Maternity nurses in the UK?

by Ingrid Robeyns on February 6, 2008

A kind reader alerted me to an article in last Sunday’s Guardian, on the proposal by the Conservative Party to introduce the Dutch system of Kraamzorg in the UK. As I briefly mentioned in an earlier post, under this system a qualified maternity nurse cares for mother and the newborn child at home in the first week after the birth.

The article gives a fair account of what these nurses do, and of the advantages of this system. Yet I’m surprised by the claim that the system would be too expensive to be introduced. Of course the question is ‘expensive in comparison with what’. In the Netherlands, one reason why mothers who give birth leave the hospital so quickly after the delivery (if they go to the hospital at all, that is), is the cost; a maternity nurse at home is much cheaper than the cost of keeping mother and child in hospital (as is the case in Belgium, for example). I don’t know what the kind of care is that is currently provided to newborns and their mothers in the UK – yet it is self-evident that if the comparison is made with no care for the newborn and mother at all, then the system is relatively expensive. But how under a system of no care at all the mothers can take the rest that they need is a mystery to me. The days that this could be provided by family members are, for most of us, long gone. Hence not a bad plan from the Tories, if you ask me.

{ 34 comments }

1

aaron_m 02.06.08 at 10:26 am

When you say that new mother’s leave the hospital quickly because of the cost in the Netherlands, is this because the cost to them is high and they choose to leave or is it because the state views the cost high and limits the time mother’s are allowed to stay?

2

Ingrid Robeyns 02.06.08 at 10:43 am

The latter. There’s no way you can choose to stay in hospital for several days — it’s only when there are serious medical reasons (like excessive blood loss or infections etc.) that mothers are allowed to stay in hospital for more than a few hours after the birth. With ‘normal’ deliveries (no complications), the mother takes a shower a few hours after the birth, and then she goes home, where the maternity nurse will be arriving almost simultaneously.

3

otto 02.06.08 at 10:45 am

I have friends in NYC who are a Manhatten uber-couple. When they had a nurse in house for several weeks after their baby was born, it was difficult not to think ‘that’s what everyone needs’.

Now of course they’re also into getting the right music-classes-for-under-ones but I think some Manhattan priorities are less vital for the rest of us.

4

chris armstrong 02.06.08 at 10:52 am

It may be that the kraamzorg system is cheaper than keeping mothers in hospital, but that doesn’t happen in the UK either, so it would represent a ‘new’ cost. Mothers with no complications are discharged the day of their child’s birth, or the next day. If you’ve had a caesarian you may stay in for perhaps four days – but would it make sense to discharge these mothers and allocate home care to them? I suspect after-care for caesarians may be different in the Netherlands, but this would be a big change in the UK. So I think the kraamzorg proposal is excellent, but I don’t see much opportunity to recoup the cost by cutting down on hospital-stays.

5

Aleid 02.06.08 at 11:03 am

Just giving birth in the Netherlands, I can only say that the kraamzorg is really excellent. Even though my delivery was very uncomplicated, it was still very nice to have someone around for a few hours a day to take care of things. It gave me the rest I needed to recover and the nurse introduced both the new parents all skills one needs when taking care of a new born. I do not know about costs either way, but it was priceless to have the burse around.
The lady who wrote the article in the Guardian is the one who needs to be questioned, what on earth was she doing out for lunch just 3 days after giving birth?

6

PeWi 02.06.08 at 11:31 am

re- uk

my wife just got back from cesarian having been in hospital for four days. we had two midwife visits and are now visited weekly by a health visitor. in emergencies we can attend her clinic. we feel fairly well catered for by the current system. what would really make a difference though is me getting a longer paternity stint and similar job promisses as in Germany were your job is being kept for THREE years after you have given birth.

7

Matt 02.06.08 at 12:10 pm

One reason beyond costs that it might be better to have a new mother and baby stay at home with a nurse rather than stay in the hospital is that hospitals are full of sick people and therefore are great places to get sick. (A really large percentage of people even in quite good hospitals get sick with “secondary infections”, meaning something they caught while at the hospital. It’s a good reason for anyone to go home if he or she is able and will get necessary care.)

