The midwife’s tale: how the Albany was closed down
It was high summer in 2007. A never-before-seen tea-party was in full swing in the boardroom at King’s College Hospital, in south London. The room was filled with balloons, and a giant cake took centre stage. Sombre portraits of Victorian medics lining the walls were temporarily covered up by blown-up photos of smiling women breastfeeding their adorable infants.
More adorable infants squealed, wriggled, crawled and toddled around the room as a succession of medical professionals, researchers and politicians spoke movingly in praise of the thing they were gathered to celebrate. The Albany Midwifery Practice was celebrating ten years of service to women in one of London’s poorest communities.
“The Albany” had grown from calls for maternity services to be focussed on what “Changing Childbirth”, a Government report led by the Conservative peer Julia Cumberlege, had emphasised as the best principles for the future: choice, control and continuity of care. The “three Cs” imply that women should be offered a fair choice in how their babies are born, should feel genuinely in control of decisions and should see the same faces from first booking to last postnatal visit.
Under contract to King’s Health Trust, the Albany served Peckham, then the most deprived part of south east London. A pregnant woman would be assigned two midwives from early in pregnancy, who would visit her at home and be on call to attend her in labour. Once in labour the woman could choose stay at home and have her baby there, or go into hospital. Over forty percent of them decided, during labour, to stay at home. More than nine times out of ten, all the Albany mothers were attended by a midwife they knew well. More than nine times out of ten, the Albany mums were still exclusively breastfeeding a month after the birth – a remarkable statistic. The perinatal mortality rate was about half the national rate and even lower compared with that in the rest of the Borough of Southwark.
These and other astonishing statistics were well documented in a retrospective study of the Albany’s ten years in practice. A Department of Health research project, not published until 2010, also focussed on the Albany as a shining example.
Yet strangely none of this data seemed to matter in a relentless campaign of allegations, cherry-picked “statistics” and bad arithmetic. It began with the midwives being summoned without warning to an early morning meeting with senior hospital managers in December 2008, where they were accused, with pointing fingers, of terrible negligence – “you are responsible for 75% of all the admissions to special care of babies with HIE” – and ended in the Albany’s closure by the King’s Trust in March 2010.
Not many people are interested in the internal politics of childbirth. Whenever a story about maternity services appears in the press, I always note how many of the comments on the page on the online edition of my newspaper begin with “When I/my wife had our baby…”
Birth is for most people a once or twice in their lives experience and these intense personal experiences inevitably form their entire view of it. Why on earth should the general public not, quite reasonably, expect all the medical professionals in this area of the NHS to be pretty much on the same page?
Yet maternity care has been fiercely divided for centuries, ever since doctors – all male, all educated by the standards of their society – felt it was only right to elbow out midwives – all female, and, because of the restrictions on their educational opportunities as women, rarely educated, except through apprenticeship and experience. But that was long ago. Wouldn’t you expect that now women, including midwives, hold professorships, become research fellows and even chair government-level investigations, such divisions would have died out?
Sadly, the story of the Albany Midwifery Practice shows otherwise — and that the classic doctors’ view of childbirth as a disaster waiting to happen, is currently in the ascendancy. That view is successfully beating back the midwifery view of birth as a natural, physiological process which needs medical expertise to be available, but only as a safety net, not a straitjacket.
Closure, a new book by Becky Reed and Nadine Edwards (Pinter & Martin, £14.99), attempts to explain how the Albany Midwifery Practice came to be closed down, while vindicating it at the same time. It is partisan, but with reason: because the full story is shocking on so many levels. We may never know the whole story of how and why an NHS Trust closed down an innovative and exemplary midwifery practice, which had been lauded all round the world and which had outstanding birth outcomes. I recommend the book warmly to anyone who wants a study of how, when bureaucrats decide to get rid of something, they always get their way in the end.
