| 1. | We are concerned that the accuracy of maternity care statistics is adversely affected not only by missing data but by data submitted according to different interpretations of the terms used to define the data required by the Maternity Hospital Episode Statistics. We recommend that the NHS Information Authority clarify the progress made to date on the Maternity Care Data Project, and in particular on the compilation of the 'data dictionary'. We further recommend that work on this important area continue, overseen by a 'national champion' for maternity care data, alongside efforts to ensure that all maternity units submit data to the Maternity HES. (Paragraph 24)
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| 2. | We recommend that data on breastfeeding rates, in terms of initiation and duration, should be standardised and collected at national level. (Paragraph 29)
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| 3. | We recommend that the Department take immediate action to ensure that maternity care data systems and population-based child health systems for both sick and healthy babies, should be linked together at national and local level in order that health professionals have all information relevant to mother and baby and in order that the long-term outcomes of pregnancy and childbirth for maternal and child health can be measured. (Paragraph 31)
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| 4. | Changing Childbirth recommended that all women should carry their own maternity notes. We are disappointed that ten years later there are still some units where this does not happen. We recommend that the Department should insist that all units support the use of woman-held notes. We further recommend the development of a national format of these notes in preparation for the Electronic Patient Record. (Paragraph 32)
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| 5. | We welcome the Department's efforts to reduce incompatibilities between data systems and to review policy on the collection of maternity care data. We recommend that this review take account of calls for a renewed focus on normal birth and of the need for accurate data on antenatal and postnatal care in order to monitor progress towards targets and reducing health inequalities. We further recommend that in reviewing the Maternity HES the Department should ensure that the figures compiled for each maternity unit take accurate account of factors such as privately-run units within hospitals, and reflect the configuration of services which take in community midwifery teams and midwifery-led units under the auspices of a hospital unit. The Department should also take steps to ensure that data are collected on births in privately-run units and on home births. (Paragraph 36)
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| 6. | We were appalled to hear of the burden of work imposed on maternity care staff in units where maternity care data systems were inadequate or nonexistent. The dramatic variation in the reliability and availability of maternity care data systems across the country cannot be rationalised by differences in size or configuration of units. We were struck by the disparity between this unacceptable situation, where staff could not retrieve information about their patients, and in turn where reliable national statistics could not be generated, and the Government's intention to use information technology to "enable NHS professionals to have the information they need both to provide … [the best possible] care and to play their part in improving the public's health." (Paragraph 50)
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| 7. | We recommend that the Department of Health Statistics Division 3G liaises with other relevant parts of the Department and the NHS Information Authority to issue a direction to trusts on the provision and maintenance of maternity care data systems, and on links between these systems and other health information systems, so that maternity units can collect and retrieve accurate data in a more efficient way to meet both local and national data needs. (Paragraph 50)
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| 8. | The process of entering data on maternity care must not compromise the quality of care that pregnant women, and new mothers and babies receive. Adequate managerial and systems support is vital. Maternity care teams should have access to the services of administrative staff who have been trained to use the data system. While clerical staff can help to alleviate some of the pressure on maternity staff in terms of data entry, it is essential that the ultimate responsibility for overseeing the quality and clinical accuracy of data lies with a senior member of the clinical team. We recommend that the Department ensure that maternity units have access to reliable hardware, systems which can support the handling of individual records, to software which can be used for data analysis, and to appropriate statistical and IT support. Provision should be made for midwives who wish to do so to acquire skills in data analysis for monitoring and audit. (Paragraph 56)
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| 9. | We recommend that in reviewing policy on the collection of maternity care data, the Department consider the merits of the system used in Scotland, not only in terms of the system itself but also in terms of other factors which might contribute to its success, such as the allocation of resources and the existence of a culture which supports staff who collect, enter and analyse data. (Paragraph 61)
