APPENDIX 34
Memorandum by the Royal College of Midwives
(MS 42)
The Royal College of Midwives represents over
95% of the UK's practising midwives, with over 35,000 members.
It is the world's oldest and largest midwifery organisation. It
works to advance the interests of midwives and the midwifery profession
and, by doing so, enhances the well-being of women, babies and
families.
This is our submission to the sub-committee's
inquiry into the provision of maternity services. As requested
in the Terms of Reference, issued through a Press Notice dated
13 January 2003, this submission concentrates on the following
areas:
— the collection of data from maternity
units;
— the staffing structure of maternity
care teams;
— caesarean section rates; and
— the provision of training for health
professionals who advise pregnant women and new mothers.
1. THE COLLECTION
OF DATA
FROM MATERNITY
UNITS
1.1 Comprehensive data needs to be collected
from maternity units because it is only with such data that the
delivery of maternity services can be properly and accurately
assessed.
1.2 This is not being achieved at present,
with statistics from the latest Statistical Bulletin on maternity[52]covering
only 67% of hospital deliveries and 12% of home deliveries. Between
1989-90 and 2000-01, these rates fluctuated between 53% and 78%
for hospital deliveries and 11% and 29% for home deliveries. Even
the most successful of these rates—78% and 29%—is not
enough, and more importantly the rate is simply fluctuating rather
than improving. Indeed, the Government Statistical Service, which
prepared the latest statistics, conceded that the submission of
data "has continued to pose substantial problems for the
NHS."
1.3 For a three-month period in 2000,
data was collected on 99% of births in England, Wales and Northern
Ireland for the National Sentinel Caesarean Section Audit[53]This
shows that the comprehensive collection of maternity data is feasible.
1.4 The Department of Health needs to look
at both the collection, and agreed data set, and accessibility
of maternity statistics: at how the information is collected by
health professionals; and at how it is collated centrally. Equipping
decision-makers with reliable, easily accessible data with which
they can feel confident, will enable them to make a more informed
and accurate assessment of the delivery of maternity services.
This is also a key quality indicator and at present there is
no baseline information from which information can be drawn or
benchmarks established.
1.5 Changing data collection systems
to capture information about normality as well as about pathology
may be catalytic in changing the focus of debate in maternity
care. This is an issue the committee may wish to consider, with
an awareness of the UK and European projects which are also underway
in this area[54]
1.6 The Department of Health may also find
it useful to review the Practice Setting Audits undertaken by
the Local Supervising Authority Officers and English National
Board. Both of these give insight and statistics not only on birth
outcomes but on a range of other issues.
2. THE STAFFING
STRUCTURE OF
MATERNITY CARE
TEAMS
2.1 For the majority of women, birth
can be a normal physiological process. Whilst facilities for intervention
must of course be available if required, there is a need, as stated
by Health Minister Lord Hunt of Kings Heath, for "promotion
of normal pregnancies and births without unnecessary intervention."
[55]
2.2 This should be reflected in the structure
of maternity care teams. The role of the midwife within the multidisciplinary
health care team is to support, advise and encourage women through
the normal processes of childbirth, preferably through dedicated
one-to-one care, as researched and described by Page and McCourt
(1996) and the RCM's Position Paper 26 on "The Role of the
Midwife", together with its accompanying Guidance Paper[56]
2.3 The Government shares this view of
the importance of the midwife in delivering maternity care. The
Secretary of State himself, speaking to the RCM Annual Conference
in May 2001, said: "Choice for women cannot be there when
there are shortages of midwives in too many parts of our country."
He went on to state: "Just 70% of maternity units are able
to offer women one-to-one continuous support during labour, this
should be 100%. The gold standard should be that every woman will
have access to a dedicated midwife when in established labour
100% of this time." [57]
2.4 More recently, in a debate on maternity
services in the House of Lords on 15 January 2003, Health Minister
Lord Hunt of Kings Heath told peers: "A number of noble Lords,
including the noble Lord, Lord Patel, asked about one-to-one care
by midwives. We have already said that that is our aim. The gold
standard should be that every woman has access to one-to-one care."
[58]In the same
speech, the Minister accepted that the percentage of units unable
to provide one-to-one care was 22%[59]which
is nearly a quarter of all units.
2.5 But there is a shortage of midwives
and this shortage is widespread. The 2002 RCM's Annual Staffing
Survey of senior midwifery managers[60]revealed
that: overall and long-term vacancy rates are the highest we have
ever recorded (the survey has been carried out since 1996), with
more units than ever before carrying unfilled posts; vacancy rates
have increased in every region of England with the exception of
London, where vacancies remain at a critically high level; and
vacancies remaining unfilled for three months or longer accounted
for 59% of all vacancies in England.