Was the practice just too costly to run? Hardly. Initially the midwives agreed to work for half pay while funding was being sought. In maternity care, the big-ticket items are doctors, operating theatres and legal costs when something goes wrong and a parent decides to sue. At present, the NHS spends nearly three times annually on payouts for maternity negligence cases as it does on the maternity services themselves. Since I began working as a doula and birth educator more than two decades ago, I’ve seen the growth of a profoundly risk-averse culture which regards all interventions as essentially benign (despite all evidence to the contrary). I can only assume that this is because of the fear of legislation.
With the Albany practice, the birth outcomes and women’s satisfaction levels were exceptional. Cost is always uppermost in NHS managers’ minds, but it was never raised as a reason for closing down the Albany.
Was the practice really dangerous? King’s insisted so, to the point of leaving a statement to that effect on their website for years after it had hounded the Albany out of existence.
The process of attacking the practice began with what is referred to throughout Closure as the “Case Series”. This was a document purporting to show that over a period of 31 months and one day (a curious time frame), 16 babies were admitted to the hospital with a condition called Hypoxic Ischaemic Encephalopathy (HIE). 12 of them were babies delivered under the care of Albany midwives, mostly in hospital.
These figures were immediately shown to be inaccurate – even the basic maths was wrong – and went through several different versions. There are 11 different definitions of HIE and King’s never stated which one they were using. Besides, HIE is well known to be “overwhelmingly related to antenatal causation”, according to Denis Walsh, one of the UK’s most distinguished professors of midwifery. In other words, it probably isn’t caused by what the midwives do or fail to do when the mother is in labour.
It was revealed eventually that 17 months’ worth of data relevant to the “Case Series” were missing and so figures had been “extrapolated” from other months and, by a strange coincidence, indicating that more Albany term babies were admitted to SCBU with HIE than babies from other parts of the Trust. The figures on which the closure of the Albany eventually hung were just a guesstimate.
A professor of midwifery at King’s London called the hospital’s data flawed and meaningless. She said later: “We know that the Albany population is at higher socio-demographic risk than the rest of the King’s College Hospital population…it is possible that these babies may have died if they had been looked after by another part of KCH, but have ended up with HIE instead. We just don’t know, because deaths have been excluded [from the data used to attack the Albany practice]”
As Reed and Edwards point out, babies get admitted to SCBU for lots of different reasons, and when the midwives eventually persuaded the hospital to let them trawl through months of handwritten neonatal records themselves, they found that of the 502 documented unexpected term (i.e. not premature) admissions to SCBU, only 15 were Albany babies – less than 3% of the total. The Albany was at the time caring for 4% of the Trust’s births. Albany babies usually went to SCBU at a rate of one or none a month. Yet the obstetricians campaigning to close down the Albany were floating the idea that the practice!“accounted for” over 40% of SCBU admissions.
Who fixed the figures? Nobody seems to know, or be prepared to say. But it’s easy to imagine a culture where when babies arrived at SCBU from the labour ward, it was “nobody’s fault”; if a baby arrived from an Albany mum – whether or not she’d had a home birth – it was “the Albany’s fault”. Moreover, the neonatal outcomes were kept on a different system to the maternity system, allowing prejudice to fester in the dark. Some bright spark in SCBU even coined the term “Albany assassins”.
Were the midwives acting outside Trust guidelines? Their way of working, with midwives undertaking “caseloads” of a certain number of women a year, had been designed carefully and shown to work well. Much time was given to educating women in the options and risks around their pregnancies. A CMACE (Centre for Maternal and Child Enquiries – a consultative body) report recommended that they should be “more directive” in the way they approached women, especially around the issue of home birth.
But after that report landed, a separate scrutiny of the 36-week “birth talk” which was a key feature of the Albany’s methods found that the care was “exemplary”. Rather than coercing women into dangerous decisions, this scrutiny observed that “risk factors [were] identified…consultation and/or referral with a consultant obstetrician always occurred”. Indeed, the authors of this study remarked that other parts of the maternity service could improve, not the Albany.
