APPENDIX 38
Memorandum by The National Childbirth
Trust (MS 47)
CONTENTS
1. Introduction
2. Data collection
3. Lack of a framework for maternity services
planning and staffing
4. Staffing levels within matenity and neonatal
services and the impact on women
4.2 The European Working Time Directive (EWTD)
4.3 Staffing levels and the type of birth
a woman is likely to have
4.4 Impact on home births
4.5 Paediatric cover and the effect on maternity
services
4.6 Networks of obstetric and midwife-led
units working together
5. Training of staff working with pregnant
women and new parents
5.1 Trainee midwives on-going training of
qualified midwives
5.3 Training in breastfeeding support
5.4 Labour and birth in water
6. Health of the baby
7. References
The Committee will investigate how staffing
levels and training affect both the type of birth a woman is likely
to have and the health of her baby in early life.
1. INTRODUCTION
The National Childbirth Trust (NCT) is the leading
UK-wide charity offering information and support in pregnancy,
childbirth and early parenthood. Every year the NCT is in contact
with 600,000 parents and parents-to-be, through our helplines,
interactive website, support networks, antenatal classes, and
local and national events. We have 48,000 members, 330 branches,
and 1,500 trained workers including antenatal teachers, breastfeeding
counsellors and postnatal leaders. We campaign for improvements
to maternity services and care in the four countries of the UK.
The NCT aims for all parents to have an experience of pregnancy,
birth and early parenthood which enriches their lives and gives
them confidence in being a parent.
Key areas of evidence for the Sub-Committee.
2. DATA COLLECTION
Collection of statistics within the maternity services
in England is poor, preventing the possibility of complete and
reliable audit of health outcomes, preventing comparisons between
services, and making it impossible to monitor changing trends.
It is not possible therefore to gauge the quality of services
or where attention is most needed to reduce inequalities in health
and improve public health.
Data for only 67% of all hospital births were
available for 2000-01, a small improvement on 60% of births for
1997-98 (latest NHS Maternity Statistics (2000-01). In the same
periods, collection of home birth data increased only slightly
from 11% to 12%. Therefore there were no pooled data for 7/8 home
births in England. The Department of Health statistician advises
that "submission of the [maternity] data tail has continued
to pose substantial problems for the NHS".1
International audit suggests that sub-optimal
care makes a significant contributor to perinatal mortality, and
that England compares unfavourably with other European countries.
2 It is important that a complete set of statistics is available
so monitoring is possible and action can be taken to reduce unsatisfactory
care.
As regards breastfeeding, several of the Department
of Health funded projects cannot tell how effective they have
been as there is no baseline data on baby feeding. It is essential
that a standardised method is agreed as definitions of breastfeeding
(exclusive, full, partial, etc) vary widely. With the new Department
target for increasing breastfeeding initiation by 2% annually
until 2006, it is vital that a comprehensive data collection system
is started straight away, with feeding patterns looked at until
at least a year from birth.
There is a demand from both users and health
providers for better maternity information. A comprehensive system
of data collection has been running in Scotland for many years
but no such system exists in England. The administrative task
of entering maternity data on to computer need not be a midwifery
task; it could be carried out by a data entry clerk.
3. LACK OF
A FRAMEWORK
FOR MATERNITY
SERVICES PLANNING
AND STAFFING
The Government published the report of the Maternity
and Neonatal Workforce Group in January 2003, 3 but it is an interim
document and does not set out Government policy on the development
of maternity services in terms of policy objectives and the pressing
constraints faced by the NHS, most notably midwifery, nursing,
obstetric and neonatal staff shortages. The document does, however,
say "Current patterns of working and service provision, based
on currently forecast level of supply, are not sustainable".
Without central guidance about the configuration of primary, secondary
and tertiary level maternity and neonatal services and staffing,
increasing numbers of units, both small and medium sized, continue
to be closed or reconfigured. These changes are taking place without
clear evidence of benefit, either in terms of safety or cost,
and without consistent objectives incorporated into the planning
stages, or sufficient monitoring of the effects.
