House of Commons - Health

Select Committee on Health Fourth Report

4 THE STAFFING STRUCTURE OF MATERNITY CARE TEAMS

How are women and babies cared for during pregnancy and the early stages of life?

WHAT ARE THE MAIN STAFF ROLES WITHIN MATERNITY CARE TEAMS?

143. Midwives provide most of a woman's care during pregnancy, labour and in the postnatal period. The midwifery profession may be entered directly by undertaking a specialised university course leading to a midwifery qualification. The minimum academic standard for a midwifery programme is a diploma although a number of programmes are at degree level. In order to practise, midwives must be registered with the statutory body for nursing, midwifery and health visiting, the Nursing and Midwifery Council. The Council maintains a register of midwives. To remain on the Register, midwives must update their knowledge and maintain a professional portfolio as evidence of their updating. To enable the Council to know which midwives are practising, all practising midwives are required to notify their intention to practice on an annual basis.

144. There are a number of career pathways for midwives, and so they may play any of a range of roles within a maternity care team. A midwife may become a clinical specialist (known as a 'consultant midwife' or 'midwife consultant'), or work in management as a head of midwifery services or supervisor of midwives at local authority level. Some midwives pursue academic careers in education and research as 'research and development midwives' and some specialise in particular aspects of maternity care work, such as IT. The majority of midwives practice within the NHS, working with other midwives and other health care professional and support staff in a maternity care team. Midwives can also practice independently and there is a small group of midwives who do so.

145. Most midwives who work within the NHS work either in hospital or community settings, and midwifery practices can vary greatly between these settings. Hospital midwives run antenatal clinics, care for women who give birth in the hospital, and look after women who stay in the antenatal and postnatal wards of the hospital. Their work usually gives them experience of interventions such as induction, EFM and use of epidurals for pain relief and they often work closely with doctors. Hospital midwives now have a much wider role than they did ten years ago. For example, some midwives have now taken over the traditional consultant task of advising women on their choices when they first visit the unit, and women now have higher expectations of midwives with regard to information and advice on testing and screening. Midwives have also taken over some tasks usually undertaken by junior doctors such as IV cannulation (inserting the narrow tubes which allow patients to receive medication intravenously) and suturing (stitching wounds). As the caesarean section rate increases midwives spend more time providing post-natal care for women who have to stay longer in hospital after the procedure.

146. New patterns of practice, particularly caseload midwifery, have allowed midwives to bridge the community and hospital service, working in a way that allows midwives to ensure that the "woman having a baby should be seen as the focus of care" as our predecessor Committee recommended.[175] This pattern is unfortunately not consistent across the country.

147. 'Community midwives' provide maternity care outside the hospital, although they will usually be affiliated to a hospital or a GP practice. They may give antenatal care in local clinics or GP practices, or visit women in their homes. Community midwives can attend women who have chosen to deliver their baby at home, or they may accompany women to hospital to give birth. They also visit women and their new babies in their homes for up to 28 days following the birth. Working away from the hospital environment, community midwives gain experience and develop skills in supporting women who give birth without medical intervention.

148. Doctors working in obstetrics provide medical care for mother and baby. Consultants in obstetrics will have undertaken four to five years of training as Specialist Registrars, during which time they will have passed examinations set by the RCOG. Most hospitals have a team of consultants who are responsible for the patients who use their services. They train junior doctors and together with these doctors and with specialists in training, they undertake antenatal and gynaecological clinics, ward rounds and operations and they supervise the labour ward or delivery suite.

149. In 2000-01, approximately 33% of deliveries were conducted by hospital doctors and 66% by midwives, although a midwife was present at over 99% of all births. The Department told us that the "overall balance between the professions has shifted steadily" since 1989-90 when about 24% of deliveries were conducted by doctors and 76% by midwives.[176] This trend corresponds with the continuing rise in the number of women who deliver their babies by caesarean section.

