Examination of Witnesses (Questions 420-439)
TUESDAY 25 MARCH 2003
PROFESSOR JAMES
WALKER, MRS
ANN GEDDES,
MS CAROL
BURNS, MS
KAREN FOX,
MS GILL
SMETHURST AND
MS PHILIPPA
MCENROE
420. What percentage of your births are at home?
(Mrs Geddes) We deliver just over 8,000 deliveries
in the city and we had 70 home births last year, so it is just
less than 1%. We work very hard through our maternity services
liaison committee to clarify the role of professionals at home
births, because we found that women were experiencing a lot of
conflict, in that they went to the GP, where they would never
allow you to have a home birth, whereas the midwife would support
that. We worked very hard to produce a document which clarified
each person's role, including women who were requesting a home
birth. That has gone a long way to actually breaking down a lot
of these barriers.
421. But you still have some GPs who would not
support it?
(Mrs Geddes) We have many GPs who would not support
it.
(Ms Burns) I think that would be where the move from
GPs having very little involvement is actually significant, because
they can influence the decision about home birth. We have certainly
been talking in Leeds about how we can improve the information
that we give to women. For example, you can change your GP while
you are pregnant to one who supports a home birth. The first contact
that women have, even though the midwife is very involved, may
traditionally be with their doctor, and so get the message that
home birth is not supported. Although I do not think there is
a huge group of women who want home births, we suspect there are
more than are having them at the moment, and that there is some
work we can do.
422. Home births, Karen?
(Ms Fox) The GPs just refer to us. If a woman goes
to a GP and says "I want to have my baby at home" they
will just say "Go and talk to the midwife", which is
the way we want it.
423. So you do not have any problem with any
of your GPs?
(Ms Fox) We do not have any problem with any of my
GPs, no.
(Ms Smethurst) But we do not expect anything from
them either for a huge part of the care. We would never call on
a GP in an emergency, and I think that over the years they have
come to understand that. When we first started promoting home
births more, about ten years ago, I think some of the GPs were
worried that they were going to get called to deal with things
that they could not deal with. Over time, they are now confident
that we are not going to call on them.
424. You are supporting home births as well?
(Ms Smethurst) Yes.
425. How many?
(Ms Smethurst) Last year we had 16% of women delivering
in the community—that is both at home and in the midwife
unit.
Dr Naysmith
426. Is there provision for continuity of carer—one
named person? I feel strongly about this, personally. I was in
hospital two or three years ago and I was given a named nurse
on my entry to the hospital and I think I saw that nurse about
twice in the subsequent three weeks. Is there provision for continuity
of carer and does it actually happen?
(Ms Smethurst) There is in a small service like ours,
because there are only seven midwives each carrying a caseload,
so the women know who their midwife is; they see her at every
contact and if they ring they ask to speak to her. We cannot guarantee
that in labour it would be that named midwife but it would be
two of the seven midwives who will attend in labour. Post-natally,
we aim that the main midwife plans with the women the post-natal
visits, so that it is the same one going. We did do team midwifery
for a while but women in our area—we surveyed them—did
not want a team of midwives, they wanted continuity antenatally
and post-natally.
427. But it does work pretty well?
(Ms Smethurst) Yes.
428. How about in Leeds? Maybe Professor Walker
could say something about doctors and the staffing of medical
units? Particularly, I know the Working Time Directive, perhaps,
will not affect things overall, but certainly the BMA are very
worked up, and some of the colleges too, about the effect it is
going to have.
(Mrs Geddes) We try very hard to maintain continuity
for women. We are very open with women that we cannot always guarantee
that during delivery because it very much depends on how long
the delivery goes on for. We are very conscious of the fact that
we need a midwife to be sharp, not over-tired and able to give
good care to the women there, but we would do that in conjunction
with the woman. Many of the midwives will stay on after their
shift, or at home, to deliver a woman if the delivery is imminent,
but if it is hours and hours away it is not good for anybody.
We tell women about this and we try to make sure, particularly
for home confinements, that they will have one of four women to
help that delivery.
Dr Taylor: I have a question on the Working
Time Directive, specifically to Professor Walker, because other
people have told us that it is a killer from the medical point
of view.
Chairman: We will come back to that.
Dr Naysmith
429. Just before we leave Goole, can we have
the information on how many home deliveries are done in your unit?
(Ms Smethurst) Last year there were 30 at home and
24 at the unit, but the unit was closed for six months last year
because we were having a birthing pool installed and we had some
problems with it. So that was the figure for six months last year.
430. Thirty at home and 24 in the unit for six
months. How do you differentiate between medical staff and midwifery
staff as far as the women and babies are concerned? Who deals
with which? Are there any kind of guidelines?