8

Slocum 02.06.08 at 12:58 pm

Both times my wife was out of the hospital within the day — not because anybody kicked her out, but because she wanted to get out of there as soon as possible and get home where it was comfortable, quiet, and private and the food was better. If we’d thought of it, leaving the domain of drug-resistant microbes would have been an excellent reason also.

Making a home-health nurse available to those who need or want one (particularly after the first child) seems like a good plan, though establishing it as standard procedure strikes me as both unnecessarily expensive and intrusive (What?!? You don’t want the nurse to visit? Note on chart: patient is uncooperative — refer to social work for a follow-up). I have a friend who had a premature infant. She had breast-fed her first child, was pumping milk for the second (who was in the ICU), had plenty stored in the freezer, and yet the lactation consultant (aka ‘milk nazi’) just wouldn’t leave her alone–she had the hardest time convincing her that her services weren’t required.

I have to say that the description in the article verges well into ‘unnecessarily intrusive’ territory:

· Monitoring visitors to the mother’s home to ensure that rest times are not interrupted;

· Keeping a diary with details of the mother and baby’s progress for use by doctors and midwives.

And BTW< this plan strikes me as highly likely to have the effect of discouraging paternal involvement.

9

otto 02.06.08 at 1:24 pm

Monitoring visitors to private residences does indeed seem to be rather dubiuous.

10

Ingrid Robeyns 02.06.08 at 1:29 pm

Slocum, I recognise the ‘intrusiveness’ aspect – I had two nurses this time around (each coming for four days), and the second one, who was very young, was giving me so much detailed ‘advice’ on breastfeeding, while she knew (1) that it was all going perfect and (2) that I had breastfed my first child for 7 months. So at a certain point she got on my nerves and I simple didn’t respond to another piece of advice, just remained silent — at which point she added, “but you know, it’s only our advice, you should of course follow your own intuition”. It’s a little difficult to keep listening to a 20-year old who just left nursing school telling you in detail how to breastfeed if you don’t need that advice at all (I just wished she left me and the baby alone in my bedroom, without standing there watching us and giving some unwanted advice once in a while).

But: this is not a feature of the system, it’s a feature of the professional. The first nurse we had (the first 4 days) was excellent and did lots of household work that she didn’t have to do according to the rules, and she gave us all the privacy we needed.

By the way, I think that one is not obliged to take kraamzorg, in fact if the parents don’t book it on time (a few months before the birth), they may be too late; and there is a small own contribution to be paid (which may be covered if one has an elaborate health care insurance). Thus, if one does not make the booking or is not willing to pay the parents’ contribution, no nurse will come to your house.

My impression is that most mothers in the Netherlands are very happy with the system.

11

SamChevre 02.06.08 at 1:58 pm

Slocum,

Your second point (keep a diary…) is what a hospital nurse does; I wouldn’t see it as particularly intrusive.

12

Troll 02.06.08 at 2:29 pm

“Th dys tht ths cld b prvdd by fmly mmbrs r, fr mst f s, lng gn.”

???vdnc????

13

Michael Mouse 02.06.08 at 2:33 pm

There were a couple of reports on the BBC the other day contrasting maternity care in the UK with that in Sweden (lowest mortality) and that in Sierra Leone (highest mortality).

Obviously one was duly appalled that the perinatal mortality rate in Sierra Leone was something absurd like 25%, but not entirely surprised.

The thing that genuinely shocked me was that the difference between the UK and Sweden was a factor of two – something like 0.6% versus 0.3%. I knew, of course, that Things Are Better In Sweden, but it hadn’t occurred to me that the difference in hard-outcome stats was so big. Half the number of deaths!

Surely that’s easy pickings for politicians?

14

Barry 02.06.08 at 3:22 pm

Michael, if it’s anything like in the US, the UK politicians will say:

(a) It’s Different Here (and somehow not get into trouble for suggesting that the UK is fundamentally worse in some way).

(b) It’s all due to Those People, whom Sweden doesn’t have (and you know who they are).

(c) If we did things like in Sweden, we’d all die from hunger like the Swedes did (didn’t they?).

15

Pete 02.06.08 at 3:33 pm

Any chance of a breakdown on those 0.6% and 0.3% figures?