Other members of the maternity care team

150. A range of other health professionals play crucial roles in maternity care teams, particularly in those teams working at large hospitals with specialist fetal medicine or neonatal units. As Dr Griselda Cooper, Senior Lecturer in Anaesthesia at the Queen Elizabeth Hospital, Edgbaston told us: "anaesthesia is an integral part of the safe delivery of maternity services" for women who require medical intervention in labour and for pregnant women who become seriously ill either through complications in pregnancy or through pre-existing conditions.[177]

151. Southampton University Hospitals NHS Trust called for the expansion of the maternity care team by maintaining that a dedicated consultant nurse in Fetal Medicine departments could play an important role in educating and supporting GPs and Midwives in the management of women who experienced complications in pregnancy[178] and the British Association of Perinatal Medicine suggested that in the neonatal service it was widely anticipated that many of the traditional junior medical roles would be undertaken in the future by advanced neonatal Nurse Practitioners.[179]

152. Obstetric physiotherapists are also key members of the maternity care team. They provide care for women before, during, and after labour, and so in busy consultant units where midwifery establishments are depleted, not only their specialist services but also their support and reassurance for women can be vital. The Chartered Society of Physiotherapy told us that the number of physiotherapists who specialised in neonatal care was rising. Obstetric physiotherapists can provide antenatal education classes, and other out-patient services in addition to in-patient work, promoting a woman's health by helping her to prepare for labour. They also play a valuable role in advising health professionals on techniques which can reduce the risk of complications such as symphysis pubis dysfunction (the over-loosening of ligaments in the pelvis, which can result in pain and loss of balance and mobility). Neonatal physiotherapy is an advanced practice sub-specialty within paediatric physiotherapy, and a minority service provided only in the larger hospitals but the Chartered Society of Physiotherapy reported how such members of the maternity team can help to improve developmental outcomes for premature and at-risk babies, and to support parents.[180]

153. Postnatal care should not be neglected. We recognise the importance of links to other providers of postnatal care such as health visitors.

154. Throughout our inquiry we heard evidence that maternity care staff valued, and in units with staffing shortages, very much needed, staff such as care assistants who helped women with aspects of their postnatal care. The Royal College of Nursing endorsed the health care assistant post, commenting that care assistants might be trained to support women initiating breast feeding.[181] The Mother and Infant Research Unit at the University of Leeds recommended to us that peer support services for pregnant women and babies should be integrated into health service care.[182]

155. We recommend that the Department research further how staff, including support staff, volunteers, and staff employed by voluntary organisations, could enhance maternity services and provide important links to other providers of postnatal care, such as health visitors. In particular, the use of voluntary breastfeeding counsellors and supporters to contribute to the education of a range of healthcare professionals and other workers should be considered. We further recommend that the NHS consider funding or sub-contracting to voluntary organisations which could support the provision of specific services such as breastfeeding support.

Relationships within the maternity care team

156. Strong lines of communication and good working relationships can influence the kind of care a pregnant woman receives, particularly if the woman's point of access to maternity care is a GP who then refers her to a maternity unit. Even after referral the GP is part of the woman's maternity care team. In written evidence, Dr Chris McCourt at the Centre for Midwifery Practice, Thames Valley University, identified a lack of communication and trust between some GPs and midwives, and a lack of involvement of midwives in PCT developments.[183] Professor Jenny Hewison from the University of Leeds called for more research into how GPs and midwives worked together and determined their respective roles. She told us that based on research already undertaken, the pattern of antenatal care received by women seemed to be strongly influenced by the type of care that a GP wished to provide and that there were "variations between practices and between GPs in the same practice."[184]

157. Community midwives play a pivotal role within the maternity care team. Rupert Fawdry, a consultant obstetrician and gynaecologist, argued that community midwives should always work in teams covering a particular part of a local area and that each team should liaise closely with a particular multi-disciplinary hospital team. In this way, Mr Fawdry told us, the majority of pregnant women would have the benefit of a "much more closely integrated group of health professionals."[185] Health visitors also have an important role to play in this group of health professionals as they support women through the postnatal period, providing a vital link between maternity units and community and social services.

158. Maternity care has always been a team effort but the professions involved seem to us to work together better and with more mutual respect than they did perhaps even ten years ago. However, in the majority of cases, GPs are also members of a woman's maternity care team as they presently provide a first point of contact with maternity services and offer advice on care. In some areas there is room for improvement in terms of communication and understanding between GPs and midwives who support births in the community and in the home.