(Professor Walker) In our unit, which has a range
of women from low-risk women to high-risk women delivering, what
we try and do is have that graduated involvement, depending on
the risk of the woman. Women who are low-risk are seen largely
in the community by midwives, they come in in labour and they
are looked after by midwives and, therefore, managed as far as
possible as low-risk women looked after by their midwives. Medical
staff can be asked to review or be involved without the need of
them being removed from the midwife. I am a great believer, personally,
that if a woman starts having problems that is when she needs
her midwife most, in fact, and the idea of her being removed from
a low-risk to a high-risk environment is wrong. There should be
some sort of graduated system that medical staff can be involved
as little or as much as is required, but midwives need to be involved
continuously all the way through. We try and get that balance.
431. Is it the same in your unit?
(Ms Fox) Yes. When the patient first comes to us we
access the medical records that we might have and have access
to the GP's medical records. Talking with the women we can decide
between us whether the pregnancy is going to be classed as low-risk
or high-risk. If it is low-risk she will stay purely with the
care of the midwife; if it is classified as high-risk, or if anything
changes through the pregnancy and it is felt that medical intervention
may be needed, then we refer to the consultant, Mr Young, who
comes out to Goole, but they still continue with the same named
midwife but they will also see the consultant at the same time.
Because the consultant clinic is run from a midwifery centre in
Goole Hospital it is midwives that run it with the consultant.
We are very closely involved there.
432. Can we just deal with the bit about staffing?
(Professor Walker) It is not just the problem of the
hours of work, there are multiple factors affecting the staffing
from a junior level. There are the hours of work but there are
also the new training requirements that take them away from clinical
practice on a regular basis. It is interesting if you look at
the numbers of juniors now compared with ten years ago, there
is not much difference, it is the fact of what they are doing
now which is different, and they are able to do less of the hands-on
clinical work they did previously, which makes it very difficult
to have the same cover that we used to have at junior level. The
problem from a consultant point of view is that it is difficult
for them to take up that load because we have not had the consultant
expansion. The difference is across the two sites in Leeds. On
one site we have 40-hour cover in our labour ward because we have
the consultants who have been appointed to actually do that, but
the other side of the city does not have it because we do not
have the consultant staff there. By having consultants present
on a labour ward you can help to reduce the problems of lack of
junior staff.
Mr Hinchliffe
433. In terms of comparing the numbers of home
births, Ms Smethurst, you said 30 last year, as I recall. That
would be out of how many?
(Ms Smethurst) It was 30 births at home out of 434.
434. How many were the 70 out of in Leeds?
(Mrs Geddes) Eight thousand.
435. That is a big difference between the two.
I am interested in what the reasons might be for that. One of
the issues that has come out is the role of the GP. In a sense,
the GP has a minimal role in your area, presumably because of
the confidence in the midwifery service that you appear to have
in Goole. Going back to when this Committee looked at maternity
services in 1990-91, I recall we went to Holland and in Holland
at the time around a third of all births were home births. However,
in Holland they had a different professional, a kind of combination
between a midwife and a GP, plus they also had a home help service,
like we used to have goodness knows how many years ago back in
ancient history, where the home help would move in with the family.
I am interest in exploring, before we move on from this group
of witnesses, your views on the appropriateness of the current
professional roles, whether we ought to be looking afresh at the
role of the midwife or the GP in this area. We tend, in Parliament,
to focus on existing roles; we do not think that we might do things
differently. Other countries do do things differently. Do any
of the witnesses have any thoughts on this area of whether, perhaps,
in future we need to be looking at the appropriateness of our
training and our specific professional roles within maternity?
(Ms Smethurst) One of the things that restricts midwives
working in the community at the moment is prescribing, prescribing
routine things, and that is got round in various ways, and there
is extended prescribing, but I think it could be made a lot simpler
for certain restricted things—antacids and things like that.
(Mrs Geddes) I think there is a role for a different
type of professional. To try to put it into context, we had 70
home births in Leeds last year. We have 70 community midwives
who work in the community in Leeds. That is, on average, one per
midwife per year. The skill of the midwife is changing because
of the lack of home confinements, but there still is a need for
that there, and I think there is a real opportunity for a new
practitioner—whatever you want to call it—to support
these women who request that service.
Andy Burnham
436. You say it is less than 1% of home births,
but what percentage of women, in your experience, begin their
pregnancy saying they will actually have a home birth—to
try and get the difference between the mismatch—
(Mrs Geddes) It is a very good question, and it is
one I have never been able to get to the bottom of. I believe
there are women who request home births who fall down on the hurdles
that they—
437. You suspect it is significantly higher
than the 1%.
(Mrs Geddes) Yes, I would consider it is.
Dr Taylor
438. Please do not think I am being confrontational,
but I just want to know: 56 deliveries by 7 midwives is eight
deliveries per year per midwife. Is that enough to keep up skills?
(Ms Fox) Yes, because we were a lot busier the year
before.
439. So this is a falsely low figure.
(Ms Fox) Yes.
Chairman: You might want to send us your data
for the year before.
(Ms Smethurst) As well as that, there are two midwives
at every birth, so as well as the midwife who is attending the
woman, you have also got another midwife there who is getting
the experience of being with a woman in labour and seeing things;
so you can double that really. We also do quite a lot of intra-partum
care for women who then go on to deliver in consultant units—women
in labour who do not want to go into hospital too early.
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