4. STAFFING LEVELS
WITHIN MATERNITY
AND NEONATAL
SERVICES AND
THE IMPACT
ON WOMEN
4.1 Midwifery staffing
There is a crisis in midwifery staffing, particularly
in London and the South East, where some units can be 40% short
of the required number of midwives4 and NCT understands that at
one London hospital, vacancies for community midwives are running
at 70%. One-to-one support in labour by midwifery staff is the
Government's "gold standard"5 but according to an audit
of midwifery practice, only 78% of women are receiving this level
of support. 6 However, a woman's idea of one-to-one support may
be different from that of a health professional, and staffing
ratios and patterns that enable women and their partners to feel
properly supported are vital.
Midwifery staffing shortages are key when looking
at the type of birth experience a woman is likely to have. A woman
who is supported continuously throughout her labour and birth
is less likely to need drugs for pain relief, or to experience
forceps, ventouse or a caesarean section. 7 Good support during
labour is particularly important for disadvantaged women and those
with special needs who may find it more difficult to access the
information they need, to communicate with staff and make their
wishes known. 8 Women who are less supported are less likely to
labour well and more likely to require medical interventions.
Women who are able to achieve a straightforward vaginal birth,
maximize their own health and their baby's health. A normal birth
makes skin-to-skin contact and breastfeeding easier, and reduces
the need for special care and early separation from the mother.
It also saves NHS resources. A straightforward birth costs £1,000
less than a caesarean and £350 less than an assisted delivery.
9 Straightforward births, including home births with two midwives
attending, use significantly less midwifery time as contact time
is focused when and where it is required and the need for clinical
care in the postnatal period is significantly reduced. 10
In addition to simply looking at the numbers
of midwives in a unit, the jobs they are doing must be taken into
account. For example, a unit may have 25 midwives, but there will
be midwives amongst that group who are involved in scanning, or
in theatre assisting with caesarean sections, and not actually
available to support women who are in labour or on the postnatal
ward. When there are midwife shortages in a maternity unit, it
is often the postnatal care of women that suffers most. There
is evidence that women feel poorly supported in the immediate
postnatal period and do not receive sufficient time or consistent
information and support when starting to feed their babies. There
are fewer midwifery staffing shortages in midwife-led units11
and so looking at how maternity care is delivered could have an
important and positive effect on midwifery recruitment and retention.
4.2 The European Working Time Directive (EWTD)
Implementation of the EWTD by Summer 2004 to
cover doctors in training will have an important effect on medical
cover in the labour ward. There is broad acknowledgement among
politicians, healthcare managers and clinicians that the current
number of maternity units and special care baby units cannot be
maintained given staffing constraints. Innovative solutions will
need to be found to ensure that women can continue to receive
high quality, safe care which is responsive to their needs yet
delivered as close as possible to their homes within a managed
clinical network.
Implementation of the EWTD can be seen as an
opportunity as well as a threat. While women and families may
have to travel further to reach their nearest hospital, there
are opportunities to develop midwife-led services in units closer
to women's homes. Some of those women who need medical care will
have further to travel and every effort should be made to make
units welcoming to women, their partners and children, easy to
access by public transport and private care, and as comfortable
as possible. All women should receive individualised care and
have access to birth rooms which are comfortable and clean with
access to an en-suite lavatory and birth pool, bath or shower.
Women using midwife-led units should be told of any additional
social support available in non-medical centres. Often those who
are socially disadvantaged can benefit from the additional support
smaller, more local units offer, including increased support for
breastfeeding. NCT would emphasise that the provision of services
in maternity units should be based on the needs of women and their
families, rather than solely around doctors' training needs
4.3 Staffing levels and the type of birth
a woman is likely to have
The philosophy amongst staff and mangers of
a maternity unit is important in determining the type of service
women and their families are likely to experience and in many
cases, the type of birth a woman will have. Hodnett found, in
a descriptive study in Canada12, that the culture of the maternity
unit seemed to be important. Units in which midwives and medical
staff shared a view that birth was a normal physiological process,
took pride in a low caesarean rate and where there were effective
multi-disciplinary staff teams were more likely to have a low
caesarean rate.
