6 CONCLUSIONS
236. The group of issues we identified in our
terms of reference as areas which warranted examination seemed
to draw together discrete or even disparate aspects of maternity
services. However, although each of the issues does indeed raise
specific concerns, collection of maternity care data, caesarean
section rates, maternity care staffing and staff training are
all closely related in terms of the causes and effects of the
problems which can compromise the quality of a woman's experience
of her maternity care.
237. The maintenance of a comprehensive and
accurate statistical evidence base for maternity services is a
vital component of work to identify trends such as rising caesarean
or induction rates, and in turn to inform national guidelines
and policies. The national statistical base should allow researchers,
maternity service providers and service users themselves to access
the information which they require; on antenatal care (smoking
cessation in pregnancy, for example), on care during labour and
childbirth (on 'normal birth' and levels of intervention), and
on postnatal care (such as breastfeeding rates) and infant health.
This kind of information is needed if access to care and quality
of care for disadvantaged groups, aspects of maternity services
which we intend to examine in our next inquiry, are to be monitored
effectively.
238. At local level, maternity care staff need
to have access to a system which facilitates the efficient collection
and entry of data on care for each woman, which is compatible
with other hospital and community information systems which
keep records on antenatal and postnatal care. Maternity units
should also be able to retrieve data which they can use in auditing
their service and in drawing up guidelines for good practice.
In terms of care for the individual woman and her baby, data systems
should accommodate comprehensive health records.
239. However, the evidence we heard during this
inquiry strongly suggests that data collection at local and national
level is seriously impaired, not only by inadequate or nonexistent
data systems and by inconsistent use of terminology, but also
by a lack of IT specialist support for maternity units. Entering
data into inefficient systems is an onerous task for midwives
who have no specialist expertise or training, and who feel that
much of the time spent on data entry would be much better spent
caring for women and their babies.
240. Caesarean section rates constitute one
area of maternity care in which accurate data collection is particularly
important and in which, as the National Sentinel Caesarean Section
Audit showed, identification of trends and use of evidence can
inform policy at local and national level to improve care for
women. All of the maternity units we heard from had policies in
place to reduce section rates and these policies were based on
evidence of health outcomes for women undergoing different levels
of intervention in labour. However, this inquiry has not allayed
our concern that caesarean rates are too high, nor that they vary
so dramatically between neighbouring areas and even neighbouring
units. We conclude that some women are exposed to risks of surgery
which are not balanced by benefits sufficient to justify caesarean
section and that there is a need both for the implementation of
evidence-based protocols and policies and an investment in staff
establishments so that doctors and midwives can spend time giving
information, advice and reassurance to women before labour, that
they can support women during labour, and so that experienced
doctors can make the decision to undertake a caesarean section.
241. We conclude from our examination of the
staffing of maternity care teams, however, that in many units
staffing levels in terms of medical and midwifery staff are not
what they should be. Depleted midwifery establishments mean that
a midwife may have to care for several women at a time, perhaps
having to rely on electronic monitoring to check on mother and
baby. In turn this means that intervention in labour starts earlier,
increasing the likelihood of caesarean section. Lack of on-site
consultant cover for maternity units can also contribute to rising
caesarean rates in that experienced doctors are not always present
when the decision to undertake a section is made. This is compounded
by the implementation of the European Working Time Directive which
is limiting the presence of younger doctors in maternity units.
242. The evidence we took from user representatives
confirmed that there is no single model for maternity care. Some
women have needs in pregnancy which can only be met at a consultant
unit based in a hospital and some women who do not have such needs
may well be reassured by the medical and technological back-up
of the hospital setting. A great many other women however, value
the opportunity to deliver their babies in the 'home-from-home'
setting of a birthing centre, and some wish to deliver their babies
at home, supported by community midwives. The most important factor
in a positive experience of birth in any of these settings is
continuity of care, where a woman is supported at all times during
labour by a member of the maternity care team. Maternity staff
who work in an environment where it is possible to provide this
level of care seem to be happier in their jobs and in their professions.
Staffing shortages at maternity units are self-perpetuating in
that they lead to recruitment and retention problems. Such shortages
threaten the existence of some maternity units, and closures impair
women's choice in relation to maternity care (an area which we
intend to examine as part of a future inquiry), and in some cases
their safety and that of their babies.
