APPENDIX 35
Memorandum by Professor Jenny Hewison
(MS 43)
This Memorandum relates to only one of the four
topics currently under investigation, namely "the staffing
structure of maternity care teams". It is submitted by Prof
Hewison in an individual capacity, but refers to the results of
a research project which she conducted, jointly with the colleagues
named below. She would be willing to give oral evidence if requested.
SUMMARY
Neither of the twin expectations that currently
underpin policy—that community based care will be midwifery
led care, and that a more woman centred service will result—are
supported by the results of a national survey of practice. The
pattern of antenatal care received by women seemed to be strongly
influenced by the type of care that a GP wished to provide. Midwives
accommodated their ways of working to high and low levels of GP
involvement. Individual childbearing women were given very little
choice—by GPs or by midwives—about the package of
care that was provided for them.
1. When the Health Committee last addressed
the topic of Maternity Care, in 1992, its report and the "Changing
Childbirth" policy document which followed called for services
to be designed around the needs of women, not the needs of the
professionals providing their care. A major reorganisation followed
in the provision of services, with a shift from hospital to community
based care. This shift was accompanied by the twin expectations
that community based care would be midwifery led care, and that
a more woman centred service would result.
2. In the recent (15.1.03) House of Lords
debate, Baroness Cumberlege reiterated the importance of women
having choices about their care, and the need for services to
be midwifery led.
3. The House of Lords debate contained no
reference to general practitioners. Midwives and GPs share much
of the care of childbearing women in the community (Audit Commission
1997), but little is known about how they work together, how their
respective roles are decided, the extent of any overlap, and what
they and childbearing women feel about the ways in which they
work together.
4. This memorandum is based upon the results
of a national survey of community maternity care, which challenge
some of the assumptions upon which the policy debate is being
conducted. The aim of the research was to describe community maternity
care from the perspective of women and of the health professionals
providing that care. The research was funded by the NHS R&D
Mother and Child Health Programme. The final report (Hewison,
Renfrew, Gregson, Young, Braunholtz, Dowswell, Hirst and Ross-McGill,
2000) has been peer reviewed, and papers submitted for publication.
This memorandum reports on the findings related to patterns of
care, and communication between GPs and midwives. The results
regarding choices for women will be the subject of a separate
memorandum.
5. The survey was conducted in 1997-98 in
a nationally representative sample of 98 general practices. Interviews
were conducted with 165 GPs, 181 midwives and 361 childbearing
women. The findings of most relevance to staffing structures are:
— GPs had high levels of involvement
in some aspects of maternity care—confirmation of pregnancy
(90%), postnatal visiting (76%), the six week postnatal check
(95%); low levels of involvement in another aspect—intrapartum
care (7% had attended a birth in the last year); and extremely
variable levels of involvement in yet another aspect—routine
antenatal care (0 to 15 plus visits).
— Higher levels of GP involvement were
not necessarily associated with higher levels of communication
with midwives. There was some evidence of the opposite pattern:
GPs who provided a lot of antenatal care themselves tended to
communicate less, not more, with the midwives attached to their
practice.
— GPs within the same practice often
worked and communicated with midwives in different ways, and patterns
of working often changed between the antenatal and postnatal periods.
— Most midwives said they worked in
teams, but a team could contain anything from two to 16 people.
— Most midwives worked with several
GPs in the study practice, and most were also attached to other
practices, where they usually worked with more than one GP.
— The antenatal care of the majority
of women could be described in terms of one of six "caretypes",
which ranged from midwife-only care (41% of the total) to GP-only
care (10%), with various combinations in between.
— No one caretype was associated with
distinctively favourable reports from women.
CONCLUSIONS AND
RECOMMENDATION
6. Community maternity care is delivered
by a diverse cast of people, interpreting their roles in a great
variety of ways. This finding is not, in itself, very surprising,
or a cause for concern. Much more unexpected was the finding that
the pattern of antenatal care received by women seemed to be strongly
influenced by the type of care that a GP wished to provide. Midwives
accommodated their ways of working to high and low levels of GP
involvement, and to high and low levels of communication with
GPs. The resulting package of care varied between practices, and
between GPs in the same practice. Crucially, individual childbearing
women were given very little choice—by GPs or by midwives—about
the package of care that was provided for them.
7. The different packages of care that could
be identified were associated with very similar outcomes in terms
of women's reports of the quality of care.
8. Neither of the twin expectations that
currently underpin policy—that community based care will
be midwifery led care, and that a more woman centred service will
result — are supported by the results of this research.
9. GPs, midwives, service commissioners,
and women, need to agree the most appropriate care and the choices
which should be offered to childbearing women.
February 2003
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