2.6 According to the latest annual statistics
from the Nursing and Midwifery Council (NMC) [61]published
in November 2002, the number of practising midwives fell in the
12 months to March 2002. There were 33,165 practising midwives
on 31 March 2002 (20% of whom were aged over 50), compared with
33,291 a year earlier and 35,127 in 1994.
2.7 Where there are shortages, of course,
midwives often have to cope with more than one delivery taking
place at the same time within a maternity unit. In this context,
it is not surprising that one-to-one midwifery care—the
"gold standard" as the Government itself refers to it—is
not being achieved.
2.8 More midwives are needed. Lord Hunt,
in last month's House of Lords debate, stated that "unless
we have enough midwives we are not going to get very far."
[62]He went on
to comment that: "The issue of one-to-one midwifery is tied
up with the recruitment of more midwives into the National Health
Service." [63]Returning
to the 2001 speech by the Secretary of State, he spelt it out
even more clearly: "We need to increase the number of midwives
and make midwifery a more rewarding career."
2.9 And the Government has targets to
improve the situation: 500 more midwives by the end of 2002; and
an extra 2,000 by the end of 2005[64]Looking
at the NMC statistics above however shows that the number of practising
midwives on their register is actually falling. The RCM is mindful
of the need to assist the Government to achieve its targets and
has recently developed a "Return to Midwifery Practice"
distance learning programme in collaboration with the Department
and the Open University. The RCM is collaborating with the Department
of Health, Workforce Confederations and NHS trusts to ensure the
successful implementation of the programme by June 2003.
2.10 But important also is why so many midwives
that the NHS does employ are leaving and thereby creating a shortage.
Research on why midwives leave their profession has been conducted
by Professor Mavis Kirkham of the University of Sheffield. Her
work involved 2,325 midwives who notified their intention to practice
in 1999 but did not do so the following year in 2000. This research
shows how presently midwifery can be for many a career that they
do not find rewarding.
2.11 A significant factor in Professor Kirkham's
research as to why midwives, and especially younger and more recently
qualified midwives, leave painted a depressing picture of women
frustrated at the difference between what their midwifery education
had prepared them to expect and what they found in practice. For
example, the requirement to rotate through all shifts and around
all areas of practice made it difficult to build and maintain
confidence and expertise and to develop and sustain relationships
with colleagues and clients.
2.12 Maternity units need to reassess their
staffing needs at a fundamental level, not least to reduce the
number of midwives leaving. Vacancy rates are currently calculated
against each maternity unit's funded midwifery establishment,
which is worked out not on the basis of what level of staffing
is required to offer the best care to the mother and newborn child,
but instead by how much money is available. To illustrate how
the current NHS system may underestimate the actual staffing needs
of maternity units, it is revealing that 71% of Heads of Midwifery,
in our latest Annual Staffing Survey, expressed dissatisfaction
with the level of their funded midwifery establishment.
2.13 The RCM and the DoH support the use
of "Birthrate Plus", which is a midwifery-specific planning
tool that places the emphasis on organising maternity care around
the needs of the woman during the antenatal, labour, birth and
postnatal periods.
2.14 Lord Hunt supports this viewpoint.
He told peers in the above debate on maternity services: "As
regards the question raised by the noble Baroness, Lady Noakes,
that funding establishments are too few, we are supporting the
use of what is described as Birthrate Plus, which is an excellent
workforce planning tool. Many Trusts are now using it. I hope
that that will lead them to a more realistic assessment of the
number of midwives required." [65]We
support the Minister and would like to see Birthrate Plus used
as standard in all maternity units.
2.15 With regard to the future, the RCM
published "Vision 2000" in that year, which set out
our vision for maternity services. It describes a service that
provides high quality, evidence-based, cost-effective maternity
care, which is responsive to individual needs and preferences,
and which promotes and sustains public health. Achieving the vision
is dependent on the successful implementation of 12 key principles:
a service which listens to women; a focus on public health; community
orientation; integration across acute and community sectors; normality;
midwifery-led care; maximised and targeted continuity of carer;
dedicated one-to-one midwifery care in labour; family-centred
care; clinical excellence; midwifery leadership; and partnership.
2.16 The RCM has also published toolkits
designed to assist midwives implement "Vision 2000",
whatever the model of care being delivered: whether working in
the acute setting, primary care, autonomous practice or birth
centres.
