APPENDIX 26
Memorandum by Royal College of Nursing
(MS 32)
TERMS OF
REFERENCE
The Sub-committee will examine the provision
of maternity services, and the variation in service provision,
across England. In particular the Sub-committee will consider:
— the collection of data from maternity
units;
— the staffing structure of maternity
care teams;
— caesarean section rates;
— the provision of training for health
professionals who advise pregnant women and new mothers.
The Committee will investigate how staffing
levels and training affect both the type of birth a woman is likely
to have, and health of her baby in early life.
INTRODUCTION
With a membership of over 350,000 registered
nurses, midwives, health care assistants and nursing students,
the Royal College of Nursing is the voice of nursing across the
UK and the largest professional union of nursing staff in the
world. The RCN promotes patient and nursing interests on a wide
range of issues. The RCN Midwifery Society has 1,325 active members.
THE STAFFING
STRUCTURE OF
MATERNITY CARE
TEAMS
Although steps have been taken to reduce the
vacancy rates in midwifery, the continuing shortage of midwives
impacts on the level of choice available for women. On a practical
level, women are often unlikely to know the midwife who attends
their birth and there may be several shift changes during their
labour. Midwives are finding that increased workloads due to shortages
meant that they have less time to help women with breast-feeding
and aftercare. There is scope for care assistants to help with
the workload and the skill-mix in midwifery units needs to be
reviewed.
The RCN is calling for an expansion in the provision
of midwife-led units (birth centres) and provision of home birth.
The Government has stated that women should have the choice to
give birth where they want, but this right is compromised by the
shortage of midwives. This can result in women who have planned
to have their baby at home being informed there are no midwives
available to attend and they must to go to hospital.
Some midwives serve communities where over a
hundred languages are spoken. This can present real challenges
to providing women with an efficient, high-quality service. NHS
translators are scarce and not easily accessible, and can take
two weeks to secure. This presents a problem in routine cases
and clearly is unacceptable in emergency cases and when complications
occur. Midwives sometimes have to resort to asking a family member
to translate, which is not ideal as family members are rarely
impartial and this can impact on the woman's choice. Further,
the additional time spent trying to understand women's needs without
the help of a translator impacts on already high workloads. The
RCN is calling for cheaper, faster and more accessible translation
services to be available to midwives.
CAESAREAN SECTION
RATES
In recent years there has been a marked increase
in the number of caesarean sections being performed in the UK.
In 1970 caesarean section rates in England and Wales accounted
for less than 3% of all births, but by 1997 an Audit Commission
report stated that 11-18% of all babies were delivered by caesarean
section. More recent figures show that this rate has risen to
30%.
Caesarean section is not subject to evidence-based
criteria, and does not always result in maximum health gain for
either women or babies. Although the procedure carries major benefits
for some women and children, there are also associated risks,
such as increased perinatal and maternal morbidity and mortality
due to operative injury and the complications of anaesthesia.
Post-operative recovery can also be lengthy. The Association
for Improvements in Maternity Services (AIMS) suggests that the
increased number of caesarean sections directly contributes to
the increase number of women having emergency hysterectomies after
childbirth.
There is much evidence to support the normalisation
of childbirth, and midwives seek to facilitate informed choice
for women and foster a non-intrusive, non-intervention approach
to birth for low-risk mothers and their babies. The RCN believes
that an expansion in the provision of midwife-led units—birth
centres—could help to counter the increasing medicalisation
of childbirth. Studies indicate that birth centres lead to the
following improvements for low-risk mothers:
— Higher normal delivery rates, lower
caesarean section rates
— Lower forceps and ventouse rates
— Less electronic fetal monitoring
— Fewer intravenous infusions
— Fewer vaginal examinations
— Lower incidence of shoulder dystocia
— Less difficulty establishing respiration
— Increased chance of successful breastfeeding
— Increased consumer satisfaction
— More appropriate use of midwifery
skills
— Women / families able to make own
birth decisions
— High midwifery job satisfaction
An example of a successful midwifery-led service
is the Wiltshire Primary Care Trust (WWPCT), which delivers 5,200
women a year. The maternity service is located at seven birthing
centres and at a consultant unit where women with more complicated
pregnancies deliver. These community-based birth centres are all
stand-alone facilities which are midwifery-managed with no medical
input, and they extend choice for women who meet the acceptance
criteria for birth without intervention. Midwives undertake the
antenatal care for those women booked to deliver in the birth
centres, and also for those booked to deliver in the consultant
unit. The birth centres are the first point of contact for pregnant,
labouring and postnatal women across the maternity services as
they are open 24-hours a day. All the birth centres have an attached
consultant who visits each of the birth centres for consultant
clinic on a monthly basis to prevent the women having to travel
in to the consultant unit. Should a woman wish to have a home
birth, services are provided by her local team of midwives working
out of the birth centres.