An observational study by Keith Greene and Mo
Harris from Derriford Hospital, Plymouth showed that having a
midwife present during labour is not sufficient. Video footage
showed midwives sitting with their back to the labouring woman,
occupied with the electronic monitor and medical notes rather
than providing physical or emotional support13. Most delivery
rooms are dominated by a bed which encourages women to lie down
and remain still, whereas evidence suggests that labour progresses
better if women are able to keep upright and mobile, and contractions
feel less painful. In units where straightforward vaginal birth
is valued, and health professionals work together to maximise
women's chances of achieving a normal birth, intervention rates
are low. In Shropshire, women are automatically booked for the
midwife-led unit rather than the obstetric unit unless there is
a medical or obstetric reason, or she requests it herself14. Caesarean
rates are the country's lowest at 10.9%, half the average for
England15. Caesarean rates varied widely between units, meaning
that there must be variations in clinical practice and standards.
The NCT believes that this is not acceptable. In the National
Sentinel Caesarean Section Audit, 16 only 3% of first time mothers-to-be
said they would choose a caesarean if there was no medical reason.
In her presentation on the psychological effects
of caesarean section at the "Rising Caesarean Rate; causes
and effects for public health" conference, Dr Sarah Clement
said that eighteen studies had looked at women's birth experiences
and all of these found that women who had had a caesarean section
perceived their birth experience more negatively than those who
had had a vaginal birth. Additionally, two of these studies found
that women are more likely to experience puerperal psychosis after
a caesarean. 17 The Sentinel Audit found that 21.5% of births
in England and Wales were by caesarean section, and of these,
62.9% were "emergency caesareans". This rate has increased
over recent years; from 56% of the total in 1980, 57% in 1990
and 60% in 1995 (England only). 18 As there is an increasing trend
and emergency caesareans are needed after a normal birth has been
attempted and failed, it is important to look at factors which
are contributing to that failure.
Staffing problems lead to stressed and tired
midwives, who may be required to look after two or even three
woman in labour at once. When close observation and support cannot
be provided there is more reliance on electronic fetal monitoring
and epidural aneasthesia in order for the system to cope. We welcome
the introduction of consultant midwife posts, although there is
much scope to expand numbers further as there are currently only
32 consultant midwives employed within the NHS. 19 Consultant
midwives can be a positive influence in ensuring high standards
of evidence-based care within the maternity unit, and all Trusts
would benefit from having one. In addition, it is vital that the
central managerial roles, Director of Women's and Children's Services
and Head of Midwifery, continue to attract the highest calibre
midwives, so that they can bring their knowledge and influence
to bear in decisions about strategic planning and financial management.
Unless senior midwives are in a position to make strategic decisions
and influence how resources are allocated, they are unlikely to
be able to develop the services and improve recruitment and retention
through improved motivation and morale. High staff turnover and
high levels of bank and agency staff break down the collective
knowledge and understanding among medical and midwifery staff;
there is less experience and less confidence among staff on the
delivery suite and in the community. These are some of the factors
affecting a woman's opportunity to have a straightforward birth
with all its attendant benefits.
4.4 Impact on home births
In his speech to the Royal College of Midwives
conference in May 2001, Alan Milburn said, "Women in all
parts of the country, not just some, (should) have greater choice,
including the choice of a safe home birth." Currently, only
around 2% of babies are born at home, but 20% of women would like
to have more information about home birth. 20 Torbay and Brighton
both have home birth rates around 10%, so providing the service
to many more women than at present is possible within the NHS.
Even when women do make a positive choice to have their baby at
home, they are often dissuaded by local staff who fear that it
would overburden an already stretched service.
However, Birthrate Plus shows that overall booked
home births involve less midwifery time than hospital births21.
Women booked for a home birth are more likely to have a straightforward
birth without the need for epidural anaesthesia, an instrumental
or operative delivery, or nursing care after the birth. When there
are midwifery staffing shortages, home birth services are often
the first to be withdrawn by Trusts, many of whom see it as an
added extra rather than a core service they should be offering
to all low-risk women in their area. The Chelsea and Westminster
Hospital recently suspended their home birth service completely
due to lack of staff. This reaction to staffing difficulties creates
a downward spiral, in which healthy women with a normal pregnancy
are referred into the acute services rather than referred to community
care when they would welcome it. Subsequently more women have
major medical interventions involving more medical and midwifery
resources.
Research has shown that low-risk women who booked
a home birth were half as likely to have a caesarean section as
those who booked a hospital birth. 21 There are long-term health
consequences for those who have a caesarean section, including
reduced fertility; they are considered high risk in a subsequent
pregnancy and will use more healthcare resources as a result.