243. Rising rates of intervention in labour
and staffing shortages create gaps in the skills mix of maternity
care teams and render post-registration training of maternity
staff all the more important. As caesarean sections and other
interventions become increasingly common, midwives and doctors
in training are less likely to gain experience in facilitating
normal birth and some of our witnesses argued a very convincing
case for doctors and midwives working in consultant units to undertake
training in other settings. Midwives now take on some of the tasks
traditionally performed by doctors and so they require special
training and support in order to feel confident in their expanded
role. Training in the use of specialist equipment and in emergency
'skills and drills' is essential to the safety of pregnant women
and new babies. The development of other types of skill (in caring
for women with specific needs, and in breastfeeding support, for
example) can enrich a woman's experience of maternity care and
improve health outcomes for mother and baby. Access to in-post
training at a maternity unit may improve recruitment and retention
rates but this access is dependent in the first instance on the
availability of staff to undertake training sessions and courses.
244. In undertaking this inquiry our intention
was not to attempt an all-encompassing survey of maternity services
or to appraise the services provided by individual maternity units,
but rather to seek a range of views on those particular issues
of concern drawn to our attention by experts in the field. This
'snapshot' approach afforded us the opportunity to explore specific
issues in some detail, but also to engage in a wider debate which
connected those issues. We also gained some degree of insight
into the experience of maternity care staff and of pregnant women
and mothers and this insight will inform our future inquiries
into inequalities in access to maternity services and choice in
maternity services.
245. Confidence appears to be a key factor in
childbirth, whether it is the confidence of the woman in her innate
ability to deliver her own baby, the confidence of her carers
(midwives, doctors, companions) in their ability to support her,
or the confidence of women in general that maternity services
will be available and responsive to the social and medical needs
of women during pregnancy, labour and the postnatal period. We
were encouraged to hear evidence from maternity units where the
confidence of women and staff was high but we found it difficult
to see how this kind of confidence could be generated at units
where staff struggled to attain basic minimum standards of safety
in managing rising workloads. An increase in staffing, especially
midwives, should lead to reduced caesarean section rates and may
have cost benefits for the NHS.
246. We are very much aware that a great many
of our recommendations reiterate those made by our predecessor
Committee and by Changing Childbirth. We recognise that
maternal and perinatal mortality rates have fallen since Changing
Childbirth and we heard evidence of good practice and of a
commitment to provide high-quality maternity care. However, it
was clear that the principles of good maternity care as set out
in Changing Childbirth had not been achieved throughout
the country. Maternity Services are not yet "based primarily
in the community." Women themselves are not yet "sufficiently
involved in the monitoring and planning of maternity services."
In all too many cases the woman still does not feel that she is
"in control of what is happening to her and able to make
decisions about her care, based on her needs, having discussed
matters fully with the professionals involved."[275]
During our predecessor Committee's inquiry, the late Audrey Wise
MP often said that, as she saw it, the best way of providing the
kind of appropriate and good quality maternity care subsequently
described by the principles set out in Changing Childbirth,
was to "staff the woman" rather than the delivery suite
itself. We conclude that this standard of individualised care,
expressed in Changing Childbirth as making the woman the
"focus of care" is one which is under-resourced, under-staffed,
and under-supported.[276]
247. A great many of those who have worked in,
and indeed used, the maternity services over the last decade have
been disappointed by what they see as the failure to implement
the reforms announced by Changing Childbirth. We share
this disappointment. We wholeheartedly agree with Baroness Cumberlege,
the Chair of the Expert Maternity Group which produced Changing
Childbirth, who said in January of this year that "it
is time that the Government put some strong political will behind
the issue and improved the lot of women and children in this country."[277]
We hope that this report will provide an opportunity for the present
Government to respond and reflect on why so many widely-supported
previous recommendations have failed to be fully implemented.
275 Department of Health, Changing Childbirth:
the report of the Expert Maternity Group, 1993 Back
276
Health Committee, Second Report of Session 1991-92, Maternity
Services, HC 29, para 384 Back
277
HL Deb, 15 January 2003, col. 300 Back
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