But this audit came in November 2009, and by then, Reed and Edwards suspect, the decision to close the practice down had probably been already made. Later, the King’s chairman, Tim Smart, a businessman with no medical background (let alone any experience of midwifery) admitted that “he had to be seen to take action, and that he had been told that if he failed to do anything about the Albany he would be to blame”. Told by whom? Evidently, he didn’t like to say.
Were the women they served unhappy with their care? Certainly not. The decision to close the Albany met with outrage from the community they had served. Inevitably — because people always think it will help — a protest march to “Save the Albany” was organised by “The Albany Mums”. Being lacking in violence, it was inevitably ignored by the media.
The practice had been deliberately planted in the midst of a then very down-at-heel district of an already down-at-heel part of London. Over half the women they saw were from BAME backgrounds. A third were single mothers, 11.4% were single and unsupported. Disadvantaged women are, sadly, more likely to lose babies or have babies with health problems — yet the Albany was in truth doing a better job with this population than anyone could have expected. As one health visitor commented, you could always tell an “Albany mum” at a postnatal visit, because she was confident, relaxed, happy.
It is well known that our chances of success in life are greatly determined by these early days. Confident, well-informed mothers improve life chances, and breastfeeding improves health prospects. Visiting the practice, the Earl of Listowel commented that “such a model (if rolled out through the nation) would go some way to ensuring that fewer children go to prison, that fewer children are taken into care, and that the cycle of failure from generation to generation is somewhat ameliorated”.
Was their way of working at fault? Was being on call for 36 births a year with 12 weeks holiday unsustainable, dangerously risking burnout? This was a constant refrain of the whispering campaign. But the on-call system had been worked out to avoid “burnout” with ample support; the midwives managed their own workloads and time off. The irony is that currently, in the mid-2020s — with home-births still as rare as 20 years ago and the recent Ockenden report into the Shrewsbury hospital scandals having recommended ending continuity of care as a target — midwives are leaving the NHS in droves. The Royal College of Midwives has warned that the shortage of midwives is now at a critical point.
CMACE suggested that the Albany midwives were isolated from the rest of the Trust’s maternity services. But this could hardly be true when they were popping in and out of the labour ward all the time, and had a link obstetrician to liaise with.
However, the Albany midwives had a habit of accompanying women to hospital appointments with doctors, and this clearly made doctors feel uncomfortable. “A lot of the women spoke quite powerfully about what they wanted, that it almost felt quite threatening,” commented Cathy Warwick, then Chief Executive of the Royal College of Midwives. “And I think people… really didn’t like that, and found that really challenging…”
Was it all about politics? Yes, but not in the way you might think. It wasn’t party politics. The Albany was inspired by a report led by a Conservative peer, Julia Cumberlege and set up under a Labour government. When it was closed, Andy Burnham, then Health Secretary, refused to get involved in “a local matter”. David Cameron, then Leader of the Opposition, said he was very sorry but couldn’t condone government interference in a Trust’s decisions. The local Labour MP, Harriet Harman, turned down requests from the Albany Mums for a meeting – she sent a message saying she “had every faith in King’s maternity services, and could see no reason to probe any further”. She was at the time Minister for Women and Equal Opportunities.
The midwives’ strongest political supporter outside the House of Lords was Liberal Democrat Norman Lamb.
Was the Albany killed by jealousy and superstition?
“What the obstetricians were really scared of,” Reed and Edwards quotes Cathy Warwick as saying, “was difference.”
From the beginning, the Albany Midwifery Practice was the subject of accolades and acclaim. When it was set up, Reed and Edwards recall, “it was only Tony Davies, Consultant Obstetrician and Risk Management Lead, who had ever been less than positive about the Albany model of care”.
Sharing Davies’ view however was Mike Marsh, initially appointed as link obstetrician for the Albany. He was replaced by a doctor called Leonie Penna after the Albany’s practice manager complained about Marsh “badmouthing” the practice — “deliberately looking for cases that he disapproves of in order to bring us into disrepute.”