Fully staffed maternity services, including midwives who are experienced
and confident in home births are vital if this is to be real option
for women all over the country as the Government envisages.
4.5 Paediatric cover and the effect on maternity
services
NCT acknowledges that there will have to be
changes in the way specialist neonatal care is provided due to
workforce issues. These changes affect the whole service and all
parents, those with complex pregnancies and those with straightforward
pregnancies who may develop an unanticipated problem. This is
why it is so important to develop fully integrated services taking
account of issues for the whole of the workforce. In Ashington
and Solihull midwives have been trained in resuscitation and examination
of the newborn. Emerging findings suggest safe care can be provided
for healthy women with a normal pregnancy without having a paediatrician
on site, provided there are clear booking criteria and good transfer
arrangements in place should they be needed to a fully equipped
tertiary unit. For pregnant women and babies with more complex
needs availability of specialist paediatric care on-site is essential.
It is important in all parts of the service to strike a balance
between meeting the social and emotional needs of sick and premature
babies and their families and ensuring that medical care can be
provided in an effective and efficient manner. Where services
are reconfigured, written information should be provided for parents
that explains the trade-offs between availability of local services
and access to more intensive nursing and medical care and greater
expertise.
Parents who have a child in special care are
going through a difficult time, and in any reconfiguration of
neonatal services, measures to make that time as easy as possible
should be of the highest consideration. Accommodation should be
provided for parents who have a baby in NICU to enable them to
stay at or near the hospital. Ideally, this should be in self-catering
units which can accommodate the whole family. It should be acknowledged
that centralisation of services, at both secondary and tertiary
care levels, will have considerable costs for families in terms
of ease of access, financial costs for travel, subsistence, accommodation,
childcare, physical separation and emotional strain.
4.6 Networks of obstetric and midwife-led
units working together
In Wiltshire and Shropshire, there are "hub
and spoke" networks of community services around a district
general hospital, enabling birth at home or in a small, midwife-led
unit to be offered routinely to healthy women with a normal pregnancy.
In each of these areas approximately 25% of women give birth in
the community rather than in hospital. This gives women the option
of a local, low-tech unit, staffed by midwives who specialise
in supporting physiological birth and breastfeeding and who know
the local community well. They have the back-up of care at the
central consultant unit should they want or need it. NCT feels
that maternity services organised in this way have a very valuable
contribution to play, in terms of giving women choice in where
they want to have their babies, in giving greater numbers of women
the chance of a positive birth and good postnatal care close to
home and midwives a supportive environment in which to work. These
units help keep caesarean rates low by giving women a peaceful,
unhurried, supportive environment in which to have their baby.
They have high breastfeeding rates, helped by full support for
the Baby Friendly Initiative (including encouragement of skin-to-skin
contact, well informed and committed staff providing time to help
with feeds, no formula milk provided by the NHS, etc) and longer
postnatal stays with care from supportive midwives. There is evidence
that there are fewer staffing shortages where midwives are able
to practice "traditional midwifery" and fully use their
skills.
5. TRAINING OF
STAFF WORKING
WITH PREGNANT
WOMEN AND
NEW PARENTS
There are several areas of weakness in the training
of health professionals which impact upon the type of birth a
woman is likely to have, the support she receives and the health
of the new baby.
5.1 Trainee midwives and on-going training
of qualified midwives
During their training, schools of midwifery
teach student midwives to provide woman-centred care based on
a social model of birth. However, most go on to do their clinical
placements and/or work immediately after training in maternity
units where a medical model and risk management take priority
over the social model of care. In order for new midwives to experience
normal birth within the context of their training and when newly
qualified, Labour Ward Managers have an important role to play
in ensuring that students learn first about straightforward births
and that this is reinforced as the norm before they are involved
in providing care for women with more complex needs requiring
medical care and interventions. This could be ensured by all student
midwives receiving a placement at a midwife-led unit or birth
centre where straightforward birth is the norm. The use of skilled
people to pass on skills that will otherwise be lost to new midwives
is vital. During their training, midwives need to learn the importance
of patient and public involvement in the development of maternity
services. Supervisors of midwives need to be committed to encouraging
engagement between staff and users of the service so they have
first hand knowledge of how listening to women can improve the
services they offer.
