APPENDIX 13
Memorandum by the Association for Improvements
in the Maternity Services (MS 19)
INTRODUCTION
1. The Association for Improvements in the
Maternity Services (AIMS) is a voluntary organisation, established
in 1960. Although we have received a small grant from the Community
Fund the AIMS Committee comprises entirely women who give their
time freely to help other women and their partners, to obtain
care that is appropriate to them. In order to do this we:
— Respond through our telephone help
line to enquires about how to access the kind of care appropriate
to each individual.
— Give information about obstetric
and midwifery practice.
— Give information and advice on how
to complain effectively about poor maternity care.
— Liaise with other organisations,
including similar groups overseas.
— Respond to requests for information
from health authorities and health professionals.
— Produce a quarterly Journal.
— Monitor obstetric and midwifery journals
and text books, and produce our own information leaflets and books.
— Support individuals throughout the
UK and Ireland who seek to improve maternity care.
2. The majority of the calls we receive
are from women who have had poor care, or who are unhappy with
the care they are receiving and are trying to find something better.
We also hear from women who have had satisfying and successful
births.
3. The accounts of women's experiences enable
us to identify potential problems and it also gives us an insight
into the huge importance a successful birth can achieve.
SUMMARY
4. Although over 10 years have passed since
the last Health Select Committee Inquiry into Maternity Services
(House of Commons Health Committee, 1992), the quality of maternity
care currently provided has not improved since then and has in
fact deteriorated further. Women still do not have choice of
maternity care, continuity of carer or control over their pregnancy
and birth, all of which were promised by Changing Childbirth (Department
of Health, 1993).
5. Birth has become increasingly medicalised,
with devastating effects on maternal health and well-being. It
has also led to a need for "obstetric nurses" rather
than skilled midwives. Those who are not prepared to act in this
way become disillusioned and leave the Health Service, resulting
in midwife shortages.
6. The Government needs to act now while
there are still midwives who retain the traditional skills of
midwifery, who can facilitate physiological birth, and support
and nurture women. These midwives are a valuable resource who
could train and re-skill other midwives.
COLLECTION OF
DATA FROM
MATERNITY UNITS
7. Over the years AIMS has sought to give
women accurate information to enable them to make decisions about
the care they require. Maternity statistics offer the potential
to give a "picture" of the ethos and practice in any
particular unit. Unfortunately, statistics are collected to inform
health providers and administrators about practices and outcomes
important to them. The statistics often do not give information
important to women.
8. The majority of women approach the birth
of their babies in the expectation that the birth will be "normal".
With growing hospitalisation and medicalisation of birth AIMS
became increasingly concerned about those women who had been traumatised
by their birth experiences and who claimed that having had a "normal
birth" last time they were signing up for an epidural or
a caesarean section the next time. Gentle probing about their
actual experience revealed that none of the women had actually
had a "normal birth". They had all endured a range
of routine obstetric interventions that perverted the normal progression
of labour. The majority of babies were delivered vaginally and
as the case notes recorded a `normal delivery' the women interpreted
this as a normal birth.
9. In 1992 AIMS wrote to the Department
of Health and the National Maternity Record Project suggesting
that, in order to determine how many women actually achieve a
normal birth, the statistics should be collected so that women
who have artificial rupture of membranes, induction of labour,
acceleration of labour, epidural anaesthesia or episiotomy should
be recorded as having a technological birth (this was later amended
to an obstetric delivery) (Beech, 1997).
10. In 2001, Soo Downe, published the results
of her study which was designed to test AIMS' claims (Downe et
al, 2001). The study found that "if normal means physiological,
the study indicates that very few women in the sample experienced
normality during their labours and births". Only one in six
first time mothers, and only one in three women who had had babies
before, achieved a normal birth. Yet, the majority of UK hospitals
claim "normal delivery" rates exceeding 60%.
11. Although most hospitals collect statistics,
many women are denied access to them. It appears that some hospitals
consider that statistical data is for internal evaluation and
should not be made available to the average woman who is trying
to assess the best place for her to give birth.