The midwives actively encourage non-pharmacological
labour care such as massage and the use of water (hydrotherapy
units are available at some of the birth centres), enabling women
to find their own ways of working through their labour in an active
and positive way. Transcutaneous Electrical Nerve Stimulation
(TENS), Pethidine and Entonox are available. Epidural anaesthesia
is not available in the birth centres, and should a woman decide
on epidural anaesthesia she must be transferred to the consultant
unit. Midwives rely on clinical judgement to determine when to
transfer a woman should she change from a low-risk to a high-risk
category. The overall transfer rate is static at 17% for intrapartum,
3% for maternal postpartum and 1% for neonatal reasons.
THE PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS
The increasing unnecessary medicalisation of childbirth
due to a false perception that this procedure is less damaging
than vaginal delivery mean that fewer midwives have the chance
to build up experience of delivering babies naturally. There is
a danger that skills will be lost, with fewer midwives having
the experience to undertake more complicated procedures confidently,
which could ultimately restrict the choices open to women[51]Hunter
(2000) describes the range of core skills required by midwives
to deliver normal births as:
— Confident to provide interpartum
care in a low-technology setting.
— Comfortable to use embodied knowledge
and skills to assess a woman and her baby as opposed to using
technology.
— Able to let labour "be"
and not interfere unnecessarily.
— Confident to avert and manage problems
that might arise.
— Willing to employ other options to
manage pain without access to epidurals.
— Responsible for outcomes without
access to on-site specialist assistance.
— Confident to trust the process of
labour and to be flexible with respect to time.
The education needs of midwives operating from
birth centres will differ from those of a midwife operating in
an obstetric maternity unit. While birth centres deal primarily
with women and babies who are healthy, the early identification
of ill or at-risk women is essential. All staff working in birth
centres must be skilled in basic life support techniques in maternal
and infant resuscitation and the management of obstetric emergencies.
In the Wiltshire Primary Care Trust, all birth centre midwives
are required to attend an Advanced Life Support in Obstetrics
(ALSO UK) course, a two-day intensive multi-professional course
using workshops and lectures.
CONCLUSIONS
— The continuing shortage of midwives
is impacting on the level of choice available to women.
— Increased workloads due to shortages
mean that midwives have less time to help women with breast-feeding
and aftercare.
— Poor provision of translation services
presents a real challenge to providing a high quality service
to women.
— The increasing rates of caesarean
sections carry associated risks of increased perinatal and maternal
morbidity.
— The increased medicalisation of childbirth
means that midwives are losing vital skills and confidence.
— An expansion in the numbers of midwife-led
birth centres would increase choice available to women.
— Studies indicate that birth centres
improve delivery for low-risk women.
50 Saunders et al, 2000; David et
al, 1999; Feldman and Hunt, 1997; Rosenblatt, Roger et al,
1997; Campbell R, 1997; Spitzer, 1995; Fullerton and Severino, 1992;
Anderson RE and Anderson DA, 1991; Albers and Katz, 1991; Rooks
et al, 1989; Kucera, 1987; Ernst 1986; Scupholme et al,
1986. Back
51 Rosser, 2001.Back
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