5.2 Doctors in training
Medical students need to learn about normal
physiological birth from the practitioners who are experts in
normal birth: midwives. Yet research suggests that lines of professional
demarcation mean medical students are seen as a low priority for
the teaching of clinical skills and knowledge on busy delivery
suites. A recent piece by Diane Fraser in the MIDIRS Journal highlighted
that medical students were easily "forgotten about"
and were a lesser priority for the trainees' co-ordinator. 22
As junior doctors' placements on the labour ward are shorter than
trainee midwives, ensuing that this time is positively spend in
a caring and supportive atmosphere that values students is important.
It is widely acknowledged that younger obstetricians tend to be
more defensive in their practice than older ones, intervening
more frequently and rapidly to monitor, augment or deliver with
instruments or surgery. If this is to be avoided in future, it
should be a priority of midwives to educate junior doctors well
during training.
5.3 Training in breastfeeding support
It is widely recognised that the training of
health professionals23 has not provided staff with skills and
information to support breastfeeding. There have been some improvements
recently, but there is a long way to go to ensure that all staff
are consistently positive about women's ability to breastfeed
and know how to support that decision. Midwives, healthcare assistants,
health visitors and other staff who have contact with new mothers
need sound knowledge about the physiology of breastfeeding, the
health benefits of breast milk, and the need for a woman-centred,
hands-off approach to providing support. In addition, staff need
to have worked through their own attitudes, so as to identify
any mental blocks they may have preventing them from providing
unambiguous support.
5.4 Labour and birth in water
Increasing numbers of maternity units are installing
water pools for women to use during labour and birth. However,
anecdotal evidence from midwives and women show that in many cases,
because staff lack the confidence and training to support women
using them, they are little used. 24 In a UK study comparing low
risk "land" and `water' births, babies born in water
were less likely to die or need admitting to Special Care than
comparable babies born on dry land. 25 Beneficial effects include
maternal relaxation, less painful contractions, shorter labours,
less need for augmentation, less need for pharmacological analgesics,
more intact perinea, and fewer episiotomies and using water may
reduce the need for pharmacological pain relief. 26, 27
6. HEALTH OF
THE BABY
Factors that are important for the health of
the baby, and which are affected by staffing levels and training
are:
6.1 Antenatal classes
Only about 50% of first time mothers attend
some antenatal classes. There is evidence that by attending
antenatal classes, first time mothers experience
better labours and are less likely to suffer mental health problems
in the early days as a new parent. 28 In areas where midwifery
staffing levels are low, or the Trust is looking to save money,
antenatal classes are often a service that is seen as dispensable.
NCT understand that currently, two large Trusts in London and
the West Midlands have cancelled parentcraft classes due to staff
shortages. In addition, to preparing women for labour, what to
expect in hospital, caring for a new baby, antenatal classes enable
women to exchange experiences and ideas with each other, providing
invaluable mutual support. Women who meet other mothers they know
around the time of the birth and in the weeks afterwards have
a ready-made support network to help them cope with the stresses
of new motherhood. We therefore believe that cutting antenatal
classes is short-sighted. NHS antenatal classes, conducted by
midwives who are trained and confident in teaching, and offered
in different languages in areas where there are significant non-English
speaking populations, should be available to all first time parents.
6.2 Breastfeeding
Breastfeeding rates in the England are amongst
the lowest in Europe, with only 28% of babies receiving any breastmilk
at four months of age. 29 Yet breastfeeding is one of the simplest
and most effective ways of improving the health of our children.
Currently the decision to breastfeed is related to age, social
class and mother's education so that children who are most at
risk of poor health (due to poor housing, overcrowding, parental
smoking and other social factors) are least likely to be breastfed.
Formula fed babies are five times more likely to be admitted to
hospital with gastro-enteritis in their first year30, twice as
likely to develop atopic eczema, wheezing31 and ear infections32
and five times more likely to have a urinary tract infection33
than babies who are breastfed for at least four months. 34 For
premature babies, there is no doubt that human milk reduces the
risk of the life-threatening bowel disease, necrotising enterocolitis,
and therefore saves lives as well as reducing hospital costs.