12. Many maternity units also fail to collect
home birth statistics and in some areas we are very doubtful of
the accuracy of the statistics that are collected. For example,
although women wish to book a home birth they are given a variety
of excuses why the booking should be delayed. In the meantime,
women are constantly "persuaded" to change their decisions.
Should they persist and go into labour at home, an excuse is found
to transfer to hospital. The birth is recorded as a hospital birth
and no record is made of the home birth transfer. This then enables
hospitals to claim that "there is little demand for home
births". (For more on home births, see paragraphs 17-22).
THE STAFFING
STRUCTURE OF
MATERNITY CARE
TEAMS
Continuity of carer
13. In 1991 AIMS gave evidence (Rodgers
et al, 1992) to the last Select Committee on Health's Enquiry
and made the following assertions.
"We would draw your attention to the study
Effective Care in Pregnancy and Childbirth (Chalmers et
al, 1989) which should provide a background to the work of
your Committee. The study found, `There is strong evidence that
continuity of personal care combined with efforts to provide social
and psychological support during pregnancy and childbirth, is
preferred by women, and that it has a number of other beneficial
effects; furthermore, there is no evidence that it has any adverse
effects."
"We would also draw your attention to the
Know Your Midwife Report (Flint and Poulengeris, 1986)
which analysed a trial at St George's Hospital 1983-1985 offering
women continuity of midwifery care. While this was clearly a system
appreciated by the women, there were also savings for the Health
Authority. In the area of antenatal care the actual costs were
20-25% less than those for women who had consultant care".
"A survey of Lothian Maternity Services
(Edinburgh Health Council, 1987) also bears out these findings.
They found that the majority of mothers made it clear in their
responses that they wanted continuity of care during their pregnancies.
In conclusion the survey found, `Woman want more and better information,
they want better and more equal relationships with the doctors
and midwives, they want to be part of making decisions about their
care, and they want as little medical/technical intervention as
is safe for them and their babies.'"
14. Having accepted AIMS' evidence, and
the evidence of other organisations and individuals the Select
Committee concluded: "that there is a strong desire among
women for the provision of continuity of care and carer throughout
pregnancy and childbirth, and that the majority of them regard
midwives as a group best placed and equipped to provide this"
(House of Commons Health Committee, 1992: para 49).
15. Changing Childbirth's objective (Department
of Health, 1993) was: "Every woman should have the name of
a midwife who works locally, is known to her, and whom she can
contact for advice. She should also know the name of the lead
professional who is responsible for planning and monitoring her
care. Within five years, 75% of women should be cared for in labour
by a midwife whom they have come to know during pregnancy."
16. It is deeply disappointing that despite
the evidence, the advice of the Winterton Report (House of Commons
Health Committee, 1992) and the Changing Childbirth Report (Department
of Health, 1993) continuity of carer is even less accessible to
women in 2003.
Home Birth
17. "On the basis of what we have heard,
this Committee must draw the conclusion that the policy of encouraging
all women to give birth in hospitals cannot be justified on the
grounds of safety" (House of Commons Health Committee, 1992:
para 33)
18. Since the publication of the Winterton
Report numerous studies have further supported this statement
(Ackermann-Liebrich et al, 1996; Davies, 1996; Northern
Regional Perinatal Mortality Group, 1996; Springer and Van Weel,
1996; Wiegers et al, 1996). Yet women who decide to give
birth at home still face enormous obstacles. AIMS receives DAILY
appeals for help from women who are being denied home births on
the grounds that there is a midwifery shortage. They are told
that if the hospital is short staffed when they go into labour
they will have to come into hospital.
19. Women choose home birth for a multitude
of reasons: they are convinced that it is safer for their baby;
they wish to avoid routine hospital procedures and deadlines;
they are anxious in unfamiliar surroundings; they are unwilling
to be attended by a stream of strangers; they have had a previously
traumatic birth in hospital and have no intention of putting themselves
or their babies at risk of a repetition; or they give birth quickly
and easily and they do not want to have to travel in advanced
labour. It is essential that this valid choice made by women is
supported by all hospital trusts.