2.17 Midwives are the linchpin to delivering
this vision of maternity services. They provide care to all pregnant
women and are present at all births, conducting two-thirds of
all deliveries, including virtually all of those which are spontaneous[66]
2.18 But more than that, midwifery practice
is rooted in public health, and for most of its history has been
community-oriented. Yet the shift of management and service delivery
into the acute sector has obscured midwifery's community focus
and inhibited its contribution to the wider public health. It
is important that midwives recognise the substantial contribution
they already make to public health, working to promote the long-term
well-being of women, their babies and their families. The RCM
believes that midwifery practice offers a significant contribution
to public health, and that this contribution should be developed
and resourced[67]
2.19 The main concern with regard to the
present provision of maternity services is the shortage of midwives
and the patterns of service provision, and the resultant effect
that is having on the quality of service the NHS is able to offer
women. The Secretary of State is correct: we need to increase
the number of midwives and make midwifery a more rewarding career.
3. CAESAREAN SECTION
RATES
3.1 The caesarean section (CS) rate in
England is rising rapidly. More than one-fifth (21.5%) of births
in England in 2000-01 were by CS[68]which
was higher than ever before. The rate was fairly stable during
the 1980s (increasing only marginally from 9% in 1980 to 11.3%
in 1989-90), but has risen rapidly in recent years. In the last
10 years for which figures are available (up to 2000-01), it increased
from 12.4% to 21.5%.
3.2 A CS operation is more costly than
a spontaneous vaginal birth. The Audit Commission, in its 1997
report, First Class Delivery: Improving Maternity Services
in England and Wales, stated: "High levels of medical
intervention are also of concern because of their cost to the
NHS ... Estimates by Clark (1991) suggest that a caesarean section
costs £760 more than a vaginal delivery, so every 1% increase
in the rate of caesarean section costs the NHS over £5 million
per annum." [69]3.3 A
CS operation carries health implications for the mother[70]In
the short term, these include the risk of operative injury and
complications of anaesthesia. Recovery can be slow after the operation,
which makes it difficult both to care for a newborn baby and to
start breastfeeding, with all the long-term health benefits that
can bring. In the longer term, the operation can also lead to
a reduction in fertility.
3.4 CS rates can differ greatly between
hospitals be as high as 30% in some hospitals, such as St Mary's
Hospital, Paddington. The reason for this is unclear but may be
largely based upon how each hospital configures its maternity
services. An example of how neighbouring NHS Trusts can have different
CS rates can be made by comparing Royal Shrewsbury Hospital NHS
Trust with North Staffordshire Hospital NHS Trust[71]
3.5 At 10% in 2000-01, the CS rate at the
Royal Shrewsbury Hospital NHS Trust is comparatively low, and
indeed lower than the preceding two years. This is the result
of a long-term strategy of promoting normality in childbirth,
which is an approach the RCM would support. In this Trust, a quarter
of births take place at home or in low-risk midwife-led units.
Mothers with babies in the breech position or who have previously
had a CS delivery, where some hospitals would opt for a CS, the
Royal Shrewsbury provide women with the opportunity to achieve
vaginal births. This approach—where pregnancy and birth
is treated as a normal physiological process in which medical
intervention is unnecessary unless there are clear indications
otherwise—results in a comparatively low CS rate.
3.6 In the neighbouring North Staffordshire
Hospital NHS Trust, however, the CS rate was 24% in 2000-01, which
had increased from 19% two years earlier Although the Trust is
concerned at its overall CS rate, normality in childbirth is not
actively promoted as at the Royal Shrewsbury Hospital NHS Trust.
The Audit Commission report (1997) concluded that while all professionals
involved in the provision of maternity care are unanimous that
the wellbeing of mother and baby is paramount, there are differences
of opinion as to how this can be best achieved and the high level
of some procedures suggested that it is local policies rather
than professional judgement that explain the frequency of some
interventions.
3.7 Another example of promoting normality
can be drawn from the RCM's centenary awards, held in the House
of Commons in December 2002. The winners of the award for working
in partnership with mothers were a team of Stoke-on-Trent midwives
for their community-based approach to providing a woman-centred,
non-interventionist service for low-risk women, focusing on normal
childbirth. This is exactly the kind of approach that needs to
be championed.
3.8 Internationally, CS rates vary but
they are not rising in every country to the extent they are in
England. OECD statistics[72]show
that the CS rate in Norway remained relatively unchanged between
1985 (12.0%) and 1998 (13.7%), the latest year for which figures
are given. In Sweden, the figure has risen slightly in the 14
years between 1985 (12.1%) and 1999 (14.4%), the latest year for
which figures are given for that country. The figure for England
doubled during that same period.
3.9 The caesarean section (CS) rate in England
is rising significantly. This is unwelcome as a CS operation is
more costly than a spontaneous vaginal birth as well as carrying
physical and psychological health implications for the mother.
And different CS rates between hospitals combined with the fact
that there are other European countries where this steeply rising
rate is not replicated suggests that a rising CS rate is unnecessary
as well as unwelcome.
