APPENDIX 20
Memorandum by the Royal College of Obstetricians
and Gynaecologists (MS 26)
1. INTRODUCTION
1.1 The Royal College of Obstetricians and
Gynaecologists is a registered charity (no. 213280) and is independent
of the State and the National Health Service. Most obstetricians
and gynaecologists in the UK work within the NHS, however, so
that the standards set by the College have a major influence upon
the good health, treatment and prevention of illness of women
and babies in all sections of the community. A major role of the
College is in providing postgraduate medical education, both for
those training to become specialists in the discipline and for
the continuing professional development of established specialists.
The College has over 4,000 Fellows (FRCOG) and Members (MRCOG)
working in the British Isles and approximately 4,500 working overseas.
In addition, the Faculty of Family Planning and Reproductive Health
Care, based in the College, has 10,500 members.
1.2 The College is pleased that the Health
Committee of the House of Commons has agreed to set up a Subcommittee
to inquire into the provision of maternity services. This is timely.
The National Service Framework for Children's Services will include
maternity services but there is concern among those involved in
this ongoing project that, in view of the magnitude of the task
to be undertaken, the needs of women and their babies may be insufficiently
recognised.
1.3 It is now a decade since the publication
of the report "Changing Childbirth." The College was
consulted in the work leading to this publication but reservations
were expressed about the feasibility of some of the recommendations.
1 Some of these reservations appear to have been justified in
that relatively few of the recommendations appear to have been
implemented. The College therefore considers it of great importance
that reports emanating from this Subcommittee and recommendations
arising from the National Service Framework should be firmly based
upon realistic opportunities for change.
1.4 This College is delighted to acknowledge
the harmonious working relationship which has developed with the
Royal College of Midwives. Both institutions have regular dialogues
and work closely with other agencies, including the Royal College
of Paediatrics and Child Health and consumers' organisations such
as the National Childbirth Trust. There is a genuine desire to
work together in order to improve services for mothers and babies.
1.5 This submission will first address the
areas specified in the terms of reference of the Subcommittee.
Additional information of potential interest to the Subcommittee
will then be provided. The College will be pleased to provide
further details if requested to do so and anticipates that its
representatives may be asked to attend meetings of the Subcommittee
for more detailed discussion.
2. THE COLLECTION
OF DATA
FROM MATERNITY
UNITS
2.1 Collection of maternity data in England
is currently by means of a special extension (the "maternity
tail") to the general Hospital Episode Statistics (HES),
first implemented in 1989. Over the years, data collection by
this system is generally recognised to have been seriously inadequate.
The proportion of births generating usable data was 57% in 1989-90,
78% in 1992-93 and 67% in 1994-95. There is even less certainty
about births occurring outside of NHS hospitals. In 1994-95 a
HES record was generated in about 28% of registered home births
and in an estimated 6% of births occurring in private hospitals.
2
2.2 These inadequacies are recognised by
the Department of Health and others. Two current initiatives
may help to improve the situation. The first is the allocation
of NHS numbers to babies, 3 the implementation of which is already
under way. It is important to recognise, however, that this project
will not identify stillbirths, a major contributor to perinatal
mortality, and may therefore fail to provide evidence upon which
to improve antenatal and intrapartum care. The second initiative
is the Maternity Care Data Project4 commissioned by the NHS Executive
and due to be fully implemented in 2003. The College has seen
the submission to the Subcommittee prepared by Professor Philip
Steer FRCOG, who is closely involved in this project, and notes
with concern his considerable reservations about the way that
this exercise is progressing.
2.3 It is important to recognise that these
inadequacies are not universal throughout the United Kingdom.
In Scotland data relating to all admissions to maternity units
have been collected on a simple and readily completed form (SMR02)
for more than 20 years. Secular analyses can therefore be carried
out over time so that trends in practice can be established and
relative risks assessed. Examples of the value of this exercise
are available on the website of the Scottish Perinatal and Morbidity
Review Advisory Group. 5 It is noteworthy that as part of the
information gathering associated with the National Sentinel Caesarean
Section Audit (see later) those responding were similarly asked
to complete a brief data set providing background information
about their maternity units. Data collection was of a very high
standard. This suggests that there would be few practical difficulties
in introducing in England a system comparable to that in use in
Scotland.