16

Slocum 02.06.08 at 4:35 pm

Ingrid Robeyns: But this is not a feature of the system, it’s a feature of the professional.

Perhaps. But my sense is that people in the ‘helping professions’ tend to take a rather expansive view of the general need for ‘professional help’. I don’t know if that’s due to the personality types they attract, or because of the training, or out of an intuitive sense of self-interest, but they often seem to have a rather negative reaction to, “Thanks, but no thanks”, seeing as a sign of pathology rather than competence.

Though I suspect home health nurses are mild in comparison to social workers. I have friends who adopted children and, therefore, found themselves under the extended supervision of social workers, who stopped by regularly for visits during which their homes and parenting styles were inspected. In fact, before they were even eligible to adopt, they were required to go through mandatory grief counseling sessions to come to terms with their infertility. And, of course, they had to take it all with carefully feigned sincerity and a smile no matter how much it annoyed them else they would be disqualified. They were enormously happy to be done with the social workers and definitely didn’t miss the advice and assistance.

SamChevre: Your second point (keep a diary…) is what a hospital nurse does; I wouldn’t see it as particularly intrusive.

I would not consider occasional notes on the chart about blood pressure and the like in the midst of a busy day during which they see many patients to be equivalent to ‘a diary’ written during extended one-on-one sessions.

17

aaron_m 02.06.08 at 5:12 pm

The policy sounds great, but is it obviously much cheaper than hospital stays?

On the face of it one would expect that one nurse taking care of one patient for 4-5 hours/per day would be more expensive than 6 nurses taking care of 20 patients in an environment where patients would certainly not need much more and possibly less than 5 hours of focused care per/day.

18

Uncle Kvetch 02.06.08 at 5:49 pm

The home health visitor is the jack-booted thug of liberal fascism.

19

PJ 02.06.08 at 6:25 pm

“hospitals are full of sick people and therefore are great places to get sick. (A really large percentage of people even in quite good hospitals get sick with “secondary infections”, meaning something they caught while at the hospital.”

Sick people are more likely to pick up opportunistic infections (like MRSA) largely because they are sick. Fortunately most pregnant women aren’t particularly ill so the delivery suite isn’t a massive infection sink. On the whole the woman is probably most at risk of her own bugs getting in through the complications of squeezing out the baby (tears, retained placenta etc).

“I would not consider occasional notes on the chart about blood pressure and the like in the midst of a busy day during which they see many patients to be equivalent to ‘a diary’ written during extended one-on-one sessions.”

A midwife is attached one-to-one with a woman during labour. And they write a lot more than occasional blood pressure observations. Even nurses on busy wards write fairly extensive nursing notes on how a patient is doing. And that’s basically the point of a health visitor.

Personally I think the NHS could do a lot more useful things with £150 million, like provide enough midwives for women at the time they give birth. I don’t think a bit of free housekeeping is going to get those maternal and neonatal mortality rates down.

20

Ingrid Robeyns 02.06.08 at 7:00 pm

pj: Personally I think the NHS could do a lot more useful things with £150 million, like provide enough midwives for women at the time they give birth. I don’t think a bit of free housekeeping is going to get those maternal and neonatal mortality rates down.

I agree with the latter sentence – the maternity nurses enable women to take sufficient rest and make the arrival of a newborn less stressful but they are not going to change mortality rates (at least, I can’t see how that would be so).

Could you expand on the issue of not having enough midwives — is that a serious issue? You’re not telling me that there are women in the UK who have to give birth without a midwife or a qualified doctor being present, I hope?

21

dutchmarbel 02.06.08 at 8:32 pm

By the way, I think that one is not obliged to take kraamzorg, in fact if the parents don’t book it on time (a few months before the birth), they may be too late; and there is a small own contribution to be paid (which may be covered if one has an elaborate health care insurance). Thus, if one does not make the booking or is not willing to pay the parents’ contribution, no nurse will come to your house.

It is optional, and you can also opt to have it for less than the maximum hours (in my time the max was 8 days and 8 hours per day). Don’t forget that ‘kraamzorg’ is also given for homebirth. In the Netherlands you have to pay a few hundred euro if you want to deliver in hospital and there are no medical reasons for it. So often the woman gives birth at home and the nurse will arrive at or just after the birth.