35
One study, based on data from Scotland and the
US, looked at the cost of lower respiratory tract illnesses, otitis
media, and gastrointestinal illness in babies. 36 In the first
year of life, after adjusting for confounders such as maternal
education and maternal smoking, there were 2,033 more visits to
the doctor, 212 more days of hospitalisation, and 609 excess prescriptions
for these three illnesses per 1,000 never-breastfed babies compared
with 1,000 babies exclusively breastfed for at least three months.
Research also suggests that, on average, children who are formula-fed
as babies have higher blood pressure37, lower scores on intelligence
tests38, a greater risk of developing obesity39 and childhood
diabetes40 all of which have economic consequences.
There are also long-term health benefits for
women. The risks of breast cancer41, some forms of ovarian cancer
and osteoporosis leading to hip fracture are higher in women who
have not breastfed. 42
It is clear that breastfeeding provides immediate
and long-term benefits to the health and growth of babies. But
there is more to breastfeeding than the simple provision of nutrients
and other factors that protect against infections, allergies and
atopic diseases. It is the unique and intimate way of nurturing
babies that may also effect the cognitive, behavioural and emotional
development of the young child. Most mothers want to breastfeed,
yet nine out of 10 who stop in the first six weeks would have
liked to continue for longer. 29 We are not supporting women to
nurture their children in the way they wish.
Breastfeeding is a skill to be learnt by both
the woman and her baby and many women find the initial hours and
days of breastfeeding challenging. However, being surrounded by
supportive staff to encourage and assist the new mother is vital.
In smaller midwife-led units, or units that have adequate midwifery
staffing levels, women are more likely to get good support from
midwives. This is demonstrated by the many small units that have
achieved UNICEF Baby Friendly Status, showing that they are committed
to helping women establish and support successful breastfeeding.
In Scotland, an audit of breastfeeding rates at hospitals that
had achieved Baby Friendly Status, showed that there was a 10%
average increase in rates. 43 NCT would like to see all hospitals
and community practices achieving Baby Friendly Standards as we
believe it would benefit the health of mothers and babies. Where
staffing levels are inadequate and midwives are very busy, there
is evidence that support for breastfeeding is neglected. 44 However,
good support in the first few days reduces the incidence of problems
such as sore nipples45 and women believing that they have insufficient
milk46, enabling more women to breastfeed for longer. "Selective
visiting" has become the norm for postnatal care by midwives
at home, which lasts for 10 days or longer. Although focussing
resources on those women who most need additional support makes
sense in terms of reducing health inequalities, there is evidence
that with less routine care, more women run into breastfeeding
difficulties that could be overcome with early encouragement can
support.
As public health can be improved significantly
through increased breastfeeding, there is a need to review patterns
of visiting and how community midwives' time is spent to see if
more effective support could be provided. Many women report that
support available to them suddenly vanishes at the end of their
care from a midwife, usually at ten days after the birth. A better
way of making the transition to health visitor care is needed,
possibly at a later time47 with more integration, more overt support
for breastfeeding from health visitors (many of whom may need
further training in this regard) and more emotional support for
women themselves.
6.3 Mental health
In every 1,000 births, 100-150 women will suffer
a depressive illness and one or two women will develop a puerperal
psychosis. 48 If women suffer mental health problems during pregnancy
and in the postnatal period, there is growing evidence about the
effect that will have on the relationship between the mother and
baby, and on the baby's future mental health and well-being. Boys
are at particular risk of developing behavioural problems. 49
Therefore training in looking for symptoms and having the time
to talk to women is important. Problems with lack of staff and
staff time, by midwives, GPs and health visitors can have a detrimental
effect on the types of services they are able to offer women and
as a consequence, on the health of the baby. Women who are identified
at greater risk of developing mental health problems may benefit
from additional postnatal visits, interpersonal therapy and/or
antenatal preparation. 50
February 2003
REFERENCES:
1. NHS Maternity Statistics, England: 1998-99
to 2000-01, Bulletin 2002/11, Office for National Statistics,
April 2002.
2. Richardus J, Graafmans W, Verlooove-Vanhorick
S et al Differences in perinatal mortality and suboptimal
care between 10 European regions: results of an international
audit. BJOG 2003:110;97-105.6.
3. Report to the Department of Health Children's
Taskforce from the Maternity and Neonatal Workforce Group, January
2003 http://www.doh.gov.uk/maternitywg/report-jan03.pdf
4. RCM, RCM concerned over midwifery
staffing shortages (press release) 27 September 2002.
