Albany Midwifery Practice

AIMS Journal, 2014, Vol 26, No 3

Jude Davis talks about the launch of a new website exploring the Albany model of care

A new website has been launched to ‘document the achievements’ of the Albany model of midwifery care as well as to ‘discuss why it came to an end, and to provide information, inspiration and support for others who would like to work in this way’, www.thealbanymodel.com. The Albany Midwifery Practice ran from 1997 to 2009 in Peckham, London.

Outstanding outcomes for an ‘all-risk’ group of women

As the website states, the outstanding work of the Albany practice ‘soon became both nationally and internationally acclaimed as ground-breaking.’ Most of my student midwife assignments contained references to the ‘gold standard of midwifery care’ given by the Albany midwives. Statistics from the practice are eye-poppingly good. For the years 1999-2007 they show a home birth rate of 44%, a spontaneous vaginal birth rate of 80%, a caesarean section rate of 16% and a forceps/ventouse rate of 3%. During this period the caesarean section rate in England was 23.5% and the instrumental delivery rate was 11.1% according to BirthchoiceUK in 2008. Breastfeeding rates were exceptionally good too, with 92% breastfeeding from birth, in contrast to the general UK uptake of 76%. 74.5% of the women cared for by Albany midwives were still exclusively breastfeeding at 28 days.

What makes Albany’s statistics even more outstanding is that this was no cherry-picked ‘low-risk’ group of middle class women, rich in organic vegetables and alternative remedies to complement excellent access to healthcare, but an ALL risk caseload in a population of wide ethnic diversity and outstanding social deprivation. Women from ethnic minorities and from areas of social deprivation are known to have increased morbidity and mortality¹. According to the post code of the area served, the Albany cared for the most deprived population quintile.² The ethnic mix served included over50% of the women describing themselves as Black (African, British, Caribbean or other), with a further 14% of women from ethnic groups other than White.

The Albany model was discussed in Robbie Davis-Floyd’s book, ‘Birth Models that Work’.³ Besides awesomely low rates of intervention, including caesarean section and outstandingly high rates of exclusive breastfeeding, the statistics reveal a perinatal mortality rate substantially lower than the national average and in fact, less than half the rate of the surrounding area where conventional health service provision is in place.

Encouraging decision-making

Keeping birth place options ‘open’ until labour was established contributed to the Albany’s outstanding homebirth rate. Why should a woman decide prior to labour how she is going to feel about how she will manage it and where she would want to be? The Albany worked in a non-hierarchical and truly woman-centred way.

I visited King’s College in 2008 for a talk given by Nicky Leap (who had studied the way the Albany midwives worked), about pain in labour. Part of Nicky’s talk focused on her filming of the midwives’ practice which documented how this model of care was more humane and more informative, enabling and strengthening of women’s understanding of birth physiology and choices than any other, not just within the NHS, but anywhere. The Birth Talk in the woman’s home when she was 36 weeks pregnant, along with those planning to be at the birth with her, contributed to this.

Closure of the Albany Midwifery Practice

One day, I imagined, when my kids were grown I might join them, or a team like them if other teams were inspired to operate with the same ethos and structure. However, within a year of my qualifying, the unthinkable happened. King’s College Hospital NHS Foundation Trust stopped the most inspirational and successful example of midwifery practice from working. Its end was sudden, shocking, demoralising, infuriating and, as articulated by numerous esteemed academics and practitioners, whose critiques are available via the links on the website, seems to have been for questionable motives and without sound justification.

A message on the King’s College Hospital NHS Foundation Trust website was posted to explain the sudden closure of the Albany practice on the grounds of safety, which remains in place today. However, while the Albany Midwifery Practice contract was terminated allegedly due to ‘unsafe’ care, all of the Albany Practice midwives were immediately offered midwifery employment by King’s College Hospital NHS Foundation Trust. This leaves one wondering quite how unsafe King’s management could have thought these Albany midwives to be? The website also describes how the campaign by the ‘Albany Mums’ and the Albany Action Group quickly formed and fought vigorously, but failed to reverse the decision.

What we have lost

I wholeheartedly want to be a part of a tax-funded, free at the point of use, National Health Service where everyone receives equal care. Simultaneously, I admire the values and skills that independent midwives have maintained whilst NHS midwives have been forced into practising outside of their philosophy when, for example, they were no longer enabled to facilitate physiological breech birth or encouraged to support women having Vaginal Birth After Caesarean in homely environments or without continuous monitoring. The Albany found a way to provide a service which was embedded within the NHS, yet within which they maintained their autonomy. This enabled them to provide authentically individualised woman-centred midwifery care for NHS service users.

