who developed it in the late 19th century, the Pinard stethoscope is an acoustic device used to listen to the fetal heartbeat during pregnancy. Its longevity and continued use in various parts of the world, including the UK, are a testament to its reliability and cost-effectiveness.

The Pinard was introduced at a time when medical technology was far less advanced than it is today. Its design, a simple hollow tube, allows practitioners to amplify fetal heart sounds without the need for batteries or electricity. This made it an accessible and essential tool for midwives and doctors, especially in resource-limited settings. Research and clinical practice have consistently demonstrated its effectiveness in identifying fetal heartbeats to assess well-being.

Historically, the Pinard was integral to routine antenatal care. Its use required significant skill and experience, practitioners had to develop a keen ear and a precise technique to discern the fetal heartbeat accurately. Studies from the mid-20th century onward highlighted the Pinard stethoscope's effectiveness when used by well-trained midwives and obstetricians.

However it has been adopted within many NHS Trusts as a go to women who opt for low risk, midwife led care. Yet, ongoing training is not currently provided by universities or within clinical placements, yet is it is used by many midwives without any audit of clinical effectiveness.

The Pinard Stethoscope in current Midwifery practice:

Advantages:

Cost-Effectiveness: The Pinard stethoscope is inexpensive compared to electronic fetal monitors, making it an attractive option amidst budget cuts.

Simplicity and Durability: Its design requires no electricity or batteries, reducing the risk of technical failures.

Training: While budget cuts have impacted all maternity training, the use of the Pinard can still offer valuable hands-on experience in fetal auscultation for midwives, usually in the antenatal period and in birth centres or suites.

Whilst claims are being made on social media platforms regarding the potential damage to hearing from 'ultrasound waves' from handheld fetal dopplers. To date, no evidence has been found to corroborate this.

Limitations:

Skill-Dependent: Effective use requires significant training and experience, which are currently limited by low staff levels, skill ability and budget constraints.

Intermittent Monitoring: The Pinard stethoscope provides intermittent rather than continuous monitoring, potentially missing transient episodes of fetal distress.

Subjective Interpretation: The Pinard relies on the practitioner’s auditory and interpretation skills, which can vary from midwife to midwife. There is the increasing ability of AI in medicine and capability of electronic fetal monitors (EFM) to have inbuilt programmes such as Dawes Redman or remote access to senior clinicians who can provide a second opinion and support.

Supporters of the Pinard point to evidence that shows that whilst EFM detects more fetal distress, this has not decreased intrapartum stillbirth or neonatal death. However, these studies were done in low or middle income countries.

The future of the Pinard

While the Pinard remains a valuable tool in certain contexts, its reliability in modern UK maternity care is compromised by many systemic challenges. The current landscape of low staffing levels, poor recruitment and retention, budget cuts, amid rising systemic safety concerns, requires an evaluation of its role.

Whilst it does offer a cost-effective and durable option, its dependence on skilled practitioners and the subjective nature of its use, limits its effectiveness in ensuring consistent or accurate fetal surveillance and scrutiny of safety in Maternity care has never been higher.

During labour, an argument in the Pinards favour is that they promote a less medicalised approach and are less constrictive than a CTG monitor. Midwives are usually familiar at being creative, many know that a handheld doppler or wireless transducers can still achieve an active birth, good mobility and a positive birthing experience. From a #maternitysafety perspective, to use a Pinard during the late second stage when contractions are their most frequent and intense, can be practically difficult to perform as gaining an accurate, audible reading when contractions are expulsive and especially, where there is a concern that distress is occurring is incredibly difficult.

There is also the little addressed issue of obtained informed consent.

Midwives must ask themselves why they choose to use a Pinard as a single surveillance method, because if you, and only you, have the exclusive joy of hearing a heartbeat, you are excluding that person and their family from listening to their baby at each and every appointment or in labour.

Statistically some of these precious babies, are the babies that ultimately, do not survive and with all of the ensuing trauma that follows, and given the fact that parents cannot audibly hear their own baby themselves or experience the comfort (albeit temporarily) this gives them.

It can also be as painful and constricting as continuous CTG monitoring by frequently asking someone to lift their body out of a pool, after a contraction every time you need to auscultate. Doesn't this unwelcome interference, disturb the very ambiance that you are trying to create and surely during a water birth, it loses the therapeutic benefits of continuous water submersion. thereby, raising the risk of an unwanted outcome?

Gaining Fetal Monitoring Consent

Should midwives be giving parents information much earlier in pregnancy to properly obtain informed consent and discover which method of monitoring is preferred, during routine care and discussing what happens when emergency situations occur.

If a midwife use a pinard as their only method of fetal surveillance, one has to question their reasoning, is this solely their own personal preference driving the desire to use the Pinard?

There is a video on you tube by an independent midwife who beautifully demonstrates how to use a Pinard. However, the video also clearly demonstrates that the client asks at the very end of the process for the midwife to confirm what has just happened and did the midwife just listen to her baby, she did not get to hear it for herself and did not appear to know what the midwife was actually doing to her.

To our knowledge no one has conducted a study on either consent for method of fetal heart monitoring or conversion from the use of the Pinard to electronic forms of monitoring in labour when required. For the stakeholders who write national guidance (NICE) parent preparation providers (NCT) and midwifery training content assessors at the NMC, some evidence based clarity would beneficial for prospective student midwives and for #safermaternity care.

In our experience during the 1990’s, a whole generation of midwives trained using handheld doppler as a primary go to, before the Pinard was recommended for use in 2001and according to one leading Pinard advocate, even she had to teach herself to use it.

However, in most labour wards they sit redundant in a drawer, with most midwives preferring a handheld electric doppler over the Pinard.

Is further study needed or is it time to hang up the horn and look new technology and a new ideology based on safety when training our future midwives?