A recent useful article presents us with “An analysis of media reporting on the closure of freestanding midwifery units in England” (Rayment et al 2019). This led me to reflect on the patterns we so often see around these closures.
Despite the well-researched cost-effectiveness and safety of such units (FMUs, often called birth centres) and the support for them in policy documents such as Better Births, 14 freestanding units were closed between 2008 and 2015. Rayment et al (2019) highlight how “despite the ‘air time’ given to service users, the dominant discourse, and by association authoritative knowledge, lies with the healthcare managers and commissioners, and with the voices of midwives themselves being noticeably absent”. The dominant discourse favours centralisation of services and a profit driven assumption that high tech services are best, despite the large body of research to the contrary.
The press coverage of FMU closures focussed on underuse by women and financial constraints as compelling reasons for closures.
Many of the units closed were opened relatively recently as a sop to local mothers and midwives when consultant units were closed and services centralised elsewhere. When such consultant obstetric units are closed, the public demand is to retain what is being cut, not be fobbed off with something else. Even the small concession of a FMU rarely lasts. Nevertheless FMUs are often well used at first and their users can be very enthusiastic about them.
To reach a situation where FMUs can be closed as under used shows the power of the dominant discourse to undermine them. Rayment et al show how “lack of demand” is presented as a “given fact”, although many women are steered away from choosing birth centres, not told they exist or, if they do find out about them, are told that they are not eligible to birth there. There seem to be many reasons for exclusion from birth centre care which are not necessarily reasons for consultant led care, such as women above or below the average age of childbearing, women with a higher-than-average BMI, women who carry GBS or women whose pregnancy has lasted longer than average; it could be argued that such women would particularly benefit from midwifery care. Beyond this, management sees the staff of FMUs as a resource that they can tap to plug gaps in the service elsewhere. Frequent temporary closures of FMUs are bound to lead women to decide against using a service which may not be there when they need it. I was recently told by the manager of a FMU that they sometimes close the unit “for reasons of safety”. Such a statement would lead any woman to book elsewhere but the threat to safety was at the consultant unit in the nearby city where the labour ward lacked staff and so the FMU midwives were moved there. Except in epidemic situations, to close a unit because of staff sickness there or elsewhere shows that the unit is understaffed in the first place.
Yet FMUs are so often starved of staff and resources to keep larger units running.
Similarly financial constrains are defined so as to protect the more costly consultant units. The cost of running FMUs was often defined as “a loss” rather than essential running costs by finance managers who saw the service as dispensable. At a meeting about the proposed closure of the Birth Centre at Darley Dale, I spoke about the unit’s excellent clinical outcomes and cost effectiveness and was told by the finance manager, “this unit is cheaper shut than open”! The assumption being that the consultant units can absorb the women who would have booked at the birth centre. The extra work for the consultant unit midwives or the slightly worse care for all the women there because of the extra numbers was not seen as an issue.
Free standing units appear as separate items on a Trust’s balance sheet which makes closing them an obvious way of saving to the management of a centralised and underfunded service. Some of the birth centres closed in recent years had served their local rural community for generations, such as those in the Derbyshire Peak District. Local support did not prevent them being starved and then shut.
Beverley Beech lists the steps which lead to closure of FMUs:
1. Launch the unit with much enthusiasm
2. After a honeymoon period begin to load the midwives with additional duties
3. Require them to be on-call for the labour ward as well as their own clients
4. Head of Midwifery fails to protect the midwives' interests
6. Ensure that there is little signage to indicate that there is a midwifery unit.
7. Fail to promote the unit to newly pregnant women.
8. Inform those that ask about the unit of 'the risks'.
9. Ensure that the unit is only open for specific periods.
10. Fail to consult with local women about closure plans.
11. Finally, claim that women do not want to go there and close it down.
Managers are so deeply immersed in the market driven values of the service that they may well not be aware that they are following this well-trodden path. Nevertheless for FMUs it boils down to sop, starve and shut.
I strongly support midwife-led units, I worked in one until its closure and loved it, as did its staff and the local community. If we are to keep any of these excellent units, we need to recognise the pattern by which they are undermined and shout about it.