HOW HAS THE GOVERNMENT SUPPORTED THE DEVELOPMENT OF THE MATERNITY CARE UNITS AND THE MATERNITY CARE WORKFORCE?

159. In March 2001, the Department initiated the use of Birthrate Plus, a local workforce planning tool which was developed in collaboration with the Royal College of Midwives (RCM). Birthrate Plus helps staff at a unit assess the experience of women using a local maternity service through the use of clinical indicators connected with their care before, during and after the birth, and then links this to the clinical workload of the midwife. The outcome of this assessment is a recommendation with regard to the optimal level of staffing and way of working.

160. In February 2001 the Department established the Maternity and Neonatal Workforce Group (MNWG) to consider workforce issues, staffing for the various models of care and configuration of maternity services. The task of MNWG, on which Royal Colleges, NHS organisations and the National Childbirth Trust and Maternity Alliance are represented, is to contribute to the development of the Children's National Service Framework. The Department told us that the Children's Care Group Workforce Team is now analysing the implications of the Children's NSF for workforce development, and that broader workforce considerations with regard to maternity and neonatal services are "high on the priority list."[186]

161. Investments have been made to increase the number of midwives, with a target of 2,000 extra midwives by 2006, to be achieved by increasing the number of midwifery training places and by encouraging qualified midwives to return to practice. The Department stated that good progress towards the target was being made, with 510 more midwives working in the NHS in 2001 than in 2000.[187] We note below, however, that in terms of whole-time-equivalent midwives, this increase was not evident to our witnesses.[188] Indeed, Department of Health figures show that the increase between 2000 and 2001 was only 371 in whole-time equivalent terms and was concentrated in only four regions, while three regions had a decrease.[189] More work will be required if the additional training places provided so far do not yield improved vacancy rates and the target figure of 2,000 extra midwives may itself have to be increased.

What are the most important workforce issues for maternity care teams?

WHAT IS THE CURRENT SITUATION WITH REGARD TO RECRUITMENT AND RETENTION OF MIDWIVES?

162. Much of the evidence we received on the staffing structure of maternity care teams made reference to shortages of midwifery and nursing staff and to concern about rising vacancy rates. Information from the Department confirmed that a survey had registered a rise in the vacancy rate in midwifery - from 2.6% in March 2001 to 2.8% in March 2002. The Department attributed the increase in the vacancy rate in part to the creation of new posts ahead of the planned expansion in the workforce but we heard a more worrying account of the state of the midwifery profession from many other quarters.[190]

163. The RCM's annual staffing survey found that London was the only region in which vacancy rates had not increased and that long-term vacancy rates in midwifery were currently the highest ever recorded. In England in 2002, vacancies which remained unfilled for over three months accounted for 59% of all midwifery post vacancies.[191] Despite the static vacancy rate in London, according to the Women's Health Directorate at University College, the recruitment and retention of midwives in London posed a major problem for maternity services.[192]

164. As we heard from maternity care staff themselves, two themes emerged with regard to staffing levels and recruitment and retention issues. In very general terms, recruitment and retention seemed to pose a greater problem for services in the South than they did in the North of England. Several of our witnesses attributed this to higher costs of living, particularly in areas close to London but not close enough for midwives to receive London weighting as part of their salaries.[193] Across the whole country, however, vacancy rates at consultant units were much higher than they were at midwifery-led units and birth centres.

165. There was consensus amongst the maternity care team representatives that midwives enjoyed practising the full range of their skills in terms of facilitating normal birth without medical intervention, and that they became disillusioned with the profession when the majority of births they attended involved high levels of intervention and when they had to divide their time between a number of women in labour. Shona Ashworth, Head of Midwifery at University Hospital, Nottingham illustrated this sense of disillusion in the most graphic of terms:

194

166. Toni Martin, Head of Midwifery at Worcestershire Royal Hospital, said that many midwives now chose to work part-time as a means of coping with the pressure they experienced on labour wards.[195] A great many others, however, have chosen to leave the profession altogether. St Mary's Hospital, Paddington took part in a London-wide project to examine midwifery establishments by comparing ratios of births to midwives. In a range from 28:1 to 41:1 St Mary's had one of the highest ratios at 38:1.[196] Use of Birthrate Plus indicated a shortage of 40 midwives at St Mary's.[197] Professor Regan, a consultant obstetrician at St Mary's told us that the depletion of the midwifery establishment had serious consequences for the service, for the profession and most importantly, for pregnant women:

198

167. There were 20 midwifery vacancies at the Rosie Hospital, Cambridge with 105 midwives in post in a unit which, according to Birthrate Plus, needed 168.8. Mrs Jen Ferry, Head of Midwifery and Operations Manager for Women's Services at the Rosie Hospital, suggested that she had not seen evidence of the progress on workforce expansion announced by the Department: "For all the discussion about the lack of midwives our region will be training across Norfolk, Suffolk and Cambridgeshire thirty extra nurses and midwives by the next three years."[199]

168. Those midwives who do not leave the profession must strive to provide good quality of care for women and babies, and at some units, to maintain a safe service. Mrs Ferry told us that extra work was being undertaken to "put in contingency plans and strategic measures to ensure that we keep the risk at a minimum whilst the staffing is so difficult."[200] Karen Connolly, Head of Midwifery at St Mary's Hospital for Women and Children described a similar situation in Manchester which had begun to experience staffing shortages in recent years:

201

169. Maternity unit staff from several regions spoke of strong relationships between universities and hospitals but registered their concern at the high drop-out rates from midwifery diploma and degree courses, particularly in areas such as Manchester where access to training places was limited. Some talked of student midwives becoming disillusioned with the service even before qualification, but there was consensus that funding for student midwives was the main barrier to qualification. As Karen Connolly told us "students that are training just cannot afford to live on a bursary. They may be more mature students where they come from previous jobs and have received a wage, and to go into a bursary has a big impact on their own home life."[202]

170. Mrs Ferry described how staffing at the unit was configured to compensate for a shortage of midwives:

203

171. Miss Alison Fowlie, consultant obstetrician at Derby City General, represented a number of units which acknowledged that shortages were stretching services in the community and in hospital, but which had put in place measures to enable midwives to practise the full range of their skills as a means of alleviating problems with recruitment and retention:

204

172. Lynne Pacanowksi from St Mary's Hospital, Paddington told us that despite being under-established, the unit had been more successful in recruiting and retaining staff since the introduction of an area with a birthing pool within the unit for women expected to deliver their babies without complication where midwives could facilitate normal birth:

205

Donna Ockenden, Head of Midwifery at St Mary's Hospital, Portsmouth said that after severe staffing problems which culminated in a 22% turnover of staff, similar measures to improve working conditions and professional development for midwives had helped to create stability.[206]

173. Undertaking work to allow midwives to use a range of skills and to provide continuity of care was also a strategy to reduce turnover of staff at units where recruitment and retention had not been such urgent problems. Ann Geddes, Head of Midwifery at St James's University Hospital in Leeds told us that such measures could ease concerns about retaining staff:

207

174. Worrying evidence was provided by the Royal College of Obstetricians and Gynaecologists (RCOG) on recent and proposed closures of consultant obstetric units. The RCOG surveyed all of its Regional Advisers in 1999 and found that 21 consultant units had closed in the late 1990s, that 28 units were known to be under threat of closure, that 31 other units were due to close within five years, and that a further 17 units were in danger of losing support.[208] We aware that the closure and merger of smaller units can lead to a loss of midwives from the profession.

175. Depleted midwifery establishments and closures of maternity units are not conducive to the return of midwives to the profession. We recommend that the Department assess whether its strategy to encourage midwives to re-register for practice takes into account the extent to which these problems influence a midwife's decision to leave the profession in the first place. The Department also needs to understand why there is a high drop-out rate on some midwifery courses and take measures to reduce the problem.

