APPENDIX 31
Memorandum by Mother and Infant Research
Unit, University of Leeds (MS 38)
1. MOTHER AND
INFANT RESEARCH
UNIT—BACKGROUND
INFORMATION
The Mother and Infant Research Unit (MIRU) is
a multidisciplinary research unit, established in 1996. With
the overall aim of contributing to the improvement in the health
and wellbeing of childbearing women, their babies and their families,
MIRU conducts research into public health related to reproductive
and infant health, the views and experiences of childbearing women
and their families, and the organisation of the maternity services.
MIRU has special interests in infant feeding, working with minority
ethnic groups, psycho-social aspects of prenatal testing, wellbeing
during and after birth, and evidence-based practice. MIRU staff
have backgrounds in midwifery, psychology, reproductive physiology,
public health nutrition, paediatrics, and health services research.
A wide range of research methods is used, including large randomised
controlled trials, national surveys, qualitative studies, and
systematic reviews. MIRU's work is informed by service users and
practitioners. In addition to its core funding from the School
of Medicine in the University of Leeds, MIRU receives funding
from the ESRC, the MRC, the Policy Research Programme of the Department
of Health, the NHS R&D programme (HTA, SDO), the Health Development
Agency (HDA), the Food Standards Agency (FSA), and a range of
local NHS and voluntary agencies.
2. SUMMARY OF
EVIDENCE
Evidence from our own studies, including new
and unpublished data, is submitted in respect of all aspects of
this committee's inquiry.
Data collection from maternity units is inconsistent
and incomplete, and needs to be addressed with urgency. The recent
national target to increase breastfeeding rates by 2% annually
is an example of an area where monitoring is not possible with
current systems.
Continuity of care during labour is important
and should be available to all women. The interaction between
midwifery and health visiting services, between community midwifery
and GP services, and between health and social services, needs
to be improved to ensure communication and avoid duplication of
services. Better communication needs to be established between
the health services and lay counsellors/supporters of breastfeeding
women, who are a source of expertise not used to best effect by
the NHS.
The rising caesarean section rate is probably
multifactorial in origin. Increased use of epidural anaesthesia
appears to be a major factor. New data also suggest that women
are more anxious about pain in labour than they were 15 years
ago, and that they report being more frightened, helpless and
overwhelmed, in spite of the changes set in train by "Changing
Childbirth".
Training is needed for health professionals
in specific areas, including supporting women experiencing domestic
violence, and supporting breastfeeding women, and in working across
the sectors with other staff and other agencies.
We would be willing to give oral evidence to
the Committee.
Where unpublished information is cited, we would
be pleased to provide copies for the committee if requested.
3. COLLECTION
OF DATA
FROM MATERNITY
UNITS
3.1 Incomplete and inconsistent data: The
current collection of data from maternity units is inconsistent
and incomplete. This results in a range of problems, well described
by others (Macfarlane and Mugford 2000), including a lack of knowledge
about interventions in labour, the clinical sequelae of birth,
the effects of different staffing patterns, and the costs of maternity
care. This in turn results in an inability to plan services effectively,
and for women, a lack of knowledge of the care they are likely
to encounter. It also limits the potential of research into maternity
services; comparisons with care and services outside of any specific
study cannot be easily or accurately drawn.
3.2 Infant feeding data: In our research,
we have found a particular difficulty with the collection of data
on infant feeding, resulting in a lack of knowledge across England
and Wales about rates of initiation and duration of breastfeeding,
and time of supplementation and weaning A target of a 2% increase
per year in breastfeeding for women from disadvantaged groups
has been set recently by the NHS (Department of Health, 2002).
Without a radical improvement in data collection systems, allowing
data to be linked from hospital to community, and analysed at
least at the level of postcode districts, it will not be possible
to monitor this target.