3. STAFFING STRUCTURES
OF MATERNITY
CARE TEAMS
3.1 Team working has been a feature of the
provision of maternity services for decades. The Royal Colleges
of Midwives and of Obstetricians and Gynaecologists have published
joint guidance on the organisation of labour wards. 6 The continuation
of team working is heavily dependent upon the recruitment and
retention of adequate numbers of midwives7 and the effective deployment
of obstetricians as well as other medical personnel. There are
many pressures restricting the availability of doctors:
— Senior doctors are less available
because limits on staff numbers preclude delegation of clinical
duties and because of non-clinical pressures on time, eg clinical
governance, appraisal and postgraduate teaching. 8
— Junior doctors are less available
because of reduced hours of working, 9 decreases in numbers of
trainees10, 11 and the provision of protected time for postgraduate
education. 12
— General practitioners are less involved
in intrapartum care. 13
— Changes in doctors' hours of work
are necessary in order to conform to the European Union Working
Time Directive. 14
— Changes in practice are changing
staffing needs, eg subspecialist feto-maternal services provided
in specialist centres.
Possible solutions to this problem have been
discussed in the recent report of the Maternity and Neonatal Workforce
Working Group. 15 This College was closely involved in the development
of that report and supports its conclusions.
3.2 In order to provide appropriate and
safe obstetric care, the College accepts that reconfiguration
of maternity services is inevitable. Indeed, it has obtained clear
evidence that this process is already well advanced. In 1999 a
questionnaire was sent to all of the Regional Advisers of the
Royal College of Obstetricians and Gynaecologists enquiring about
recent and proposed closures of consultant obstetric units. The
response rate was 100%. The results indicate that more than a
quarter of such units had closed or merged recently or were currently
under review. Furthermore, it seems likely that this process
will continue as other support is withdrawn from maternity units:
an even greater proportion of units could be affected (Box).
RESPONSES TO QUESTIONNAIRE TO RCOG REGIONAL
ADVISERS (DATA FOR THE ENTIRE UNITED KINGDOM: APPROXIMATELY 240
CONSULTANT OBSTETRIC UNITS)
| Question | No
|
| How many consultant obstetric units in your region have closed in the last five years?
| 21 |
| How many consultant units in your region are currently known to be under threat of closure?
| 28 |
| How many other consultant obstetric units are planned to merge or close in the next five years?
| 31 |
| How many consultant obstetric units currently have no resident paediatric support?
| 18 |
| How many consultant obstetric units may lose support in the next five years?
| 17 |
What was noteworthy about this exercise was the apparent
lack of strategic planning at national level underlying these
developments. Since the collection of these data, the Scottish
Executive has published A Framework for Maternity Services
in Scotland16 and, more recently, a document setting out plans
for its implementation. 17 While the details of the Scottish
scheme may not be applicable throughout the United Kingdom, the
principles underlying the development and implementation of a
strategy for maternity care are certainly worthy of scrutiny by
the Subcommittee.
3.3 It is probable that closure of consultant obstetric
units has resulted in an increase in the number of midwifery units.
There have been valuable studies on the safety, effectiveness
and popularity of midwifery units adjacent to consultant units,
where transfer is usually straightforward if problems develop.
18, 19 Transfer rates from such units into consultant units have
been reported to be of the order of 25-30% overall. There is less
certainty about the safety and effectiveness of midwifery units
when these are situated at a distance from consultant units. Evaluation
of the unit in the Royal Bournemouth Hospital suggested that only
about two-thirds of women booked for the unit actually gave birth
there and that about 9% of booked women were transferred in labour
to the consultant unit in Poole General Hospital (a journey of
nine miles). 20 There is also some uncertainty about the proportion
of women who would choose to give birth in such a unit, where
the absence of medical staff precludes the use of epidural analgesia
or rapid surgical intervention in an emergency. If insufficient
women choose to use a freestanding midwifery unit, it may become
non-viable, both for economic and for professional reasons. It
seems to the College to be essential that further research is
undertaken in this important area.