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| 10. | Most of the midwives and doctors who spoke to us did not recognise the requirements of the Maternity HES as a common data set, because they had not heard of them, or because they felt that definitions of the data required were not clear, or because the Maternity HES did not correspond with the more detailed information they collected independently for the purposes of care for individual mothers and babies, and development of their service. This is an indication of the disparity between national policy on and local knowledge of, collection of maternity care data. If maternity unit data collection systems are to be improved, communications between the Department and individual trusts and maternity units must be strengthened. We recommend that the Department should set out the implications of the electronic patient record initiative for maternity care data systems, including agreement of data definitions for maternity care, and further that it should consult and communicate with trusts on developments relating to the minimum dataset required by the Maternity HES. (Paragraph 62)
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| 11. | We believe the current state of maternity care data systems at units across the country to be so grave as to warrant specific attention by PCTs and trusts, and, where needed, the allocation of funds for the purpose of installing and maintaining adequate systems and for recruiting and training appropriate staff to undertake data entry, analysis and system support. We recommend that maternity care data systems should form part of Local Delivery Plans. (Paragraph 63)
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| 12. | We recommend that in undertaking caesarean section audits, all hospitals should classify the degree of urgency of a caesarean section in the same way. We further recommend that the classification scheme used by the National Sentinel Caesarean Section Audit be considered as a standard scheme and that the data items needed to construct it should be included in the Maternity Care Data Dictionary. (Paragraph 82)
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| 13. | The issue of women's choice in undergoing caesarean section when there is no clinical need is a fraught one. The NHS does not generally provide other major operations for patients when there is no clinical need, nor does the NHS tend to offer choices of treatment to patients when one costs on average £760 more per patient than the alternative, since it is obliged to make the best use of NHS resources. It remains to be seen whether the National Institute for Clinical Excellence will allow choice for caesareans when in other areas of the NHS patients do not have comparable freedom. We would like to see a distinct shift in emphasis to ensure that elective caesareans as a 'lifestyle choice' are not supported by the NHS and that caesarean section should be a procedure undertaken only when medically or psychologically necessary and after appropriate support and counselling. (Paragraph 98)
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| 14. | We look forward to the publication of NICE guidelines on caesarean section and recommend that these should serve to support maternity care staff not just in assessing the medical indications for caesarean, but also in giving consistent advice and information to women considering the procedure. (Paragraph 99)
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| 15. | We share the concerns of maternity care staff who wish to protect women from the risks associated with caesarean section. We are particularly concerned for those women who choose caesarean section because they are anxious about delivering their babies. While their fears about childbirth should not be compounded by new anxieties about the risks of caesarean section, these women should be made aware of the implications of surgery for women and babies and of services which help to reduce anxiety. We recommend that maternity units examine how women who request caesarean section are cared for, what kind of information and advice they receive, and how the women themselves feel about their discussion of caesarean section with midwives and consultants. (Paragraph 100)
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| 16. | We understand that in some cases interventions in labour are necessary to protect the health of mother and baby. However, women should be made aware that interventions such as EFM, epidural and induction may increase the likelihood of a caesarean delivery. Raising a woman's awareness in these areas should not entail merely the transmission of clinical information but rather it should involve discussion with a health professional in the context of the individual woman's background and concerns. (Paragraph 104)
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| 17. | We were disappointed to hear that so few caesarean section audits involved the views of users. The woman's experience is an important facet of the analysis of caesarean section rates and we recommend that maternity units consider this aspect of the audit process, even if women's views can only be sought through questionnaires. (Paragraph 112)
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| 18. | We agree with those witnesses who told us that ideally the decision to undertake a caesarean section should be made in the physical presence of a consultant. Whilst this is not practicable within current staffing levels we believe that consultants should always be consulted over the decision to undertake a caesarean section except in the rare cases where immediate section is necessary. Although caesarean section is now a much safer procedure than it once was, we are concerned that some women undergo unnecessary sections on the recommendation of doctors who lack experience owing to the time limitations imposed by the New Deal and the European Working Time Directive on their training. This situation renders the process of auditing caesarean sections at individual maternity units all the more important as a form of training for junior staff as well as a means of ensuring that decisions made by consultants have been appropriate. We recommend that the forthcoming NICE guidelines on caesarean section should be supported by advice on audit procedures. (Paragraph 113)