4. THE STAFFING
STRUCTURE OF
MATERNITY CARE
TEAMS
4.1 Organisation of maternity care: In 1998
we published a book called "Continuing to Care. The organization
of midwifery services in the UK: a structured review of the evidence"
(Green et al, 1998) in which we reviewed the evidence available
on the organisation of midwifery services. An earlier observational
study (Green et al, 1986, Coupland et al 1987, Green et
al 1989, Kitzinger et al 1990, Green et al 1994)
considered the implications of changes to medical staffing structures
for doctors and midwives on the labour ward. The authors' opinion
resulting from that study was that most systems are workable if
the people working within them want them to work, and, conversely,
may be unworkable otherwise. This was still considered to be a
valid observation in the review, "Continuing to Care".
The final chapters of "Continuing to Care" (pp 120-138)
provide a Discussion, Conclusions and Recommendations which we
believe are still highly relevant to the debate. Conclusions included:
4.1.1 People work more happily in a system
that they have chosen than in one that has been imposed upon them.
4.1.2 Continuity of carer is at least as
important for midwives as it is for women.
4.1.3 Attendance in labour by a known midwife
should not be the main determinant of a service; antenatal continuity
is likely to be as least as important (see also 4.2)
4.1.4 The way in which midwives are organised
within the health care service is less important to a woman than
the quality of the interactions that she has with her caregivers.
4.1.5 The book raised concerns about the
sustainability of some schemes because of the demands that they
placed on midwives. Evidence that has been published subsequently
suggests that "caseload" schemes (where each midwife
is responsible for specific women) are more successful than "team"
schemes (where a group are collectively responsible).
4.2 Continuity of care and carer: much reorganisation
of maternity services has been undertaken with the goal of increasing
"continuity". However, this term can have many different
meanings and the literature on what aspects of continuity matter
to women has rarely been consulted (Green et al 2000).
This literature suggests, as summarised above, that being cared
for in labour by a known midwife is relatively unimportant. In
contrast, continuity during labour is important, indeed evidence
suggests that the single most effective intervention in labour
to avoid instrumental births, increase breastfeeding duration,
and enhance women's self confidence, is having a consistent caregiver
present during labour (Hodnett 2002). This is not the norm for
women in the UK, and should be made a priority in the maternity
services. If it is not possible to provide women with such care
from trained midwives, doula support (lay support) under the supervision
of trained midwives, should be considered/evaluated.
4.2.1 Our recently completed and, as yet,
unpublished, survey of women's expectations and experiences of
birth in 2000 records a slight decrease in the proportion of women
cared for in labour by a midwife that they had met before compared
to our earlier survey in 1987 and no change in the proportion
having one midwife throughout labour (75% of multiparous women
and 50% of primiparous).
4.3 Interaction between midwifery and health
visiting services: Additional evidence comes from our recently
completed study funded by the NHS R&D programme entitled "Detection
of fetal abnormality at different gestations: impact on parents
and service implications". Two reports have been produced
from this study (Statham et al 2001, 2002), one reporting
the experiences of parents who had a fetal abnormality detected
and the other the experiences of healthcare professionals
4.3.1 The accounts of parents draw attention
to a number of instances where their needs were not met as a result
of the way in which local midwifery services were organised.
4.3.2 The accounts of health visitors, community
midwives and GPs draw attention to major gaps in communication
between primary and tertiary services (Statham et al, in
press). Where a specialist screening co-ordinator is in post,
this appears to improve communication.
4.3.3 The working relationships between
health visitors and midwives are in need of further examination.
Current arrangements appear frequently to be characterised by
tension and a lack of clarity between the two professional groups
to the detriment of women and babies (eg Statham et al
2002).
4.4 Community based maternity care; interaction
between midwifery and GP services: Another issue that arose in
our study of community-based maternity care, funded by the NHS
R&D programme (Hewison et al 2000), concerns the variation
in the division of labour between community midwives and GPs,
when providing community-based care. Antenatal care at present
can be provided almost entirely by GPs, or almost entirely by
midwives, or divided in some way between them. The way in which
care is organised seems to be decided by the GP, rather than by
the woman herself, or by the midwife. There appears to be no advantage
in terms of clinical outcomes to any particular system of care.