3.4 In its evidence to the Maternity and Neonatal Workforce
Working Group, the College accepted the likelihood that there
would in the future be more freestanding midwifery led units.
It suggested that for all obstetric units there should be neonatal
cover and an experienced obstetrician resident throughout 24 hours
(an experienced obstetrician would have, as a minimum, completed
two years as a specialist registrar and would have proven competencies
in obstetrics). For smaller units there would be two tiers of
cover and for tertiary centres, three tiers. Some consultants
would be resident when on call. These recommendations have been
extensively discussed at meetings of members of the College and
are widely accepted by obstetricians.
3.5 The changes in configuration of maternity services
suggested by this evidence and implicit in the College's recommendations
will necessitate the development of a more highly organised, streamlined
approach to maternity care. The College strongly recommends that
further work be carried out in order to established managed clinical
networks, making use of agreed protocols for the delivery of effective
and appropriate maternity care.
4. CAESAREAN SECTION
RATES
4.1 The National Sentinel Caesarean Section Audit21 was
the most comprehensive analysis of Caesarean Section ever undertaken.
It involved the Royal Colleges of Obstetricians and Gynaecologists,
of Midwives and of Anaesthetists as well as the National Childbirth
Trust. The audit represents a major contribution to the world
literature and provides valuable insights into clinical practice
in the United Kingdom. On the basis of the findings, anevidence-based
guideline has been commissioned by the National Institute for
Clinical Excellence and is due to be published in 2004.
4.2 The Audit was a comprehensive exercise, covering
99% of all births. Response rates for organisational surveys ranged
from 92% to 100%, for the survey of women's views was 84% and
for obstetricians' views was 77% (at least one consultant responded
from each of the participating units). The information is therefore
robust.
4.3 Adequate staffing is essential in order to provide
support for labouring mothers and to ensure appropriate decision
making by midwives and doctors. Continuous support for the mother
in labour was reported to be achieved by 93% of units on at least
60% of occasions. In contrast, only 16% of units were able to
achieve the RCOG/RCM recommended standard of 40 hours of consultant
time dedicated to the labour ward. There was evidence (still to
be published in detail) that better staffing ratios were associated
with lower caesarean section rates. Another important obstetric
staffing target was, however, met: Consultants were present in
theatre for 21% of potentially complicated caesarean sections.
The appropriate target was 10%.
4.4 Women's views were an important part of the audit.
Almost all mothers expressed a wish to have a birth that was "the
safest option for their baby". A significant proportion reported
that they would like more information on the risks and benefits
of caesarean section. 5.3% of mothers reported that they would
prefer to deliver by caesarean section. Women who had previously
had a caesarean section were more likely to express this preference.
4.5 Consultant views appeared to support maternal views
in decision-making about mode of delivery. Many consultants regarded
a caesarean section rate of 20% as being "too high".
The majority agreed that elective caesarean section was not the
safest option for the mother, although 50% thought that it was
the safest option for the baby. There was consensus that elective
caesarean section reduced the chances of faecal incontinence.
4.6 Smaller units appeared to have more difficulty in
providing one to one midwifery care. Caesarean section rates in
these units were similar to those in larger units, taking account
of case-mix.
5. TRAINING FOR
HEALTH PROFESSIONALS
WHO ADVISE
PREGNANT WOMEN
AND NEW
MOTHERS
5.1 All those providing advice about pregnancy and motherhood
must have the knowledge and experience necessary to explain the
options available, including their advantages and disadvantages.
