Conveyor Belt Maternity Care

February 22, 2016


I have worked on many labour wards across the UK and visited and worked in them in other parts of the world. I felt I was lucky as a midwife in that I had a basic training based on “normality, mobility and making birth as like home as possible”.

Sadly, my experience on many  Delivery Units however, has highlighted the “conveyor belt” type of care that is routinely provided even in 2016.  The series “One Born Every Minute” seems to illustrate this to women as the care to expect.  Women are processed rather than cared for, despite the midwife’s best efforts to the contrary.

The environment, the lack of beds, the lack of good triage facilities, means that bed occupancy is the main driver of care. Many birth units have up to 15 birth rooms but never 15 midwives on a shift to give the suggested one to one care advocated by NICE (2014).

Frontline of maternity services is the local obstetric unit. The place where most women with a problem are encouraged to birth.  Many women without problems also choose to deliver here as they believe this the safest place to give birth.  The ideals of relaxation, mobility in labour, music etc. are frequently compromised by the need to “get on with it”.

There are obvious valid reasons to get on with births – fetal distress, antepartum haemorrhage, maternal high blood pressure etc. There is no doubt that “getting on with it” in acute circumstances has saved lives.

But in the process, many of the nice bits of birth are sacrificed by the need to monitor the fetus by continuous monitoring.  This can be difficult especially with women with raised BMI, so then you get the need to use a fetal scalp electrode.  The ‘cascade of intervention’ talked about years ago is alive and well in 2016.

The need for the acceleration of birth with syntocinon medication is there for every induction of labour unless the artificial rupture of membranes is intervention enough. There is a reason why that baby should be born so why “mess about”.  Even the recommended term plus twelve or fourteen days is reason enough to intervene based on an accepted evidence base. But the need for speed may be too fast for the parents and potentially the fetus. If there is time, we should take time.

These same parents might be at a loss to understand when we insert a pessary that may take twenty-four hours to work. If there is a reason to intervene why can it not be quicker? If they are ready for an artificial rupture of membranes(ARM) why is there a delay in going up to labour ward. They think – is there a reason to intervene or not? We do give mixed messages dependent upon the capacity of the service to deliver.


The women as a result get lost in the routine of the obstetric ward. They are left in the care of midwives too stretched to give one to one relaxed care.  The doctor pops in when available or on designated ward rounds or when there is a problem. It is always a question of capacity, not care, when inductions are put off because labour wards are full.  Care could be compromised because medical staff are not available for review because they are in theatre with another case – despite the NICE recommendation about medical staff availability on labour wards.

“units with between 2500 and 6000 births a year or classed as high risk should provide at least 40 hours a week of consultant presence (Paragraph 4.2.3 Safer Childbirth 2007) “

Midwives on this frontline are always looking over their shoulder, as the care they give is under constant scrutiny. If there is a poor birth outcome they are investigated within an inch of their lives, which does not encourage them to go out there again and try and work with the woman, but only stick to strict guidelines that may or may not fit with that individual woman.

The woman who wanted a straightforward vaginal birth during her pregnancy is now faced with lots of questions and the abandonment of their birth plan because they have developed a problem. Giving them time to come to terms with this change is really important, unless of course imminent emergency birth by caesarean is required. Debrief afterwards is equally important. But professionals who deal with this scenario every day may forget about the parents needing to digest what they have been told. It might be their first baby, their very first time in an obstetric arena that we as professionals are so used to. Spending time whilst the family adjust to the new scenario is important but medical staff are often needed elsewhere leaving midwives appropriately to talk the family through the decision making process.

These are the mothers who may go on to have terrible birth experiences. Where their choice and control does not seem to matter in the conveyor belt obstetric atmosphere.  How that care is done does matter!  #matexp  on Twitter is exploring this and giving women and midwives a voice.  The RCM has a project to promote Better Births.

But I would like to support the voices of all the midwives who do not want to work in this way either.  They do not wish to process women quickly through the system and then on to the next lady as the workload demands.  It is soul destroying and extremely tiring type of care to provide. I highly recommend the Book “Roar behind the silence” by Sheena Byrom and Soo Downe which gives ideas as to how we must try and work with the current system to provide better patient centred care.