Our view is that all women should as a routine be offered community-based
maternity care from their midwife, with additional care from their
GP if they wish. This would enhance women's choice, and at the
same time, reduce over-provision of more expensive care by GPs.
4.5 Breastfeeding support services: Our
work on breastfeeding support has found that: 1) peer (lay) support,
and small informal groups led by health professionals in pregnancy,
can increase the initiation rate of breastfeeding, especially
among women from disadvantaged groups, and 2) both peer (lay)
and professional support are effective in increasing the duration
of breastfeeding in all social class groups (Fairbank et al
2000, Renfrew et al 2000, Sikorski et al 2002, Protheroe
et al in press). The problem is, however, that there is
little integration of peer support with mainstream health service
work. Often, there is tension between these groups. Encouraging
the integration of peer support services into health service care
could address this problem.
4.6 Integrating health and social services:
The same problem of lack of integration of services occurs across
the health and social care divide; this is a problem we have encountered
in a number of our studies. There are examples of successful Sure
Start schemes across the country, but work is needed to ensure
a consistent approach between their staff and health professionals.
5. CAESAREAN
SECTION
5.1 Rising caesarean section rates: The
recent sentinel audit identified the rising rate of Caesarean
Section (CS) in the UK, with a national rate of CS of 21.3% (RCOG
Clinical Effectiveness Support Unit 2001). Whilst this issue
has received significant attention from both professionals and
representatives of service users, the rising rate will continue
to impact on service requirements due to higher levels of maternal
morbidity associated with this procedure (Savage 2002). The suggestion
that women are contributing to the increase by requesting CS in
the absence of obstetric indications may, in fact, be over-stated
and reflect instead a lack of appropriate information.
5.2 We have recently completed a survey
of women's expectations and experiences of intrapartum care (Green
et al, in preparation) based on a similar survey carried
out in 1987 (Green et al, 1988, 2nd edition 1998). Among
the changes observed over this time were major increases in all
forms of assisted delivery, especially for first-time mothers,
as shown in the following tables. Note that increases in planned
caesareans are not matched by decreases in unplanned caesareans
or instrumental deliveries.
First-time mothers
| Year of study: |
1987 | 2000 |
| n=277 | n=543
|
| % | % |
| Planned caesarean section | 2
| 7 |
| Unplanned caesarean section | 6
| 19 |
| Instrumental delivery | 18 |
23 |
| Unassisted vaginal delivery | 74
| 51 |
Women who had had a baby before
| Year of study | 1987
| 2000 |
| n=431 | n=735
|
| % | % |
| Planned caesarean section | 5
| 10 |
| Unplanned caesarean section | 4
| 6 |
| Instrumental delivery | 4 |
4 |
| Unassisted vaginal delivery | 88
| 79 |
5.2.1 The increase in unplanned caesarean sections and
instrumental delivery is paralleled by a large increase in epidural
use: 38% used an epidural in labour (59% of primiparous women,
22% of multiparous women). This represents a fourfold increase
over the 1987 data where only 9% of women used epidurals (19%
of primiparous women and 4% of multiparous women).
5.2.2 Other studies have drawn attention to higher rates
of obstetric intervention for women who have epidurals. These
are supported by our data. Women who had epidurals were six times
more likely to have an instrumental delivery (multips 17.7% vs.
2.0%, primips 45.8% vs. 15.5%) and six times more likely to have
a caesarean section (multips 17.4% vs. 1.8%, primips 26.0% vs.
7.0%). Overall, only 50.2% of women who had an epidural had an
unassisted vaginal delivery compared with 91.0% of those who did
not (multips 67.6% vs. 96.2%, primips 41.3% vs. 78.1%).
5.2.3 The study also found an increase in induction of
labour from 16% in 1987 to 23% in 2000, despite the rise in planned
caesarean sections. Induction of labour is associated both with
epidural use and with unplanned caesarean section. Only 63% of
women who were induced had an unassisted vaginal delivery compared
with 78% of those not induced.