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| 19. | Such variations in clinical practice, while they might not compromise a woman's safety, may affect her role in making decisions on the mode of delivery for her baby if she does not have access to information on the risks and benefits of caesarean section. We are not convinced that it can be justified for women to have a significantly increased chance of a major operation because of an individual consultant's judgement of the risks of caesarean against normal birth and we hope that the NICE guidelines will create a consistency of approach across the country. Although we recognise the sensitivity of releasing individual consultant data we believe this data should be given to all users together with national and local comparisons so that women are aware of their consultant's caesarean section rate. (Paragraph 122)
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| 20. | We strongly endorse innovative approaches to reducing caesarean sections which involve women in detailed discussion about their maternity care and help to raise awareness of the risks and benefits of the different kinds of intervention in labour. We believe that this involvement is key to a positive experience of childbirth and of maternity care, and that the development of strong relationships between women and well-trained, confident midwives is crucial. The information gathered from discussion of previous experiences could be vital to the development of maternity services, particularly in relation to caesarean section. We recommend that information from women on their previous caesarean section should be incorporated into audits. (Paragraph 136)
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| 21. | We are encouraged to hear that maternity care staff value NICE guidelines and evidence based on research commissioned by the Department as tools for developing strategies to reduce caesarean section rates and to increase 'normal' birth rates. We recommend that the Department continue to support research and evidence-gathering initiatives and in particular the work on caesarean section audit. (Paragraph 137)
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| 22. | Based on evidence we heard from maternity units, we see a relationship between high rates of caesarean section and low levels of staffing. It seems to us unacceptable that a woman should undergo a surgical procedure that might have been avoided had she been better supported during pregnancy and/or during labour. It is clear from strong evidence that one of the most important means of reducing the caesarean section rate is to provide adequate support for women in labour. The level of staffing and organisation of care should enable women to be supported at all times. (Paragraph 142)
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| 23. | 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. (Paragraph 155)
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| 24. | 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. (Paragraph 158)
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| 25. | 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. (Paragraph 175)
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| 26. | 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. (Paragraph 178)
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| 27. | 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. (Paragraph 179)
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| 28. | 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. (Paragraph 192)
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| 29. | 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. (Paragraph 199)
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| 30. | 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. (Paragraph 212)
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| 31. | We recommend that the Government should ask the appropriate bodies to commission a review of training for health professionals in maternity services. In our view all members of the maternity care team should receive training on and gain experience of normal births in a range of settings. Midwives play a crucial role in supporting normal birth. The Nursing and Midwifery Council should ensure that curricula, and practical experience elements of training allow student midwives to develop appropriate skills in the support of normal birth. All student midwives should undertake placements within a midwifery-led unit or birth centre, and with a team of midwives who assist at home births, and the Government should also encourage the use of midwives in educating junior doctors on normal births. (Paragraph 219)
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| 32. | We recommend that all midwives and doctors receive training together in emergency procedures, including the use of appropriate equipment. (Paragraph 223)
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| 33. | We recommend that a review of training programmes should emphasise the importance of skills in informing, advising and counselling mothers and families, and in promoting the development of bonds between parents and their babies. In particular, we recommend greater emphasis on support for breastfeeding. All newly-registered maternity staff should be aware of the special support needs of some families. (Paragraph 227)
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| 34. | Current training seems to us not fully to acknowledge the changed nature of maternity care today. We therefore recommend that steps should be taken promptly to ensure that the Colleges and the Nursing and Midwifery Council develop appropriate training on a multi-disciplinary team basis, including where possible the participation of such members of the maternity care team as physiotherapists and health visitors. (Paragraph 235)
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