APPENDIX 27
Memorandum by Dr Yuk Lun Chang (MS 33)
My name is Dr Yuk Lun Chang and I have been
a Consultant Paediatrician at Mayday Hospital, in Thornton Heath,
Croydon for almost 10 years. I am writing to you to raise concerns
I have regarding the limited remit of the maternity services review
committee in that it looks solely at the maternal provision and
not at the appropriate level of care available to neonates who
may have significant medical needs even if they are born to healthy
mothers. The focus of your report is on issues of data collection,
the staffing structures of maternity care teams, caesarean section
rates, as well as provision of training for health professionals
who advise pregnant women and new mothers. I have however listed
below my concerns that are pertinent to your brief.
1. COLLECTION
OF DATA
FROM MATERNITY
UNITS
Data is collected in maternity units on all
deliveries but is limited by the accuracy in its inputting. Ideally,
a basic matched subset of data should be collected on all pregnancy
outcomes to ensure that units can be compared. There should be
a link to the data collected within each maternity unit to the
data from the neonatal unit that is attached to that maternity
unit. The BMJ article into birth outcomes over ten years ago highlighted
that data collected often contained obviously incorrect data for
even simple birth weights and gestations yet was still recorded
into the labour ward books. Reliance on data recorded and inputted
by nursing staff (and most maternity units do this) will cause
significantly aberrant data. As there is a national shortage of
midwives already and those who remain in the profession are under
huge amounts of pressure it would seem appropriate to employ clerical
staff that would most likely provide accuracy not available from
hard-pressed midwifery staff. Midwives should be providing skilled
care to both the mother, as well as the newborn baby, without
having to divert time to inputting data into a maternity system
as well.
2. THE STAFFING
STRUCTURE OF
MATERNITY CARE
TEAMS
The maternity team, at present, usually includes
a lead obstetrician, supported by a cohort of junior doctors and
a team of midwifes. The recruitment and retention issues common
to medical teams has been compounded by the effects of the European
working time directive: whereas in the past a single doctor could
be on call and work 100 hours per week, this is now being curtailed
to a maximum of 48 hours. This means that there is a need to double
the number of staff to provide the same level of service and does
not even allow for staff being less experienced because of the
fewer hours they have trained for. The Royal College of Midwifery
has already issued guidelines on the increased numbers of midwives
needed to cater to the needs of pregnant women in addition to
the already significant vacancy rate in established midwifery
posts.
3. CAESAREAN
SECTION RATES
The rise in both elective and emergency Caesarean
rates comes as no surprise to any of us particularly in respect
to the consideration given to patient choice. The popular perception
is that caesarean section will help give the baby a safer mode
of delivery, as well as protecting the woman's perineum from damage
and allowing the birth to be conveniently timed.
The rise in emergency Caesarean rates reflects
concerns regarding the risks of litigation if a vaginal delivery
is seen to be in difficulty or might be considered in hindsight
to have been managed inappropriately. If the pregnancy outcome
is not what was anticipated by the parents then there is a natural
assumption that there has been negligence and it is actionable.
It is only natural to assume that when faced with this dilemma
clinicians will choose to be highly interventional to ensure they
do not face the risk of being sued. And hence a high emergency
caesarean rate. In addition, changes in other specialities, such
as in Anaesthesia, make it increasingly difficult to have anaesthetists
with obstetric experience. It may mean that to provide a safe
emergency service one will require smaller number of larger units
to ensure the safe delivery of women. In America this pattern
is already emerging as small units close because of their inability
to pay high insurance premiums. Potentially, the mothers have
to travel greater distances to the larger Units, or do without
any form of care.
4. THE PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS WHO
ADVISE PREGNANT
WOMEN AND
NEW MOTHERS
Training for professionals can take two strands.
The medical training is enshrined within the various Royal College
guidelines. As a basic minimum, the junior SHO will have one year's
general houseman training, and may even be a GP trainee. Their
expertise in advising women would therefore be limited. Career
Doctors are becoming more difficult to recruit: we are finding
District Hospitals relying more and more on Non- career grade
Doctors. The work load then has to shift to the Consultant's instead
who will not work a 24 hours a day, seven days a week shift patterns
on a labour ward training, as well as performing the tasks. Much
of the medical work may well shift to midwives who are already
stretched and may lack the training and support they require to
take on these roles.
With an over stretched work force, it is difficult
to reconcile the training of student midwives, as well as meet
the service needs. Furthermore, all midwives should be trained,
not only in advising the mothers, but be able to provide immediate
basic emergency care to both the mother and the new born baby,
if required.
I hope my observations are of use to the committee's
work looking into Obstetrics within UK and I look forward to its
conclusions. I remain very apprehensive as to the future prospects
of an NHS maternity service and hope the committee is able to
consider the views of those working within the current system
and their commitment to improving services. It is essential that
consultation is an ongoing process to ensure that there is confidence
in the outcomes and advice provided by committees such as this.
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