5.2.4 Overall in this study, there was an increase from
1987 to 2000 in the report of negative emotions during labour
such as being frightened, helpless and overwhelmed and a decrease
in positive feelings such as being confident and involved. Antenatal
data also suggest that women are more anxious about pain than
they were in 1987.
5.2.5 In both 1987 and 2000, women who had a vaginal
birth were more satisfied than women who gave birth by CS. For
women of all parities, those who gave birth by unplanned CS were
less likely to have immediate close contact with their baby; this
may well have long-term implications, including a detrimental
effect on breastfeeding. Women were more likely to be breastfeeding
at 6 weeks if they had had an unassisted vaginal delivery (54%
cf 39% of those who had an unplanned CS).
6. PROVISION OF
TRAINING FOR
HEALTH PROFESSIONALS
WHO ADVISE
PREGNANT WOMEN
AND NEW
MOTHERS
6.1 Training for supporting women who have experienced
domestic violence: The preparation of midwives for the public
health components of their role such as supporting women experiencing
domestic violence has, until recently, been achieved through attendance
at single study days and conferences. We were commissioned to
evaluate a short course for midwives provided by Leeds Inter-Agency
project. Our evaluation addressed midwives' experiences of putting
this training into practice and identified areas of concern for
midwives in both the professional and personal arenas. Midwives
felt better prepared to support women, had tools to help them
and were better informed about other agencies. We found that there
were areas where midwives required more training and guidance;
midwives had concerns about personal safety and needed mechanisms
for updating and continuing support (Protheroe, Green and Spiby
2001). This research was not, however, able to evaluate impact
on the experiences of women receiving care from midwives who had
been through the training programme. There is an urgent need for
research in this area.
6.2 Training for promoting and supporting breastfeeding:
Our recent study of the training needs of health professionals
and other workers who may come into contact with breastfeeding
women indicated that they (midwives, health visitors, paediatricians
and general practitioners) feel poorly prepared for this role
(Smale, Renfrew and Spiby, in preparation). The impacts of this
are well-known and include negative attitudes towards breastfeeding,
conflicting advice, lack of appropriate support and a lack of
skills, for example, in facilitating discussion of this with women
and their families. Breastfeeding appears poorly integrated into
education programmes and usually follows a medical rather than
societal approach. Whilst use of evidence is increasing, it does
not occur in all settings. The model often encountered by respondents
was that of `giving advice' with little attention to listening,
counselling or small-group skills.
6.2.1 The systematic and structured reviews conducted
by our group identified interventions that are effective in promoting
and sustaining breastfeeding (Fairbank et al 2000, Renfrew et
al 2000, Sikorski et al 2002). However, there is little
known about whether the information from these reviews is applied
in practice or that health professionals who wish to apply them
have appropriate support.
6.2.2 There has also been the belief that breastfeeding
and related education should be the preserve of health professionals.
The extensive and highly trained networks of voluntary breastfeeding
counsellors and supporters (such as through the National Childbirth
Trust and the Breastfeeding Network) have not been accessed to
best effect and alternative approaches to supporting women's breastfeeding
include an increased use of consumer-focused approaches such as
peer support (Stapleton et al 2001). Our alternative approach,
the Consumer-Practitioner in breastfeeding (a project funded by
the Department of Health) has aimed to do that by using experienced
breastfeeding counsellors to work with women and their families
and also to contribute to the education of a range of healthcare
professionals and other workers. An independent evaluation identified
the need for such an approach as being appropriate, providing
evidence-based information and being useful to health professionals
and a range of healthcare and other workers. A report to the funders
will be completed by end March 2003.
7. OTHER ISSUES
We note that there is much interest nationally in the maternity
services at present. There has been a recent House of Lords debate,
as well as this enquiry by the Health Committee. Further, the
National Service Framework for Child Health will be making recommendations
for maternity care, which will have a major impact on policy and
practice. It is not clear if these national initiatives are connected,
or whether there is a risk of mixed, potentially conflicting,
messages being given from several influential sources in the same
time period.
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