REFUSAL TO
SEND A
MIDWIFE
20. In December 2002 we were contacted by
Mrs Tracy Todman. The following is an extract from her letter,
quoted in a recent AIMS Journal (Todman T, 2002):
I planned a home birth from the start of my
pregnancy and, from that point onwards, I was made aware that
there would always be a risk that no midwife would be available
when the time came. This did not deter me, but I do know of women
who have been put off the idea of home birth for this reason.
In the event, when I rang in labour, no midwife
was available. My daughter was delivered in the back of an ambulance
en route to the hospital.
No midwife was available as the midwife on call
was rostered to the labour ward, which was too busy to release
her. The hospital had adequate notice that my labour was imminent.
I had phoned the labour ward the night before, in early labour,
and was actually having contractions eight minutes apart while
having a CTG in hospital 12 hours before I delivered. Yet, the
Trust still expected its midwives to be in two places at once
(on call for me at home and working the night shift in the labour
ward) . . .
I rang again at 10.15pm (my contractions were
now four minutes apart) and, by chance, spoke to my team midwife.
She was very sympathetic, but still unable to come out to me and
asked if I would consider coming in either by ambulance or car.
I called the ambulance at 10.30pm and left home at 10.50pm. Within
10 minutes, my contractions were three minutes apart and, five
minutes after that, the baby was born—on a petrol-station
forecourt in the back of an ambulance.
21. It is AIMS' view that giving birth in
the back of an ambulance is far more dangerous than either giving
birth at home or in hospital, yet increasing numbers of women
are forced into this position by the Trusts' failure to provide
an adequate home birth service.
22. In those areas that do not support home
birth women are visited by senior members of staff, supposedly
to "discuss" their decision to birth at home, but these
discussions are often an exercise in bullying, intimidation and
shroud-waving. or example:
"So Monday at midday . . . the midwife
turned up. We were told how we were playing with our child's life
and had we thought of what we would do if something went wrong,
with a few suggestions of disasters thrown in for good measure.
It was implied that we might find that when we ring up in labour
there would be no midwife available to come out to me. Also that
if there was a midwife that she would not be able to bring pain
relief (gas and air) with her and would have to ring the supervisor
and discuss the situation, and that by the time someone brings
the pain relief with them I might be wishing I was in hospital.
The health of our baby was the most mentioned" (Harrison,
2002)
Shortage of Midwives
23. There is a very serious midwifery shortage
throughout the country. One of the major causes for this is
the failure of Trusts to enable midwives to give continuity of
care and the medicalisation of birth in large, centralised, obstetric
units. Those units that have nurtured midwifery practice and encouraged
continuity of care do not have midwifery shortages (for example,
Edgware and Torbay).
24. Not only does this shortage seriously
affect women's choice of place of birth it also has a seriously
detrimental affect on midwifery education (see paragraphs 36-39).
Independent Midwives
25. Numerous letters from the Department
of Health state, "Satisfying a woman's request for a home
birth needs to be carefully balanced against the need for safe,
clinically effective and efficient services. Although the NHS
has a legal duty to provide a maternity service, there is no legal
obligation to provide a home birth to every woman who requests
one" (Yvette Cooper, pers.comm.)
26. These shrewdly phrased words allow Trusts
to refuse to supply a midwife if they judge that the woman should
be in hospital. Safety is determined by the service providers,
and the parents' views of safety are not considered. Some Trusts,
having judged that the woman was, in their opinion, "high
risk" and faced with continued requests for a home birth
will suggest the woman seeks the help of independent midwives:
"My recommendation remains that you are
cared for by the obstetric team in the hospital. The midwifery
staff do not offer expertise in abnormal deliveries (breech) and
I reiterate that I am unable to support a breech waterbirth at
home."
"With respect to your proposal, I am unable
to recommend an Independent midwife personally, however, the address
of the Independent Midwives Association is: . . ." (J. Ferry,
pers.comm.)
27. Increasingly, we see cases of Independent
Midwives attending women who are considered by their local Trust
to be "high risk" and therefore have been told that
the Trust will not "support a home birth". Those women
that could afford it have engaged independent midwives. Those
who have been unable to pay the midwives' fees have either stood
their ground and suffered months of anxiety and distress; given
up and gone into hospital; or have delivered their babies without
calling a midwife at all.