176. Community midwifery, and home birth support services in particular are also threatened by staffing shortages. This in turn limits the range of skills which midwives can gain and practise. Sheena Appleby told us that the home birth service at Derby continued "because of the commitment of the midwives" but that reconfiguration of staffing structures was crucial:

209

177. As Sue Breslin, Women's Services Manager at the Royal Shrewsbury Hospital pointed out to us, maternity units which promoted a philosophy of low intervention in labour and allowed midwives to practise a full range of skills, had to invest extra time in their new recruits, midwives and doctors, who had no experience of such a philosophy at work:

210

178. Evidence we heard throughout our inquiry has led us to conclude that it will be difficult to invest sufficient time to allow midwifery and medical staff to gain experience of normal birth but it is crucially important to the range of skills they practise and the quality of care they provide. We welcome the introduction of workforce planning tools and the drive to train and recruit more midwives. However, particularly in consultant units, some midwifery establishments are depleted to seriously low levels, as workforce planning tools have shown. In some units staffing cannot be reconfigured to compensate for shortages and where unit mergers or closures are poorly handled, staffing problems are compounded. Several witnesses told us that they had seen no evidence at all of Government initiatives to increase staffing levels. We recommend that the Department take steps to ensure that every maternity unit has the opportunity to use Birthrate Plus to make an assessment of minimum and optimum staffing levels. We further recommend that the Department ask PCTs and hospital trusts to review their investment in midwifery and critically examine their caesarean rates. There needs to be adequate staffing to provide good quality maternity services. The Department also needs to review and renew its efforts to recruit, and bring back to practice, midwives.

179. Given the positive effect of midwifery-led services on recruitment and retention we would urge PCTs and hospital trusts to do all they can to develop midwifery-led services and to be aware of the possible impact of closing units on staff morale, recruitment and retention. Given the general recruitment problem in the South of England and the high cost of living in these areas, we recommend that the Government assess whether the Agenda for Change proposals will tackle the geographic differences in recruitment that we have seen in our inquiry.

WHAT EFFECT HAVE THE EUROPEAN WORKING TIME DIRECTIVE AND OTHER CHANGES TO DOCTORS' HOURS HAD ON MATERNITY CARE TEAMS?

180. The Department told us that the number of consultants working in the field of obstetrics and gynaecology had increased by 21% since 1997 but it did not provide figures for losses in numbers of junior doctors and in time spent training in obstetrics. The Department acknowledged that the vacancy rate had increased (by 0.2% since 31 March 2001 to 1.7% on 31 March 2002) but noted that it was still lower than the vacancy rate of 3.8% across all specialties.[211] However, we heard some worrying evidence that the number of junior doctors choosing to pursue careers in obstetrics was in decline. The intensity of out-of-hours work in obstetrics, and perhaps the comparatively restricted opportunities for private practice (while private practice in gynaecology is common throughout the country, obstetric private practice is concentrated in London and in the larger metropolitan areas), might lead doctors to specialise in gynaecology rather than obstetrics.

181. Christoph Lees, a consultant obstetrician at the Rosie Hospital in Cambridge was very much aware of a downturn in the popularity of his specialty and described a worrying scenario:

212

182. David Redford, consultant obstetrician at Royal Shrewsbury Hospital also drew our attention to problems with "recruitment into obstetrics as a profession", reporting the results of a recent study of the intentions of medical graduates one year after qualification, which showed "a halving of the medical graduates thinking of doing obstetrics and gynaecology compared with ten years ago and that is a very real worry."[213]

183. The RCOG has recommended that all consultants should have set sessions devoted to labour ward or delivery suite work, providing 40 hours per week of consultant cover for the labour ward or delivery suite. Out of these hours the labour ward or delivery suite should be staffed by junior doctors with the Consultant providing cover from home. An RCOG survey found that only 16% of units were currently able to achieve this standard.[214]

184. In discussing caesarean section rates and decision-making with regard to delivery, we heard that increased consultant presence on labour wards was of benefit to women who faced difficult decisions in labour and we received written evidence which called for the introduction of a 24-hour consultant service in larger consultant units.[215] However, those maternity units which could provide the recommended 40-hour per week consultant cover found that it intensified work for staff and that it exerted pressure on some aspects of the maternity service. St Mary's Hospital, Paddington now met the RCOG recommendation but as Professor Lesley Regan told us, the transition period was proving difficult:

216

185. Despite the task of reconfiguring the service to accommodate increased cover, and despite the increased demands on consultant time, maternity unit staff felt that finding the capacity to provide 40-hour consultant cover was a significant achievement for maternity units and also a necessary means of tackling other problems with medical staffing. According to Professor Walker from St James's University Hospital, Leeds: "by having consultants present on a labour ward you can help to reduce the problems of lack of junior staff."[217]

