Introduction
The United Kingdom is unique in that it is the only country where midwifery supervision is enshrined in legislation. The Local Supervising Authorities (LSAs) are responsible for the provision of statutory supervision of midwives in their area. They appoint supervisors of midwives to undertake statutory supervision and ensure that every midwife in the LSA area has a named supervisor of midwives. Every midwife who practises in the UK needs to notify her intention to practise to a supervisor of midwives. The supervisors of midwives pass on the notification of intention to practise to the LSA, which in turn informs the Nursing and Midwifery Council (NMC) that the midwife is practising within the LSA area. The LSAs also ensure that all midwives have access to a supervisor of midwives for support and guidance at all times. Through this system safe and effective midwifery practice is facilitated. By enabling safe and effective practice, supervisors of midwives protect the public and ensure that midwives are supported in their everyday work.
History
In order to understand what statutory supervision of midwifery in the UK is today, it is essential to understand how the midwifery profession and statutory supervision have evolved over time.
Supervision is not a new concept. In their book on the history of midwifery, Towler & Bramall (1986) reported that in the 1500s the chief physician of the city of Frankfurt supervised midwives. The earliest records of midwifery show that medicine and men have attempted to control midwifery practice (Donnison 1977, Witz 1992).
The drive to legislate midwifery practice in the UK arose from a desire to reduce the high perinatal and maternal morbidity and mortality evident in Victorian England, and ‘protect’ the public from untrained midwives. Midwives were characterised as ignorant, drunk and lazy, and ridiculed in the guise of Sairey Gamp in Charles Dickens’ Martin Chuzzlewit (Heagerty 1996). Heagerty (1996), however, notes that most midwives were hard-working and skilled. With the founding of the Midwives’ Institute (the forerunner of the Royal College of Midwives), a number of prominent women began to push for legislation which would legalise the practice of midwifery and gain greater recognition for the profession (Towler & Bramall 1986).
Statutory supervision of midwives came into effect when the Midwives Act was enacted in England and Wales in 1902. Scotland followed in 1915 and Ireland in 1918 (Jenkins 1995). Midwives were recognised legally and appropriate training had to take place before registration with the Central Midwives Board (CMB). Registration was not without its opposition as many saw that this was putting midwives under the control of men/doctors (Donnison 1977, Kirkham 1995, Robinson 1990, Witz 1992). Kirkham (1995) notes that men and non-midwives dominated the composition of the CMB. It was not until 1920 that the CMB was required to include midwives, although several notable nurses and members of the Midwives’ Institute were already members. LSAs were responsible for enacting statutory supervision of midwives and reporting to the CMB. The CMB was the statutory body that was to rule midwifery for the next 70 years until the formation of the United Kingdom Central Council of Nursing and Midwifery in 1983.
Statutory supervision of midwives
1902–1937
Supervisors of midwives were known as inspectors of midwives until 1937. Inspectors were selected from women, for example middle-class and wealthy women, who had undergone nurse training but did not go on to work in nursing (Kirkham 1995). Towler & Bramall (1986) note that the focus was on the social and moral aspect of the midwives being supervised rather than their clinical skills. This finding is supported by Heagerty (1996), who recorded that these inspectors of early midwifery had little or no education in midwifery supervision. Almost all were from the middle or upper class and their knowledge and inspection methods were more concerned with cultural and moral issues than actual clinical practice. With little or no background knowledge apart from what was available to them in largely medical textbooks and the Midwives’ Rules, there was no possibility of these inspectors being able to offer constructive comment on clinical issues.
Reports to inspectors from other sources such as doctors were often made without any substantive evidence (e.g. the midwife being drunk at a birth), even though this could result in midwives being struck off the register or severely censured (Heagerty 1996). The midwife had no leave to appeal and Kirkham (1995) reports that many were struck off simply because of ‘offences’ relating to the poverty of their clients when the rules required the midwife to summon medical aid but the family would not and could not as they had no means to pay the doctor’s fee. This left the midwife in a dilemma between the rules that governed her practice and the wishes of her clients.
Donnison (1977) regards the Midwives Act 1902, along with all subsequent Acts, as a disadvantage for midwifery on several counts compared to other professions. She regards midwives as subjected to supervision and likens it to controls on tradesmen; it therefore did not promote the profession. Investigations of misconduct, which included review of the private life of the midwife, were defined under strict criteria with no recourse to appeal if the midwife was struck off. Leap & Hunter (1993) describe the fear many midwives experienced as unannounced visits from an inspector were common.
