APPENDIX 17
Memorandum by The Royal College of Midwives
(PH 30)
INTRODUCTION
The Royal College of Midwives is the professional
organisation and trade union representing 95 per cent of practising
midwives in the UK. Midwives play a key role in public health,
as the lead carer for women during pregnancy, childbirth and the
postnatal period. As part of this role, they:
— work to a holistic philosophy of
care which emphasises the interdependence of women's physical,
psychological and social well-being, and which locates maternal
health within its family and social context;
— provide integrated care across hospital
and community settings, and in women's own homes;
— provide advice and information on
nutrition, exercise, smoking, alcohol, home safety and general
health;
— offer a range of antenatal screening
and testing services;
— support women in initiating and sustaining
breastfeeding, with its significant health benefits for both mother
and child;
— provide information and appropriate
referral for medical, social, financial and relationship difficulties;
— monitor psychological well-being
and detect postnatal depression;
— support women and their families
through the transition to successful and confident parenthood;
and
— provide advice and support in the
postnatal period; reducing long-term morbidities and enhancing
infant well-being.
Midwives are key public health practitioners.
Their contribution to public health is currently under-utilised,
however. This paper:
— argues that maternal and infant health
should be given higher priority in national and local policies
and practice;
— identifies key obstacles to improving
the public health of mothers and babies; and
— provides recommendations on how the
maternity services could fulfil their potential contribution to
the nation's health.
Why prioritise maternal and infant health?
Recent analyses of determinants of population
health, and of inequalities in health, show the likely importance
of early life influences on health and the lifetime cumulative
effect of experiences and exposures. Focusing on families with
children will not only help with immediate problems of maternal
and child health but may help reduce the longer-term risks of
adult chronic illnesses such as bronchitis and coronary heart
disease[5].
In 1998 the Independent Inquiry into Inequalities
in Health recommended that, "a high priority is given to
policies aimed at improving health and reducing inequalities in
women of childbearing age, expectant mothers and young children"[6].
It noted that the babies of women in disadvantaged
groups are more likely to have reduced growth rates in utero,
and that this is associated with coronary heart disease, diabetes
and hypertension in later life. In addition, babies born to disadvantaged
mothers are less likely to be breastfed, which decreases the incidence
and severity of many infections of infancy and later health problems,
and which may also protect maternal health. Smoking in pregnancy
is markedly higher among women from poorer social groups, and
this increases the risk of low birth weight and sudden infant
death syndrome.
Women who are socially excluded—perhaps
as refugees, or homeless, or drug using, or because do not speak
English—may have particular problems accessing the advice
and support they need during pregnancy and after birth, and this
will have a damaging impact on their ability to care for themselves
and their child during the first weeks and months of life. Poor
care during this time does not just undermine health gain; it
also contributes to social problems such as poor parenting, marital
tension and family breakdown.
While the RCM has welcomed Government initiatives
to address maternal and infant health, such as SureStart and the
national childcare strategy, it does not believe that the recommendation
of the Acheson Report has been met in a coherent or co-ordinated
way. If we are to make a real impact on public health, we must
start at the start of life; and in order to do that we need a
national strategy for maternal and infant health.
What are the obstacles?
Maternity services have been largely neglected
in recent public health policy and initiatives. This is partly
due to lack of understanding of the role of the midwife, who is
often seen as someone who delivers babies in hospital settings.
While intrapartum care is a core component of midwifery practice,
it takes up a relatively small amount of the midwife's time. Most
midwifery work is antenatal or postnatal care, and much of that
takes place in community settings or in women's own homes. Nevertheless,
because midwives are usually (though not always) employed by and
managed from acute sector settings, and because the acute sector
is not at the forefront of public health activity, midwives are
often excluded from the development of health improvement programmes,
or SureStart initiatives, or other developments with a public
health focus.
The fact that midwives provide an integrated
service across the acute and primary sectors should not disqualify
them from participation in the public health agenda; indeed, such
integration should be seen as a model for other areas of healthcare.
The sectoral gap between the primary and the acute sectors is
one of the key obstacles to developing a public health-focused
NHS.
Integration is also needed across the health
and social care sectors. The major drivers of health and health
inequalities lie outside the health service: poverty, poor housing,
social exclusion, air pollution, inadequate transport facilities,
crime and the fear of crime are not within the NHS remit, although
their effects eventually become NHS responsibilities.
This is clear within maternity care. Pregnancy
and childbirth are not merely physical episodes, but life experiences
of enormous social and psychological importance. While midwives
have worked hard to integrate a social care perspective in maternity
services, this is often hard to justify within a system which
prioritises short-term medical outcomes. For example, providing
social and emotional support during pregnancy is clearly linked
to shorter labours, less analgesia and operative delivery, improved
APGAR scores at birth, and higher breastfeeding rates[7].
Yet efforts to increase support for women in pregnancy—for
example through the development of caseload midwifery schemes—have
been undermined by staffing or funding shortages[8].
To give another example, postnatal support has
been shown to sustain breastfeeding, improve the detection and
management of postnatal depression, reduce long-term maternal
morbidities, reduce mother-child relationship problems and child
behaviour problems, and reduce rates of childhood injury[9].
Yet postnatal care continues to suffer from poor resourcing and
is the most criticised aspect of maternity care[10].
RECOMMENDATIONS
1. If the public health agenda is to achieve
its aims, it must be given due priority as a core orientation,
rather than a bolt-on extra. This priority must be clearly defined,
responsibilities must be allocated, and resources must be provided.
2. Serious and radical efforts are needed
to co-ordinate and synergise the activities of the health, social
care and voluntary sectors.
3. Equally, it is vital to prioritise public
health with the acute sector, and to further integrate cross-sectoral
working within the NHS.
4. Income inequality is a key issue in maternal
and infant well-being; urgent action is needed to improve maternity
leave, maternity pay, flexibility in return to work, and childcare
support.
5. The Government should respond to the
Acheson report's recommendation that high priority is given to
women of childbearing age and expectant mothers, by developing
a coherent co-ordinated strategy for maternal and infant health.
6. The Government should recommend to the
National Institute of Clinical Excellence that a national service
framework on maternity care should be given high priority.
7. The Government should review maternity
services spending, to ensure that resources are targeted to where
they will have most impact on health outcomes, and to guide the
apportioning of resources between medical, psychological and social
care.
8. The NHS should invest in training and
continuing professional development opportunities to enable all
midwives to develop their public health role.
9. The Government should invest in midwifery
remuneration and career development, in order to address the current
crisis in midwifery staffing.
10. Locally and nationally, health policy
and strategies should be evidence-based and should be monitored
to assess their impact on public health and health inequalities.
July 2000
5 Macintyre S (2000) Prevention and the reduction of
health inequalities. BMJ 2000; 320: 1399-1400. Back
6
Acheson D (chair) (1998) Independent Inquiry into inequalities
in health. London: TSO. Back
7
Elbourne D, Oakley A, Chalmers I (1989). Social and psychological
support during pregnancy. In: Chalmers I, Enkin M, Keirse M (eds)
Effective Care in Pregnancy and Childbirth, vol 1. Oxford:
Oxford University Press. Back
8
Royal College of Midwives (2000) Vision 2000. London: RCM. Back
9
Hodnett E, Roberts I (1998) Home-based social support for socially
disadvantaged mothers. In: The Cochrane Database of Systematic
Reviews (ed) The Cochrane Library, Issue 2. Oxford: Update
Software. Back
10
Audit Commission (1997) First Class Delivery: improving maternity
services in England and Wales. Abingdon: Audit Commission
Publication. Back
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