The Albany’s high home birth rate was a thorn in the obstetricians’ sides. Many obstetricians simply don’t hold with home birth, even for low risk women, despite all the evidence to the contrary. The Birth Place Study, a vast retrospective study of UK births published in 2011, showed definitively that in our system, home birth for low risk women is as safe as hospital birth for women having second or subsequent babies and only very marginally more problematic for women having their first baby. Another study in the Lancet in 2020 reaffirmed these findings.
Yet throughout the Albany midwives’ encounters with authority, it was home birth which was held up as the risky practice. “Nobody is suitable [for home birth] and nobody should be considering it”, a King’s obstetrician reportedly told a woman booked at another practice.
But while the Albany was under investigation, the worst did happen. A baby died after being born at home — and brought straight into hospital — under the care of an Albany midwife, Becky Reed. The subsequent coroner’s report drew on comments from an independent expert witness – a consultant obstetrician – to conclude that the baby’s death could not have been predicted by Reed, nor was it caused by her or her colleagues’ failure.
Yet as soon as the episode happened, the Albany’s home birth service was suspended. So was Reed, who spent years trying to clear her name, until the coroner’s inquiry exonerated her.
From 2003 onwards the practice had been garnering international acclaim and it was about then that Mike Marsh and Tony Davies began keeping a “list” of every woman and baby booked with the community midwife practices where the birth was not entirely straightforward. No comparative “list” was made of hospital cases, and no such study would exist until the Birth Place Study.
Reading Reed and Edwards’ book, I find myself considering the recent inquiries into tragic deaths in the maternity services and the demonising of midwives – with the concomitant glorification of doctors — which they inevitably seem to bring in their wake. I think of the Ockenden Report, which made some recommendations which are hard to justify unless you believe firmly that midwives must be kept in their place, controlled and divested of all autonomy.
I fear that the closure of the Albany practice was the first stage in a process of over-medicalising childbirth and removing the concept of informed consent, which seems to be proceeding at a relentless pace. In the maternity units near me in London, I see caesarean rates of around 40%, some months up to 45%, and we seem to see a rise in inductions of labour (which can double the likelihood of an emergency caesarean for a first time mother). There is constant doublespeak: yes, you have choice…but we recommend VERY STRONGLY that you do THIS, in THIS place, in THIS position. Or your baby might die.
I think of the recent warnings by the RCM that more than half of midwives are thinking of leaving – and many do, faster than they can be replaced. I think of attitudes in the public media such as that of Adam Kay, the obstetrician whose book “This is going to hurt” was made into a BBC TV series, starring Ben Whishaw. In his book, Kay smugly tells us that home “delivery” is “for pizzas, not babies” and cheerfully mocks “floaty-dressed” women who dare to say what they want. Fortunately for women, Kay has turned full-time to comedy writing.
How galling, how infuriating, it must have been for the obstetricians to come on the ward for a night shift and hear about that lovely tea-party in 2007 celebrating the Albany’s ten years. A party where the portraits of their esteemed, frock-coated predecessors were covered over by blow-up photos of shameless, breastfeeding women. A celebration attended by peers of the realm, where inspirational speeches were made – including one by the practice’s own link obstetrician Leonie Penna. Just 17 months later she would be accusing the Albany of bad practice — with hardly any evidence to back it up.
How irritating for everyone else slaving away in the Trust must have been all that international acclaim for the Albany in the press and midwifery journals, praising the practice as “the jewel in the crown”.
Davies, Marsh and Penna seem to be no longer involved directly in delivering babies, but have moved sideways and upwards, including into private practice. I wonder how they and the senior managers at King’s feel about the Albany and the messy data sets that were used to close it down. I have no doubt they genuinely thought, and still believe, that by closing down the Albany they were saving babies’ lives. We are all a bit afraid of the unknown, are we not? Even when it’s backed up by pages and pages of data and reports.
“The NHS finds it hard to accept competitors, however small, which prove there are better ways to care for women, their babies, and their families,” wrote Baroness Cumberlege in one of a series of powerful statements from significant figures which are dotted throughout Closure. I feel she has put her finger on it.
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