28. There is no choice at all in many areas,
and women and babies are put at unnecessary risk by the NHS's
failure to provide a comprehensive community-based midwifery service.
CAESAREAN SECTION
RATES
29. In 1985, AIMS Chair, Beverley Lawrence
Beech, took part in the WHO Inter-Regional Conference for Birth.
The delegates from Europe, and from North and South America concluded
that, `There is no justification in any specific geographic region
to have more than 10-15% caesarean section births'. The available
medical evidence suggests that caesarean rates above 10% are unnecessary
(Savage, 1997). In 1970 the caesarean section rate in the UK
was 4.5% and in 1995 it had risen to 16%. Today it is over 20%
and in some London hospitals has exceeded 30%.
Choosing a caesarean
30. The majority of women contacting AIMS
about caesarean sections are seeking help to avoid having one.
Some will have had a caesarean for their first birth and want
to avoid a repetition. Very few women indeed seek our help to
obtain a clinically unnecessary caesarean section. Of those who
do, the majority have had such a traumatic experience before that
they want to book a caesarean the next time. Most of them change
their requests once they have understood that the problems arose
as a result of the, often unnecessary, routine interventions to
which they were previously subjected.
Needing a caesarean
31. The majority of women who have had a
caesarean section could have had a different outcome had midwifery
based care been available (Saunders et al, 2000). It is
ironic then, that those women who need a caesarean, or who have
a considerable fear of birth, are unable to get one, or are put
at increased risk by delays in getting one.
32. The following letter was received by
AIMS from an independent midwife in January 2003:
"In December I needed to transfer a woman
into hospital from Brockley (King's area). She had planned a home
birth but needed medical intervention for clinical reasons. I
phoned six labour wards. King's College was closed (lack of beds);
Queen Elizabeth, Greenwich was closed and had been sending cases
to Lewisham all night; Lewisham was full; Guy's was full; St Thomas'
was two midwives down and could take no more cases although there
were two beds available; St George's had two beds but was awaiting
a case from King's and was two midwives down and could not take
my case. St John and Elizabeth and the Portland would not take
an emergency un-booked case in labour. Eventually after three
hours we managed to get into Kings where we could use our honorary
contracts to provide the midwifery care. Neither St Thomas' nor
St George's would consider issuing an honorary contract for us
to provide midwifery care where there were beds available but
no midwives. The only reason it was okay to go into King's was
because we could provide the care because they were run off their
feet too. It was extremely fortunate that this transfer was not
time sensitive. The woman ended up having a caesarean section
which I consider was completely appropriate and both she and her
baby are well."
Breech birth
33. The Hannah study (Hannah et al, 2000),
comparing vaginal breech delivery with caesarean sections for
a breech presentation, found improved outcomes for those women
and babies who had the caesarean section. As a result, we now
find increasing numbers of women contacting us appealing for help
to enable them to avoid a caesarean section.
34.The Hannah study has been extensively criticised
in the midwifery press, primarily because it failed to compare
a midwifery managed breech birth with the standard obstetrically
managed breech delivery. The skills enabling midwives to assist
a woman to birth a baby by the breech safely have largely been
lost by hospital midwives who are accustomed to following the
procedures laid down by their obstetric colleagues. However,
there are experienced midwives who have the skills and growing
numbers of midwives keen to develop these skills.
35. Even with the routine use of ultrasound
in pregnancy it is still possible for a baby to emerge by the
breech unexpectedly. It is therefore imperative that midwives
do not lose these skills.If women are to have real choice in deciding
what is best for their baby and themselves, they should be able
to have confidence that the midwife will be able to assist them.
THE PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS WHO
ADVISE PREGNANT
WOMEN AND
NEW MOTHERS
36. Over the last few years AIMS has increasingly
heard from midwives who, having completed their training, realise
that they have seen very few normal births. We believe that,
even though midwives learn the theoretical principles of normal
birth, the majority of training centres are in large, centralised,
obstetric units. Here midwives have become obstetric nurses who
follow protocols and expect labours to follow a time-limited pattern.