Albany was a small group of self-employed previously independent midwives who negotiated a special contract with King’s to provide care for NHS users. It meant that rather than women paying independent midwives for the luxury of continuity and truly individualised care, women received this as standard NHS care. The Albany midwives self-managed, and although their care was more in line with government recommendations such as choice, control, and continuity of care as described in Changing Childbirth than in most of the NHS, their autonomy appears perhaps to have unsettled the powers that were.

The past few decades have seen insidious change within the NHS and encroaching privatisation as UK health care has increasingly morphed from ‘service’ to ‘business’. For decades independent midwives have battled to maintain their status within a world ever dominated by dictates of insurance companies via Clinical Negligence Schemes for Trusts (CNST) and Welsh Risk Pool schemes. The Royal College of Midwives appears to have been unable to support midwives to practise outside the NHS and now we are sadly witnessing the erosion of their ability to practice their profession legally.

Whilst certain alternative midwifery models are springing up and appear to provide valuable continuity of carer, as inspired by the Albany model, they are significantly different enterprises. Their caseloads will not be ‘all-risk’. Many aspire to reach a point whereby their services will be free at the point of contact, but are currently far from it. Their users will also lack the clear and easy access to all support services as was the case for Albany mums, within the changed and increasingly fragmented health service as it now stands.

Lack of evidence for the closure

Despite everyone’s best efforts, hopes and aspirations, there isn’t a maternity service anywhere in the world that has a zero perinatal mortality rate. If the accusation of unsafe practice and high numbers of poor outcomes stood up to scrutiny, which by all accounts it doesn’t, the closure of the Albany remains unjustified. Indeed, despite all its flaws described by critiques on the Albany website, the investigation into the Albany Midwifery Practice by the Centre for Maternal and Child Enquiries (CMACE) did not recommend its closure. Also, when more than twice as many babies survive under your care than in the surrounding local service, it seems inevitable that there would be an increase in the numbers of babies who survive, but with some degree of morbidity.

The website describes how the end came for Albany when management at King’s College called the Albany midwives in and announced that the practice had had an unacceptably high level of babies with Hypoxic Ischemic Encephalopathy (HIE). Statistics used to justify the actions appear to have been targeted around a cluster of ill babies from which it was surmised that the Albany midwifery practice was unsafe. CMACE carried out indepth confidential studies into perinatal and maternal mortality and this organisation was used by King’s to review this cluster of poor outcomes.

Links to relevant documents, statements and critiques (including those by AIMS and the Association of RadicalMidwives) of what happened are all accessible via the website (www.thealbanymodel.com/articles/) and give further insight and opinion on the termination of this inspirational service. Denis Walsh makes excellent points in his review including how the report by CMACE commissioned by King’s to investigate the poor outcomes was flawed with ‘hindsight bias’, failed to use appropriate midwives to appraise normal midwifery, failed to acknowledge the outstandingly good and internationally acclaimed outcomes of the practice or to recognise that most cases of HIE are not thought to be related to intrapartum events as the report implies. It also failed to note that evidence supports the idea that the low rates of preterm labour and growth restricted babies that the Albany practice had could be linked to their case loading and socially supportive model of care.

Please keep this great resource of the best model of midwifery care in your ‘favourites’ and read beyond its pages to the wealth of information in its links. Albany should not be forgotten. It should be emulated and information about it widely disseminated just as the Albany midwives hoped it would be. It should continue to inspire generations of midwives. Students can no longer visit the practice, but at least they can read about how such a fantastic service can not only happen, but it can, within the NHS, provide cheaper, safer and more satisfying midwifery care than perhaps has ever been provided before or since.

Jude Davis is a community and birth centre midwife in London

References

1. Lewis, G (ed) (2007) The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.

2. CMACE (2009) The London Project Centre for Maternal and Child Enquiries (CMACE Report PDF accessed online: thealbanymodel.com/wp-content/uploads/2012/11/CMACEreport.pdf

3. Reed B, Walton C (2009) The Albany Midwifery Practice. In Davis-Floyd RE et al. Birth Models that Work. University of California Press, 141-158.

4. Department of Health (1993) Changing Childbirth Parts 1&11 London. HMSO.