4. THE PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS WHO
ADVISE PREGNANT
WOMEN AND
NEW MOTHERS
4.1 A midwife is usually the first and main
contact for the expectant mother during her pregnancy, and throughout
labour and the postnatal period. A midwife is the key health professional
in the provision of maternity services.
4.2 An individual can enter the midwifery
profession by undertaking an approved midwifery education programme
leading to a midwifery qualification. Midwifery courses can
be accessed as a direct entry route or following previous nursing
qualification. Both are offered at diploma and degree level,
however funding for diploma, degree and students holding a nursing
qualification is different and causes severe tensions. This is
particularly so as the outcome for both is midwifery qualification
and registration on Part 10 of the NMC register
4.3 Student midwives, over and above other
students, struggle to make ends meet and to fit in study commitments.
The profile of student midwives is different from that of other
students as a whole. The majority are now women over 25 with financial
commitments, and many have dependent children. Set against the
financial hardship, students feel further compromised in clinical
settings due to the shortage of midwives and prevalence of the
biophysical model of care. There are also issues around recruitment
to degree programmes due to different bursary rates, student preferring
to opt for diploma course instead of degree programme this has
implications for profession and modernising of maternity services.
Indeed, the RCM is gathering evidence to inform a possible Student
Hardship Campaign.
4.4 In a profession that is struggling to
recruit and retain skilled professional staff, additional government
help to support students through their training is essential.
A number of student midwives are forced to leave because of financial
hardship and childcare problems and are lost to the profession
forever.
4.5 This situation is not reversed after
graduation. A newly-qualified midwife can expect to earn a starting
salary of between just over £17,000 and just under £19,000,
whereas graduate starting salaries in the private sector can be
up to £37,000, according to the Association of Graduate Recruiters[73]
4.6 Put this against a background of acute
shortages of midwives throughout England and it becomes clear
something needs to be done to support student midwives through
their studies to ensure that more make it into practice to help
deliver the modernisation agenda and shape maternity services
that is truly women centred.
February 2003
The national Sentinel Caesarean Section Audit Report. RCOG Clinical
Effectiveness Support Unit. 2001.
52 NHS Maternity Statistics, England:
1998-99 to 2000-01. Department of Health. April 2002. Back
53 The national Sentinel Caesarean Section Audit Report.
RCOG Clinical Effectiveness Support Unit. 2001. Back
54 Reference (BJOG and International Journal of Obstetrics and
Gyanecology February 2003, Vol 110, pp 97-105), Richardus J et
al, The EuroBatal Working group. Back
55 House of Lords Hansard, 15 January 2003, column 298. Back
56 Accessible in the "Informaton centre" of www.rcm.org.uk Back
57 Department of Health News release 2001/0212, Milburn announces
£100 million boost for maternity units and 2,000 extra midwives
by 2005, 2nd May 2001, accessible through www.gnn.gov.uk Back
58 House of Lords Hansard, 15th January
2003, column 296. Back
59 ibid. Back
60 Information contained in "Evidence to the Review Body
for Nursing Staff, Midwives, Health Visitors and Professions Allied
to Medicine for 2003". The Royal College of Midwives. 2002. Back
61 "Statistical Analysis of the register: 1 April 2001
to 31 March 2002". The Nursing and midwifery Council. 18th
November 2002. Accessible through www.nmc-uk.org Back
62 House of Lords Hansard, 15th January 2003, column
296. Back
63 House of Lords Hansard, 15th January 2003, column
297. Back
64 Department of Health news release 2001/0212, Milburn announces
£100 million boost for maternity units and 2,000 extra midwives
by 2005, 2nd May 2001, accessible through www.gnn.gov.uk Back
65 House of Lords Hansard, 15th January 2003, column
297. Back
66 Paragraph 2.8.1, NHS Maternity Statistics, England: 1999-99
to 2000-01. Department of Health. April 2002. Back
67 RCM Position Paper 24: The midwife's role in public health.
June 2001.
Back
68 Statistical information on CS rates is taken from ibid. Back
69 Paragraph 97 of First Class Delivery: Improving Maternity
Services in England and Wales. Audit Commission. 1997 Back
70 ibid and Postnote Number 184: Caesarean Sections.
Parliamentary Office of Science and Technology. October 2002. Back
71 Information for this example is taken from Postnote Number
184: Caesarean Sections. Parliamentary Office of Science and Technology.
October 2002. Back
72 OECD Health Data 2002, accessible via www.oecd.org Back
73 "July 2002 Graduate Salaries and Vacancies Half-Yearly
Review", Association of Graduate Recruiters, as reported
on prospects.ac.uk (the UK's official graduate careers website)
Back
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