The diary is mainly a chart with the temp and pulse of the mother and the baby and with the number of wet nappies (when you breastfeed the easiest way to make sure that the baby gets enough milk is to count those).

Monitoring visitors means that she will provide something to drink and eat (traditionally a rusk with aniseed sprinkles) and will ask them politely to leave after half an hour or so – unless the mother specifically requests them to stay longer. It’s more to defend the mother than to keep track of who visits.

22

Martin Wisse 02.07.08 at 8:21 am

Ingrid: My impression is that most mothers in the Netherlands are very happy with the system.

That’s because intrusiveness is inbred to the Dutch. This is the country that leaves its curtains open at night, after all.

Haven’t had first hand experience with the kraamzorg as such, but I know my mother was very glad to have them after the birth of my youngest brother and sister.

23

chris armstrong 02.07.08 at 10:26 am

There is certainly a shortage of midwives in the UK. It doesn’t mean that women give birth without them present, but anecdotal evidence does suggest that facilities are often in danger of being centralised (e.g. closing down smaller and more relaxed birthing centres to concentrate provision in large hospitals). Which is not a good thing.

On the kraamzorg and ‘free housework’ thing – I thought there were now fairly strict rules in Holland about exactly what you could ask your nurse to do? They’re not going to iron the father’s shirts, for example?

24

Ingrid Robeyns 02.07.08 at 11:08 am

Chris, there are indeed fairly strict rules, but a nurse can decide to do more/other work if she sees that this is what is most/very needed in the household. For example, if the father has his hands full with the older child(ren), then she may clean the kitchen or vacuum clean the living room, whereas this is not something she officially has to do. I don’t think any of them would start ironing the father’s shirts. Personally I don’t think this is strange: after all, many professionals in the ‘care/educational/health sectors’ (including teachers!) who are committed to their profession sometimes/often do things that they are not officially required to do.

25

Katherine 02.07.08 at 11:41 am

Like Pewi’s wife @6, I just had my daughter by cesarian (well, a month ago) – I couldn’t wait to get home , but I don’t know that I would have wanted a maternity nurse there or to have to say “no” to one – I had my mother for nearly 2 weeks and my husband for 3 weeks – yet another person would have just got in the way. I had 3 follow up midwife visits, and now the health visitor a couple of times and the clinic to go to. Higher need women, theoretcically, get more. What would have helped me much more than a maternity nurse would have been more paternity leave for my husband, who is hating being back at work so soon.

There are plently of women without such support for whom this could be essential help. But when the funding for the post-birth midwife visits and health visitor visits have been slashed consistently, you have to wonder about the thinking behind these proposals. Sounds like announcement-itis to me – after all, it would be much less dramatic if they’d said “we’ll put the money back where it used to be”, wouldn’t it?

26

Alex 02.07.08 at 1:09 pm

Someone should write a song about this called “Maternity in the UK”.

27

Slocum 02.07.08 at 1:58 pm

The home health visitor is the jack-booted thug of liberal fascism.

Nah — I think they usually wear sensible shoes:

http://www.hslda.org/hs/state/nc/200310030.asp
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2002/06/10/BA118333.DTL

But sometimes they do bring a couple guys in boots along just in case:

http://www.hslda.org/hs/state/tx/200712041.asp
http://www.gopusa.com/ohio/news/thewalshes0303p.shtml

I don’t mean to make too much of this–and obviously parents have no right to abuse their children behind closed doors. But it’s not implausible that a universal postnatal home nursing program might morph into this kind of social work with the nurses/social workers tasked with assessing the fitness of the parents and making recommendations for continuing supervision. In the U.S. anyway — perhaps that’s not a danger elsewhere.

Certainly this is a minor issue in comparison to the kind of no-knock paramilitary SWAT raids that Radley Balko has been documenting, but there are similarities: agents of the state feeling like they have a free hand in dealing with certain kinds of people — poor and minority people, in case of the SWAT-teams raids, and home-schooling evangelicals in the social work cases (whereas I know with near certainty that neither would ever happen in my upper-middle class neighborhood).

28

nick s 02.07.08 at 11:24 pm

In the U.S. anyway—perhaps that’s not a danger elsewhere.