1937–1974
In 1937 the term ‘inspector’ was dropped in favour of ‘supervisor’, and a two-tier system of medical and non-medical supervisors came in. The medical supervisor was usually the Medical Officer for Health for the area, with the non-medical supervisor being a midwife, nurse or health visitor. Strangely, although it was recommended that the non-medical supervisors of midwives should have some experience in midwifery practice, it did not recommend that those who were currently in clinical practice should be supervisors of midwives (Kirkham 1995).
Towler & Bramall (1986) report that the creation of medical and non-medical supervisors was an acknowledgement of unsuitable appointments in the past. As the medical supervisor of midwives was usually the Medical Officer for Health and was therefore aware of the social and public health issues of the area, supervision was more knowledgeable and demonstrated understanding of the everyday issues that midwives encountered in their practice (Allison & Kirkham 1996).
Allison & Kirkham (1996) describe how non-medical supervisors were community based during the 1940s. These supervisors were practising midwives and worked in the community as part of the domiciliary maternity service. They knew the conditions in which the midwives worked and therefore were much more supportive than the previous inspectors. They formed a valuable resource and were also responsible for recording and passing on to the medical supervisor statistics that enabled information on birth and maternity outcomes to be produced (Allison 1996).
Jenkins (1995) and Kirkham (1995) believe that the changes that took place in statutory supervision of midwives in 1937 sowed the seeds for what supervision should be today, i.e. the supervisor being the supporter and friend of the midwife.
Throughout the 1940s and 1950s most women continued to give birth at home. A small number chose to give birth in hospital and midwives were employed to provide care for women who delivered there and also to assist doctors. Supervisors did not have any control over hospital midwives until 1942, when it became mandatory for these ‘institutional’ midwives to notify their intention to practise to the LSA (Bent 1993). Statutory supervision was provided to hospital midwives by senior community-based supervisors (Robinson 1990).
Kirkham (1995), in a consensus conference report, discussed the 1951 Midwives Act and noted that supervision continued to be linked with issues of control. This Act stipulated that midwives were required to attend a refresher course every 5 years, and it was in the remit of the supervisor to check that midwives adhered to this.
1974–1985
Jenkins (1995) notes that despite major consolidation of midwifery legislation in 1951, there were no changes to the requirements for supervision until 1974. The changes in legislation, when they came, were a result of the reorganisation of the National Health Service. This transferred the powers of the LSAs from local authorities to regional health authorities (England), area health authorities (Wales), health boards (Scotland) and health and social services boards (Northern Ireland).
All midwives were now employed by the NHS and supervision was transferred from community-based supervisors to hospital-based midwives, with the supervisor usually being the head of midwifery services (Jenkins 1995).
Medical supervisors of midwives also became obsolete with the reorganisation of the NHS in 1974 and this finally ended with an order in 1977 that all supervisors had to be experienced practising midwives, which also dropped the criterion that a supervisor required a year’s experience of domiciliary practice (Jenkins 1995).
1985–2002
The Midwives’ Rules (UKCC 1993) saw the addition of Rule 45, which detailed how a LSA must discharge its functions. One of the features of this rule was that for the first time, each LSA had to make available to all midwives practising in its area a list of all supervisors and how contact could be made with a supervisor on a 24/7 basis. This was to facilitate support to midwives whenever they needed it and to heighten awareness of who the supervisors in each LSA were. A more comprehensive definition of the role of the supervisor of midwives was considered by the UKCC for inclusion in the revised Midwives’ Rules of 1998. This, according to Steene (1996), was an effort to improve the understanding and purpose of supervision.
The Association of Radical Midwives held a consensus conference in April 1995 following the publication of Draft Proposals for Midwifery Supervision (ARM 1994). The consequences of this conference were far-reaching with the spotlight being firmly placed on supervision and its relationship in supporting changes in midwifery practice, as described in Changing Childbirth (DH 1993). The conference proceedings were to become one of the first books on statutory supervision of midwives and this was followed shortly afterwards by Kirkham’s Supervision of Midwives (1996).