Health professionals, in addition, should be skilled in assessing
factors specific to each woman, so that advice can be tailored
to suit individual needs. Midwifery students are trained in community
and hospital settings and therefore are more likely than medical
students to understand the advantages and problems associated
with community based care. It seems unlikely that the undergraduate
medical curriculum will be extended to provide additional experience
of community-based obstetrics. It is therefore important that
postgraduates undertaking maternity care should be adequately
trained in normal pregnancy and birth in both hospital and community
settings. Such training is likely to enhance mutual understanding
and respect and thereby facilitate seamless transfer between community
and hospital should this be needed. In order to allow women and
their families to make informed choices about care during and
after pregnancy, it is essential that all relevant health professionals
acquire appropriate communication and counselling skills.
5.2 The College was in the forefront of the development
of competency-based postgraduate training and has recently revised
its training portfolio. Considerable prominence has been given
to the assessment of communication skills, which are tested directly
in the major postgraduate examination organised by the College.
Specific skill targets during training have been set for counselling
about prenatal screening, genetic diseases and other fetal problems,
communication in an emergency and bereavement.
5.3 There would clearly be opportunities for joint training
sessions to be arranged with midwives. There is evidence to suggest
that interprofessional training can be valuable in team building
for emergency procedures but that it can be counterproductive
in other areas. It would be valuable for those responsible for
training doctors and midwives to undertake formal assessment of
interdisciplinary training programmes.
6. OTHER ISSUES
6.1 One of the most pressing issues in relation to current
maternity services in the United Kingdom is the alarmingly high
rate of maternal death associated with social deprivation. The
most recent report of the Confidential Enquiries into Maternal
Deaths22 demonstrated that 40% occurred in women of social class
9. In this group of socially excluded women the maternal mortality
rate was similar to that in economically disadvantaged countries.
There was also clear evidence that women from ethnic minorities
were at greater risk of maternal death and the importance of domestic
violence was highlighted. Health professionals need to be educated
to assess social circumstances and women identified to be at particular
risk need to be counselled about appropriate options for their
care.
6.2 A recent international audit of perinatal mortality
and suboptimal care23 suggested that suboptimal care was associated
with perinatal death more frequently in seven former NHS regions
in England than in any other of 10 European regions investigated.
There is an urgent need to determine prospectively whether this
is a true reflection of British maternity practice. If these findings
are confirmed, there needs to be a major initiative to correct
them.
6.3 The National Collaborative Centre for Women's and
Children's Health, based in the College, has an important role
in developing NICE guidelines for clinical practice. Guidelines
on electronic fetal monitoring (EFM) and induction of labour (IOL)
have already been published. Guidelines on caesarean section and
antenatal care are currently in preparation. Guidelines for intrapartum
care and postnatal care are likely to gain Ministerial approval
in the near future. There is evidence that guidelines can be effective.
Implementation of the NICE guidelines for EFM and IOL in Basingstoke
has resulted in a reported decrease in caesarean section rates
from 30% to 15%.
7. RECOMMENDATIONS
7.1 Collection of data about maternity services in England
needs urgent improvement. The applicability of the Scottish model
throughout the United Kingdom should be assessed.
7.2 A national strategy for the provision of maternity
services should be developed and consideration given to its application
systematically throughout the United Kingdom.
7.3 Managed clinical networks should be developed, with
clear protocols for the delivery of effective and appropriate
maternity and neonatal care.
7.4 The Subcommittee should endorse the development of
guidelines for caesarean section and should encourage the development
of other evidence-based guidelines relevant to maternity care.
7.5 Training programmes for midwives and obstetricians
should be based upon a common understanding of options available
and the development of agreed techniques for impartial counselling,
enabling women to make informed choices.
7.6 The Subcommittee should inquire into the effectiveness
of current maternity services, particularly in relation to the
effects of social deprivation.
8. References
1. Dunlop W. Changing Childbirth. Commentary II. British
Journal of Obstetrics and Gynaecology, 100:1072-74, 1993.
2. Department of Health. NHS Maternity Statistics, England:
1989-90 to 1994-95. Bulletin 1997/28. 1997.
3. NHS Information Authority. NHS Numbers for Babies.
http://www.nhsia.nhs.uk/nn4b/.
4. NHS Information Authority. Maternity Care Data
Project. Overview, updated June 1999. NHSIA reference no.