‘In your head’, shurely? There’s also a risk that your public garbage collection might turn into a surveillance system that rifles through the trash for samizdat. This means you should store all of your home refuse in your bedroom.

Further: maternity leave is the slavery of liberal fascism.

There are a few issues here: the need to ensure safe childbirth without overly medicalising the process; the provision of midwives; and some provision to make sure support’s there in the first few weeks.

29

praisegod barebones 02.08.08 at 8:02 am

‘this is not a feature of the system, it’s a feature of the professional.’

I suspect it may also be a feature of being young and inexperienced (20 years old). The obvious solution is to make sure that no-one does the job who hasn’t got several years of experience of doing it before.

I think that the real ‘danger’ of having a kraamzorg is that they might do things like making sure that the father was able to change a nappy within forty-eight hours of the child being born. That – rather than concerns about jackboots – is what I suspect might be really fueling resistance to the idea in some people’s minds…

30

PJ 02.08.08 at 6:35 pm

“Could you expand on the issue of not having enough midwives—is that a serious issue? You’re not telling me that there are women in the UK who have to give birth without a midwife or a qualified doctor being present, I hope?”

Women will always have a widwife with them (if they so wish) but a maternity unit may well be full and a pregnant women near or in labour sent to another unit, probably further away. Shortages mean that homebirths can be difficult to arrange.

Women with low risk pregnancies delivering at home or in community midwife lead units do not have obstetrics cover in the UK and any complications will require ambulance transfer. You won’t have a doctor present at the birth of a normal delivery.

In terms of reducing maternal mortality, the conifidential enquiry reports: “Despite the limitations, the assessors classified 64 % of Direct deaths and 40% of Indirect deaths as shown in Table 1.11 as having some degree of substandard care. Table 1.12 gives the degree of substandard care compared to the previous two Reports. The overall rate of sub-standard care for women dying of Direct causes has fallen a little compared to the 67% reported for the last triennium whilst there has been a very small rise in the rate for Indirect deaths. By contrast, only about 10 % of both Coincidental and Late deaths had elements of sub-standard care. The major concerns about the care provided for these groups of women were a lack of liaison and communication between the health and social services in providing support for vulnerable young girls and a lack of multidisciplinary or co-ordinated care.”

Incidentally, comparisons between the UK and other countries should be borne with at least some caveats since many women avoided or had difficulty accessing maternity care: “Many of the women who died found it difficult to seek, or to maintain contact with, maternity and/or other health services. The many possible reasons for this have been discussed throughout this Chapter and the main characteristics of the women who found it diffi cult to attend are summarised in Table 1.27.” where these factors are ethnicity, language skills, employment, domestic abuse, immigration status, and social services/child protection issues.

31

Katherine 02.08.08 at 9:22 pm

Regarding the latter paragraph of comment #30, it has been a little-commented-upon consequence of the NHS charges put in place to put off so-called “health tourists” that some women of insecure immigration status have had difficulty accessing maternity services.

Strictly speaking, maternity services are counted as primary services, meaning that they must be provided up front without cost. However, the costs can be chased up afterwards and there have been unpleasant stories of NHS debt collectors chasing impoverished new mothers for the costs of their maternity care. And some frankly scary stories of women being put off scheduling much needed cesarians because they know they will have to shoulder the cost later. Some women have even been known to turn up at A & E to give birth, having fallen through the cracks altogether until right at the point of giving birth.

Now that is the sort of thing that plays havoc with your maternal mortality rates, as well as, y’know, resulting in dead babies.

32

Katherine 02.09.08 at 12:39 pm

But I doubt very much that the Tories would want to put money into those services, since that would involve the “i” word. Hypocrites.

33

Ingrid Robeyns 02.09.08 at 7:37 pm

So I think I should have qualified my enthusiasm for this proposal from the Tories — it would be a good proposal if it came on top of a decent maternity care programme, not if there are still more urgent things needed as pj’s and katherine’s comments make clear. Thanks for these explanations and clarifications.

34

chloe 02.10.08 at 10:23 pm

Most of you don’t even know what a maternity nurse is/or what they do, and have all these people posting negitive comments been left alone with a newborn?

Comments on this entry are closed.