186. Professor Walker, along with all of those who represented consultant units, drew our attention to the reduction in hours worked by junior doctors which has taken place over the last decade. The 'New Deal' on junior doctors' living and working conditions, including guidelines for hours of work and work intensity, was introduced in 1991. New Deal compliance was incorporated into pre-registration House Officer contracts from August 2001 and was to be a condition of Senior House Officer and Specialist Registrar contracts from August 2003. However, the New Deal guidance, which hospitals were already struggling to implement, has been superseded by the European Working Time Directive (EWTD). The EWTD will, by law, reduce junior doctors' working hours to 48 per week, and will necessitate full shift working for all doctors resident out of hours. By 2004 resident doctors will only be allowed to work 13 hours out of 24.[218]

187. Dr Johnston from St Mary's Hospital for Women and Children, Manchester gave us an insight in to the kind of restructuring and reconfiguration of staff roles which compliance with EWTD entails:

219

188. However, in some cases reconfiguration did not represent a solution to the problems posed by the EWTD which remained a daunting prospect for some units and threatened the existence of others. David Redford, a consultant obstetrician at Royal Shrewsbury Hospital told us that:

220

189. Others talked in even plainer language about the threat of closure. Rick Porter, Clinical Director of Maternity Services at Royal United Hospital, Bath told us that "only one person has to be off on long-term sick and the unit is nigh unto closing, it is that close"[221] and Antony Nysenbaum from Trafford General Hospital said that unless more middle-grade doctors were employed, "we would not be able to provide cover, and therefore we would no longer be viable."[222]

190. Doctors working to become specialists in obstetrics now encounter difficulties in gaining experience as the hours they spend in training have been reduced, and as the registrar and senior registrar grades have now been merged into a single Specialist Registrar grade.[223] Professor Regan from St Mary's Hospital, Paddington argued that it was now difficult for trainees to follow the care of a patient:

224

191. Professor Regan commented on the longer-term implications of the EWTD for staffing in maternity units:

225

She went on to say that "it has had a massive, devastating impact on the sort of standards of care we have been able to provide."[226]

192. Moves to implement the New Deal and the European Working Time Directive have already had a profound impact on the levels of experience that obstetricians gather as trainees and are already threatening the viability of maternity units which currently serve as consultant obstetric units. This might create welcome opportunities for the development of midwifery-led units for women with low-risk pregnancies but we are extremely concerned that women who experience complications in pregnancy and in labour should have access to skilled, experienced and confident obstetricians. We welcome the Department's work to assess the implications of the EWTD but are concerned that any action on this work will come too late for the current generation of trainee obstetricians, and indeed for those units threatened with closure. If the EWTD is to be implemented, more investment in training and recruitment of doctors is required so that adequate levels of staffing and levels of experience can be maintained. We are very concerned that the Government is not sufficiently aware of the difficulties the professions face on account of the European Working Time Directive.

What impact do staffing and configuration issues have on women and babies?

ACCESS TO MATERNITY CARE

193. The staffing of a maternity care team affects the kind of care a woman will have from the moment she first seeks professional advice on her pregnancy. In the majority of cases a woman will seek that advice from her GP. Some GPs help to provide their patients' antenatal care and a few follow through to attend at the delivery but most will provide advice and then refer pregnant women to a maternity service. Levels of communication and working relationships between GPs and maternity services vary and this variation can influence the kind of delivery a woman envisages.

194. We heard evidence of mutual trust and respect between GPs and midwives in the community, working relationships which allowed GPs to support women in their choices, including delivery in community units or at home. For example, Gill Smethurst, representing Goole Midwifery Centre, said that GPs recognised midwives as experts in maternity care and were happy to refer women who chose home birth: "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'."[227] In 2002, 30 out of 434 women who were cared for by Goole midwives delivered their babies at home.