In 1996 consortia of LSAs were organised in England and Wales as a result of the abolition of regional health authorities. The reason behind the consortium arrangements was that there were technically 127 LSAs in England alone, which hardly fostered equity of supervision standards across the country. The LSAs were amalgamated into eight regions with one or two LSA midwifery officers being appointed to each region on a full-time basis. This provided equity of approach in the provision of support and advice to supervisors and midwives alike (Sauter 1997).
How have the Midwives’ Rules impacted on the health and well-being of women?2002 to present day
The Nursing and Midwifery Order (HMSO 2001) led to the establishment of the Nursing and Midwifery Council (NMC) and the continuing recognition and support for statutory supervision of midwives. The NMC came into being on 1 April 2002 and has developed many standards for statutory supervision. Statutory supervision of midwives was recognised as being a pivotal part of maintaining good midwifery services.
Enquiries such as Northwick Park (NMC 2005) and more recently Morecambe Bay (NMC 2011) highlighted that where statutory supervision was not adequately recognised and supported within a service, poor standards of maternity care were unlikely to be escalated and acted upon. Safe Births: everybody’s business (King’s Fund 2008) recognised the value of statutory supervision of midwives and supported its continuance in that it promoted safe and effective practice ensuring safety of women and their babies. Midwifery 2020: delivering expectations (DH 2010) likewise extolled the virtues of statutory supervision and how it is an essential prerequisite for all midwives in practice.
The NMC developed Standards for the Supervised Practice of Midwives (NMC 2007), ensuring that such programmes had equitable standards across the UK. Although the Midwives’ Rules and Standards (NMC 2012c) revoke the 2007 standards, programmes supported by the LSAs which address individual midwives’ poor practice continue and provide support and an opportunity for remedial action rather than direct referral to the fitness to practise directorate of the NMC.
Previous consortium arrangements for England and Wales were adopted across the UK and in 2006 all LSAs had a practising midwife holding the post of LSA Midwifery Officer. The LSA Midwifery Officers formed the LSA Midwifery Officers Forum (UK) and meet on a regular basis to develop and implement the NMC standards. They work with key stakeholders such as the NMC, Royal College of Midwives, Independent Midwives UK and Departments of Health from all four countries of the UK. Outputs from the Forum include national guidelines, strategic direction and an annual report.
A dedicated LSA Midwifery Officer Forum website is available at:All LSAs are required to submit an annual report defined within Rule 13 of the Midwives’ Rules and Standards (NMC 2012c). Since 2009 the NMC has compiled an analysis of all LSA annual reports. These publications, entitled Supervision, Support and Safety (NMC 2012b), form part of the NMC’s quality assurance process of the LSAs.
Where would you go to access your LSA’s annual report? What would you expect to see in that report?The NMC also developed a system for reviewing LSAs and ensuring that the rules and standards for statutory supervision have been met in each LSA. These reviews are available on the NMC website at:
www.nmc-uk.org/Nurses-and-midwives/Midwifery-New/NMC-Review-of-LSA-reports/.
Midwives’ Rules and Standards
The Midwives’ Rules and Standards (NMC 2012c) is the legislation under which every midwife practises in the UK. Supervisors of midwives use the Rules alongside The Code: standards of conduct, performance and ethics for nurses and midwives (NMC 2008) to guide midwives through the principles of professional, safe and effective midwifery practice.
One criticism of previous editions of the Midwives’ Rules is that until the 2004 edition, they had passed down virtually unchanged from the first Rules issued following the passing of the Midwives Act 1902.
The early Rules dictated clinical practice in an effort to stop the spread of infection, promote competent practice and safeguard the mother and baby. Something the modern-day midwife may find amusing is that the Rules did not confine themselves solely to professional practice and also specified, for instance, suppliers of official uniforms.
The Midwives’ Rules and Standards (NMC 2012c) now provide midwives and supervisors of midwives with a framework in which safe and effective midwifery practice can be based. By providing rules, standards and guidance in one document, the NMC has combined legislation and practical advice for all midwives.
Role and responsibilities of a supervisor of midwives
Rule 8 of the Midwives’ Rules and Standards (NMC 2012c) details the minimum role and responsibilities of a supervisor of midwives. However, this does not give a descriptive account of what the supervisor of midwives may encounter in her role. This has led the LSA Midwifery Officers Forum UK to develop role descriptions under three main categories of what is expected of supervisors of midwives (see Box 19.1).