1999-1A-54
5. Operative vaginal delivery. http://www.show.scot.nhs.uk/isd/sexual_health/bis/births_in_scotland.htm
6. Joint Working Party of the Royal College of Obstetricians
and Gynaecologists and the Royal College of Midwives. Towards
Safer Childbirth. Minimum Standards for the Organisation of Labour
Wards. London: RCOG and RCM, 1999.
7. English National Board. Midwifery Practice: Identifying
the Development and the Difference. An Outcome Report Arising
from the Audit of Maternity Services and Practice Visits Undertaken
by Midwifery Officers of the Board 1998-99. London: English
National Board, 1999.
8. Royal College of Obstetricians and Gynaecologists.
Planning for the future as consultants in obstetrics and gynaecology.
A discussion document. London: RCOG, 1999.
9. NHS Management Executive. Junior Doctors, The New
Deal, Working Arrangements for Hospital Doctors and Dentists in
Training. London: Department of Health, 1992.
10. Shaw RW. Medical Workforce Crisis in Obstetrics
and Gynaecology (in England and Wales). An update from the President.
Royal College of Obstetricians and Gynaecologists, 1999.
11. Royal College of Paediatrics and Child Health. The
Medical Workforce in Paediatrics and Child Health. London:
RCPCH: 1998.
12. Department of Health. Hospital Doctors—Training
for the Future. The report of the working group on Specialist
Medical Training (Calman Report). London: Department of Health,
1993.
13. Royal College of General Practitioners. The role
of General Practice in Maternity Care. London. RCGP, 1995.
14. Department of Trade and Industry. Measures to implement
Directive 2000/34/EC of the European Parliament and of the Council
amending Council Directive 93/104/EC concerning certain aspects
of the organisation of working time to cover sectors and activities
excluded from that Directive. Public Consultation Document URN
02/1424. www.dti.gov.uk/er/work_time_regs/hadconsult.htm 2002.
15. Department of Health. Report to the Department of
Health Children's Taskforce from the Maternity and Neonatal Workforce
Group—January 2003. http://www.doh.gov.uk/maternitywg/report-jan03.pdf
16. NHS Scotland. A Framework for Maternity Services
in Scotland. http://www.show.scot.nhs.uk/publications. Scottish
Executive, 2001.
17. NHS Scotland. Implementing A Framework for Maternity
Services in Scotland. Overview Report of the Expert Group
on Acute Maternity Services. http://www.show.scot.nhs.uk/publications.
Scottish Executive, 2003.
18. Macvicar J, Dobbie G, Owen-Johnstone L, Jagger C,
Hopkins M, Kennedy J. Simulated home delivery in hospital: a randomised
controlled trial. British Journal of Obstetrics and Gynaecology,
100:316-323, 1993.
19. Hundley VA, Cruickshank FM, Lang GD, Glazener CM,
Milne JM, Turner M, Blyth D, Mollison J, Donaldson C. Midwife
managed delivery unit: a randomised controlled comparison with
consultant led care. British Medical Journal, 309:1400-1404,
1994.
20. Campbell R, Macfarlane AJ, Hempsall V, Hatchard K.
Evaluation of midwife-led care provided at the Royal Bournemouth
Hospital. Midwifery 1999,15:183-193.
21. Thomas J, Paranjothy S. Royal College of Obstetricians
and Gynaecologists Clinical Support Unit. National Sentinel Caesarean
Section Audit Report. RCOG Press, 2001.
22. Lewis G, Drife J. Royal College of Obstetricians
and Gynaecologists. Why Mothers Die 1997-1999. The Confidential
Enquiries into Maternal Deaths in the United Kingdom. RCOG Press,
2001.
23. Richardus JH, Graafmans WC, Verloove-Vanhorick SP,
Mackenbach JP, The Euronatal International Audit Panel, The Euronatal
Working Group. Differences in perinatal mortality and suboptimal
care between 10 European regions: results of an international
audit. BJOG,110:97-105.
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