195. However, some GPs may be reluctant to support women in choosing home birth or delivery in midwifery-led units located at some distance from hospital. As Carol Burns, a user representative from St James's University Hospital, Leeds told us, although she did not think that there was a 'huge' group of women who wanted home births, "we suspect that there are more than are having them at the moment."[228] Mandy Grant, another user representative (from Dorset) said that "most women tell me that their GPs can often be quite off-putting about going to the low risk unit … some GPs are a bit frightened; they think women should go where the technology is in case something goes wrong."[229]

196. Christopher Guyer, Clinical Director of Obstetrics at St Mary's Hospital, Portsmouth, which has a number of peripheral, midwifery-led units, explained to us why so many GPs were reluctant to support births away from consultant units, and suggested a way of changing perceptions:

230

197. Ann Geddes, Head of Midwifery at St James's University Hospital, Leeds (where 70 of 8,000 births took place at home in 2002) outlined a similar strategy with regard to home birth:

231

198. A number of witnesses suggested to us that midwives, rather than GPs should be the first point of contact for a pregnant woman. Julianna Beardsmore, representing users of maternity services in Bath, saw "the midwife as a key information giver for the woman" and felt that women should not have to confirm where they would deliver their babies until 32-36 weeks into pregnancy by which time they would have explored all of their options.[232]

199. Women should be able to take time over their initial decisions on maternity care. It is important at this early stage in pregnancy that women should not be subject to any undue influence in relation to the type of maternity unit they are to choose. We recommend that national guidance be issued to support GPs in referring women for appropriate maternity care and in particular to clarify the role of the GP in relation to home birth i.e. that GPs do not need to take responsibility for this. We further recommend that the Government consider the idea of making the midwife rather than the GP the first point of contact for a discussion of maternity care choices.

ACCESS TO ANTENATAL AND POSTNATAL CARE

200. A woman is referred to a maternity service not just to 'book' care for the delivery, but also to receive care and support during pregnancy. This antenatal care can help a woman to be aware of her own health and that of her unborn baby and to reassure her if she is anxious about her pregnancy or birth. Antenatal care in the form of classes often help women to develop a support group of their peers in the class, which may endure beyond the birth of their babies. Davidica Morris, from the Maternity Services Liaison Committee at Worcestershire Royal Hospital argued that antenatal classes "are very important and they give parents the knowledge to make more informed choices … and help them in making decisions during their pregnancy and labour."[233]

201. Midwives recognised the importance of antenatal care, particularly for very young mothers and for disadvantaged or socially excluded women, and worked to provide the models of care that women feel most comfortable with: "we have tried one-on-ones, we have tried small groups and at the moment we are trying what we call a drop-in centre where we have a room with midwives available."[234] Where maternity services are integrated, with midwives working in the community and at maternity units, antenatal classes may help women to get to know the midwives they will see at the unit, and in turn to feel more familiar with the unit itself.

202. However, Toni Martin, Head of Midwifery at Worcestershire told us that when maternity units were short of staff, quality of care for women in the antenatal period could be compromised: "antenatal classes are less important than delivering the babies because the babies have to be delivered."[235]

203. In the same way, staffing shortages can affect care for a woman after she has delivered her baby. As Professor Regan from St Mary's, Paddington stated: "The postnatal ward is always the poor relation. Wherever there is a staff shortage that is where they are lost."[236] The postnatal period can be a vulnerable one for a woman and her baby and even where both are healthy, professionals can give support which promotes the development of bonds between parent and child. Perhaps the most vivid example of this kind of support is breastfeeding which has proven health benefits, but which can also be difficult to initiate and sustain without help. Mandy Grant from Dorset Maternity Services Liaison Committee illustrated the importance of midwifery support to a woman's attitude to breastfeeding:

237

204. At Edgware Birth Centre, where seven whole-time equivalent core staff deliver around 500 babies, midwives keep detailed statistics on breastfeeding. Some months see 100% breastfeeding on departure from the Birth Centre. This may be explained at least in part by the fact that no formula milk is kept on the premises, but on follow-up at three to four months, midwives found that women were usually still breastfeeding.[238] We heard from Selene Daly of the value of simple advice and reassurance given by midwives who have time to spend with women and their babies in a maternity unit where continuity of care is routine:

239

THE CONCEPTS OF CONTINUITY OF CARE AND CONTINUITY OF CARER

205. One of the strongest themes to emerge from our inquiry was the importance of continuity to pregnant women and new mothers; continuity in terms of the person or people who care(s) for the woman, and continuity in terms of constant support in labour. User representatives from consultant units and birth centres alike insisted that continuity was a condition of good quality care for women and babies. Catherine Eccles from St Mary's, Paddington told us:

One thing that I know women want and would produce better results in labour is one-to-one care. Continuity of care as well. Being supported all the time by a midwife … actually having the same midwife who has seen you antenatally and then is supporting you through labour with a relationship of trust that has been evolved through pregnancy towards labour.[

240

Selene Daly from Edgware Birth Centre defined what she saw as the ideal for maternity services, one-to-one care:

241

206. This could not be further from the situation in maternity units stretched beyond capacity owing to staffing shortages:

pip,pip,pip

242

207. This kind of situation raises questions about quality of care, if not in terms of safety or even of avoiding unnecessary medical intervention which could lead to caesarean section, but in terms of a woman's feelings about her experience of childbirth. Another user representative, Davidica Morris from Worcestershire Royal Hospital, insisted that "not always having a midwife with [the woman] is a big issue."[243]

208. In some areas women have access both to continuity of carer, where the same midwife or midwives provide antenatal, intrapartum and postnatal care, and continuity of care, where the woman is supported in labour at all times. At Goole Midwifery Centre, two midwives attend every birth.[244] The Albany Midwifery Practice in Peckham employs seven midwives, each on-call 24 hours a day, seven days a week (but with twelve weeks' holiday a year). Each woman is assigned to two midwives and in 95% of cases, one or both midwives attended at the birth.[245]

209. In many other areas staffing issues and team structures render continuity of carer impossible and continuity of care difficult to provide. However, it seems that in struggling to balance the needs of staff and pregnant women, continuity of care is an aim which informs all plans to develop maternity services at local level. Shona Ashworth, Head of Midwifery at University Hospital, Nottingham said that asking midwives to take on caseloads of women they would care for throughout pregnancy and the postnatal period was unlikely to yield a positive response:

246

210. Evidence from user representatives suggested that women appreciated every effort that was made to promote continuity of care, even if continuity of carer was not possible; and that women felt secure knowing that continuity was the aim and the guiding philosophy of the maternity unit. Clare Hodgson, a user representative from Trafford General Hospital, and Alex Silverstone from St Mary's Hospital for Women and Children, Manchester described women's experiences:

I had one particular midwife … the same midwife actually stayed with me for most of the night and was going to outstay her shift, but unfortunately could not stop any longer because of her own children. The point at which I got to the delivery suite, another midwife came in and she stayed with me for the rest of the labour and I was very happy and confident that there had been continuity.

247

211. At some units it was felt that women whose pregnancies were judged to be high risk, and who were under close medical supervision, were more likely to receive continuity of care. At other units, such as that in Royal United Hospital, Bath, special effort was made to have women with high risk pregnancies meet and get to know the midwives as well as the doctors at the unit.[248] Whether pregnancy was high or low risk, it was acknowledged that women needed continuity of care, and it was affirmed that midwives wanted to provide it but that they were hampered by under-establishment and staffing shortages. Helen Shallow, Midwife Consultant at Derby City General Hospital insisted that flexibility was the key element in reconfiguring services to maintain quality of care for pregnant women and job satisfaction for staff:

249

212. We agree that the issue of continuity of care is of crucial importance to women and families and we urge the Department to facilitate the sharing of good practice in configuring services to provide continuity of care-giver across the country. In particular, we recommend that the Department liaise with PCTs to promote the development of services based on one-to-one care. We would welcome the creation of midwifery networks to share examples of innovative practice in the primary care setting. We recommend that the Department issue guidance on standard definitions for one-to-one care, continuity of carer and continuity of care.

175 Health Committee, Second Report of Session 1991-92, Maternity Services, HC 29, para 384 Back

176 Ev 156 Back

177 Ev 264 Back

178 Ev 240 Back

179 Ev 130 Back

180 Ev 129 Back

181 Ev 206 Back

182 Ev 214 Back

183 Ev 190 Back

184 Ev 225 Back

185 Ev 183 Back

186 Ev 157 Back