On a visit to present the new model from the Royal College of Midwives (RCM) (2017), ‘Stepping up to Public Health’, to midwives in Sweden, I was struck both by how much we have in common and how much is different. There is nothing like seeing UK midwifery through new eyes to make you re-evaluate what we do and how we do it!
Unlike in the UK, all Swedish midwives qualify first as a nurse and then undertake an 18-month midwifery programme. In conversation, Swedish colleagues were therefore surprised to find out that, in the UK, the majority of new midwives are not nurses. We discussed different approaches to midwifery education and I described how midwifery philosophies of care are seen as fundamental from the start of preparation programmes in the UK. Some shared their concerns that such an approach could risk losing nursing skills, while others recognised that these are easily included in training programmes. For us in the UK, work on updating our midwifery education standards continues with opportunities to influence and comment.
During the conference, many themes familiar to a UK audience were raised: for example, the challenges of providing continuity of carer and personalised care were ‘hot topics’. It was clear that our Swedish colleagues also want to be able to identify and provide additional care to those with particular needs, and they have a strong understanding of the value of relationship-based care for both women and midwives. Midwives in rural areas were more likely to get to know the women and families they cared for, whereas in larger towns and cities this is not always the case. Like in the UK, although the evidence of the effectiveness of continuity of carer models is clear, moving from a fragmented care model is not so simple.
Variations in care and the lack of standardisation are also common concerns. The midwives were aware of guidelines from the National Institute for Health and Care Excellence (NICE), but yearned for a more uniform approach, simply within units—let alone between them. The creation of protocols within the multidisciplinary team seems less developed than in the UK, with many obstetricians maintaining their own ways of practising. Having experienced this here many years ago, I can recall how midwives needed to hold totally different care processes in their heads, depending on which obstetrician was supervising. Swedish maternity outcomes are so often held up as good, but how much better could they be if best evidence was always followed?
In discussions on how the quality and safety of clinical practice could be improved, there were many similarities, including how to recognise and support women with mental health concerns; the need to reduce the incidence of third- and fourth-degree perineal tears; and high levels of maternal weight gain during pregnancy.
However, it was postnatal care that most interested me. In the majority of districts in Sweden, once they have left hospital, women have to visit clinics for postnatal care. This means that poorer women are much less likely to attend, and when women have concerns, they often attend A&E, where care is not always optimal. Although paediatricians care for a baby's health after birth, they do not provide breastfeeding support, and there is great concern about the drop in breastfeeding rates after birth and the low level of exclusive feeding at 6 months. While we in the UK might be envious that 40% of Swedish women exclusively breastfeed at 4 months after birth, we also know how easy it is to lose ground when there is a lack of effective postnatal support. Swedish midwives have recognised this and are calling to extend their role up to 1 year after birth so that midwives can be a family's first point of contact when they have concerns or questions. This way, regular contact could be made with women, rather than waiting for them to get in touch.
In the UK, were are all aware that midwifery care in the community after birth has been reduced, due to a lack of time and funding. Our health visiting colleagues also report large caseloads and increasingly complex safeguarding issues. Perhaps now is the time, as NICE updates the postnatal care guideline, for a wider discussion about new parents' support needs and who is best to provide it.
Of course, there are clear differences between Sweden and the UK in the populations we serve and the position of midwives and their associations. But, as with the UK, I was delighted to hear that our Swedish colleagues see huge opportunities for health promotion and during pregnancy and the postnatal period (and that they feel that maternity needs a greater share of health resources). There are important differences between our countries—but as midwives, there are a huge number of similarities!