APPENDIX 19
Memorandum by Dr Christine McCourt (MS
25)
EVIDENCE FOR
SUBMISSION TO
THE ENQUIRY
Basis of submission
The CMP is a research and development centre
with an academic university base and active links with NHS maternity
services in the West London and Thames Valley area, and with consumer
organisations. The centre includes academic staff (teaching and
research) and associate practice-based staff including consultant
midwives, lecturer-practitioners, practice-development midwives
and maternity consumer representatives. We also work in collaboration
with other research, practice and education groups Nationally
and Internationally.
We have conducted large and smaller-scale research
relevant to the terms of the enquiry, as noted below.
The centre is also involved with education of
midwives at pre-registration, masters and PhD level and has conducted
educational research.
1. The staffing structure of maternity care
teams
Evidence from our research indicates that this
is an area in need of considerable attention. Key issues include:
1.1 Poor morale and motivation among midwives
working in conventional services and midwives/students planning
to leave the profession without change (Stevens, PhD; Thomas PhD).
1.2 Increased satisfaction in new models
of practice that give greater autonomy to midwives and allow greater
continuity of care and carer (Stevens & McCourt 2001-2; Stevens
PhD; McCourt & Page 1996; Beake, McCourt & Page 2001).
1.3 Widespread confusion and misunderstanding
regarding evidence on new models of midwifery practice following
Changing Childbirth. Poor definition in much research and development,
patchy and uneven development of models of staffing following
Changing Childbirth and lack of support for development (McCourt
& Page, forthcoming).
1.4 Lack of good economic research on system
costs of different models of service and staffing (Piercy, McCourt
& Page, forthcoming; Piercy PhD).
1.5 Evidence of considerable opportunity
costs in current conventional care and economic viability of alternative
models of care (Piercy 1996; Beake, McCourt & Page 2001; Piercy,
Page & McCourt, forthcoming).
1.6 Evidence of lack of communication and
trust between general practitioners and midwives, lack of involvement
of midwives in primary care trust developments but potential for
midwives to work from a more community-led base in collaboration
with other primary care professionals and agencies (McCourt &
Beake 2000; Beake and McCourt 2002).
2. Caesarean section rates
2.1 Evidence that consumer choice is not
a driver for rising caesarean section rates (Weaver, forthcoming;
McCourt 2002) or for other interventions (Gholitabar PhD).
2.2 Evidence that maternal choice and information
is severely constrained and professionally-led in the current
services McCourt 2000 & forthcoming.)
2.3 Evidence is beginning to build from
various sources that the environment, "culture" and
organisation of care have an important impact on childbirth intervention
rates.
2.4 Evidence that midwifery-led care may
reduce intervention rates (Harvey PhD; Page, McCourt et al. 2001).
3. The provision of training for health professionals
who advise pregnant women and new mothers
3.1 A number of midwifery students and new
graduates perceive a theory-practice gap in terms of disappointment
with the reality of maternity services in practice and many consider
leaving before or soon after qualifying (McCourt & Thomas
2001.
3.2 A number of students placed in London
teaching hospitals report they are unable to develop skills relevant
to supporting normal birth and have limited experience of women
giving birth without interventions such as epidural pain relief.
3.3 There is some early evidence that problem-based-learning
may be an effective approach to midwifery education, equipping
students for continuing learning and enquiring, evidence-based
approach to practice. However, this is not always supported in
practice placements (McCourt & Thomas 2001).
RECOMMENDATIONS FOR
ACTION
Research
— more research is needed into the
configuration of maternity services, alternative models of care
including inter-professional working, community-based care, caseload
practice, midwifery-led care and birth centres;
— more attention is needed to midwives'
morale and retention. Much of earlier attention has focused on
superficial issues rather than with the changing nature of the
work and its underlying conditions;
— More support is needed to develop
the evidence-base for midwifery—research since 1990 has
continued to be rather poorly co-ordinated and resourced. Much
research conducted by midwives is un-funded (and so small-scale,
though often high quality) and is not well disseminated, used
or followed up in further research.
Policy and practice
— attempts to develop services including
new configurations and models of care have been poorly funded
and co-ordinated;
— there is a need for more consistent
support at national and local levels;
— midwifery managers need the authority
to match their responsibilities;
— midwives need to be able to exercise
the level of autonomy in practice that they were prepared for
in education;
— development is needed for models
of service that will be accessible to the whole community and
that will support normal childbirth and midwifery practice;
— further attention is needed to the
role of midwifery in a primary-care-led service. The use of language
that subsumes midwifery under "nursing" has been unhelpful
in this respect since many midwives do not recognise developments
as relevant to their work as a result. There are some good models
under development that could be pursued further;
— there is good evidence that continuity
of midwifery care is not a "luxury" that cannot be afforded
but can convey tangible benefits. Therefore, service developments
should consider ways of enhancing this and facilitating midwives
wishing to work in a less fragmented service.
February 2003
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