Select Committee on Health Written Evidence


Memorandum by the Association for Improvements in the Maternity Services (MS 19)


  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.


  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.


  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).


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.


  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.


  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.


  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).


  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.


  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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  Todman T (2002). Born in the back of an ambulance. AIMS Journal, Vol 14, No 3, p 15.

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