As a result, instead of being "with-woman" they are
"with-machine" and the midwifery skills developed over
decades have been seriously eroded and, in some cases, almost
completely lost. Midwives have not only lost their understanding
of the progression of normal birth, they have also lost their
skills in helping women cope with the pain of labour without recourse
to pharmacological drugs.
37. As a result, labours are unnecessarily
speeded up or slowed down. Pharmacological pain relief is the
initial response to a woman in pain, and caesarean sections and
other interventions have reached unacceptably high levels. Consequently,
the intensity of the psychological damage caused by childbirth
experiences in British hospitals is often severe. We see many
cases of avoidable post traumatic stress disorder (PTSD) which
have become chronic through lack of diagnosis and treatment and
we have now published a paper on this (Robinson, 2002). As
with PTSD in war veterans, we find there is a high divorce rate.
This is a serious public health problem, since it has now been
estimated that 10,000 new cases per annum are caused by childbirth.
We would remind the Committee that the last Confidential Enquiry
into Maternal Deaths (CEMD, 2001) showed that suicide is the largest
single cause of maternal death, and many of the traumatised women
who come to us are suicidal.
38. To help a woman birth normally, a midwife
needs to spend time with a woman. Labour does not proceed in
a clearly defined way: some women's labours stop and start and
some women's labours can be very quick and fierce. A woman needs
to find her own rhythm and a midwife needs to develop her skill
in assisting her to do that. How can midwives support and learn
about normal birth when they rarely see it? How can they understand
the subtleties and differences inherent in normal birth when fewer
than one in six women have that experience? It is a sad indictment
of maternity care that the majority of hospitals enthusiastically
offer epidural anaesthesia yet water pools for pain relief are
very limited. Even those hospitals which do have pools often
require women to leave the water for the birth rather than train
every midwife to be confident in delivering a baby in water.
39. Unless radical action is taken to re-evaluate
midwifery education and practice, normal birth will only be practised
by the small numbers of independent midwives and those few, brave,
midwives who are not prepared to blindly follow protocols and
hospital rules. If midwives are to regain these skills of supporting
women without drugs and unnecessary interventions, midwifery
management requires sweeping changes (see our recommendations,
para 40).
RECOMMENDATIONS
40. AIMS recommends the following action:
(a) Gather maternity statistics so that meaningful
evaluations can be carried out, particularly to establish normal
birth rates.
(b) Establish a community-based midwifery
service that is entirely separate from obstetric services.
(c) Ensure that all women are referred initially
to a midwife to enable her to receive midwifery-led care, unless
she is referred to a consultant by a midwife, or she chooses to
book consultant care only.
(d) Establish free-standing midwifery units
similar to the Edgware Birth Centre.
(e) Enable midwives to "case-load"
and work in small teams (not exceeding four FTE midwives).
(f) Ensure that all Trusts have in place
a system to engage the services of independent midwives.
(g) Ensure that all midwives are trained
to assist women who wish to birth their breech babies vaginally.
(h) Enable midwives to undertake their training
on an "apprenticeship" model thereby enabling them to
learn their midwifery from skilled, experienced, community midwives.
CONCLUSION
41. The Winterton Report in 1992 clearly
identified the problems with maternity care. The report revealed
that the medical model of care was inappropriate for the majority
of fit and healthy women and babies:
". . . we made normal birth of healthy
babies to healthy women the starting point and focus of our inquiry.
Getting this right is vital for society as a whole and has a
fundamental bearing on the quality of life of most women and their
families."
42. It is unfortunate that ten years later
maternity care is still not "right". Indeed it is far
worse than it was at that time. There is a need for a radical
change in direction. Research clearly demonstrates the benefits
of midwifery based care and continuity of carer. Instead of establishing
more small, free-standing midwifery units, the closures continue,
and the drive to centralise into larger and larger obstetric units
continues, without any evidence that this type of care is of benefit
to the majority of women and babies.
43. Midwives do not want to work in these
units and women do not want to give birth in these units, yet
any woman who tries to book into an alternative unit will be told
that she cannot do so "because you are outside our area".
These imaginary boundaries reduce women's choices and ensure that
those units offering a poor standard of care will continue to
do so because the option of "voting with one's feet"
is blocked.
February 2003
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