5. Milburn A, Secretary of State for Health
More Midwives, More Choice; speech to RCM Conference, 2
May 2001.
6. English National Board for Nursing, Midwifery
and Health Visiting. Midwifery practice. Report of the Board's
midwifery practice audit 2000/2001. London: English National
Board for Nursing, Midwifery and Health Visiting, 2001.
7. Hodnett ED. Caregiver support for women
during childbirth (Cochrane Review). In: The Cochrane Library,
2, 2001. Oxford: Update Software.
8. Singh D, Newburn M (eds). Access to
Maternity Information and Support. The Needs and Experiences of
Women Before and After Giving Birth. London: National Childbirth
Trust, 2000.
9. House of Commons Written Answer, Hansard,
1 November 2001.
10. Ball J, Washbrook M. Birthrate Plus
- A framework for workforce planning and decision making for midwifery
services. Books for Midwives, 1996.
11. Saunders D, Boulton M, Chapple J et
al. Evaluation of the Edgware Birth Centre. Edgware: Barnet
Health Authority, 2002.
12. Hodnett, E. (2000) Attaining and maintaining
best practices in the use of Caesarean sections, An analysis of
four Ontario hospitals, Report of the Caesarean section working
group of the Women's Health Council, www.womenshealthcouncil.com
13. The Rising Caesarean Rate—from
Audit to Action. Report of a joint conference organised by
the Royal College of Obstetricians and Gynaecologists, the Royal
College of Midwives and the National Childbirth Trust in London;
31 January 2002; London: National Childbirth Trust, 2002.
14. Oxenham J. What it's like to work
in . . . Shropshire. Pract Midwife 2002; 5(9): 27-9.
15. Dodwell M, Gibson R. Normal Birth
Rates: England (2001). Prepared by BirthchoiceUK from Department
of Health Statistics. Presented to the APPG on Maternity, 2 July
2002.
16. J Thomas, S Paranjothy Royal College
of Obstetricians and Gynaecologists, Clinical Effectiveness Support
Unit. National Sentinel Caesarean Section, Audit Report. RCOG
Press; 2001.
17. The Rising Caesarean Rate - causes
and effects for public health. Report of a joint conference
organised by the Royal College of Obstetricians and Gynaecologists,
the Royal College of Midwives and the National Childbirth Trust
in London; 2000 7 November; London: National Childbirth Trust,
2000.
18. HES Statistics 1980-1994-95.
19. Lord Hunt, House of Lords Hansard, 15
January 2003.
20. Singh D, Newburn M (eds). Access
to Maternity Information and Support. The Needs and Experiences
of Women Before and After Giving Birth. London: National Childbirth
Trust, 2000.
21. Chamberlain G, Wraight A, Crowley P
(eds). Home Births. Report of the 1994 Confidential Enquiry
by the National Birthday Trust Fund. New York, London: Parthenon,
1997.
22. Fraser DM. MIDIRS Midwifery Digest,
vol 12, No 4, Dec 2002, pp 553-556.
23. UNICEF Baby Friendly Initiative.
Introducing the Baby friendly best practice standards into breastfeeding
education for student midwives and health visitors. London.
November 2002.
24. Garland D. MIDIRS Midwifery Digest,
Vol 12 , No 4, Dec 2002, pp 508-511.
25. Gilbert R and Tookey P. Perinatal mortality
and morbidity among babies delivered in water: a surveillance
study and postal survey. British Medical Journal 1999. 319:483-87
(21 Aug).
26. Schorn M, McAllister J, Blanco J (1993)
Water immersion and the effect on labour. Journal of Nurse
Midwifery 38(6): 336-342.
27. Garland D and Jones K (2000) Waterbirth:
supporting practice with clinical audit. MIDIRS Midwifery Digest
10(3): 333-336
28. Scottish Intercollegiate Guidelines
Network (SIGN) guideline, Postnatal Depression and Puerperal Psychosis,
June 2002.
29. Hamlyn B, Brooker S, Oleinikova K, Wands
S. Infant Feeding Survey 2000. BMRB International. 2002. London.
The Stationery Office.
30. Howie P W, et al Protective effect
of breastfeeding against infection BMJ, 1990, 300 11-16.
31. Wilson AC, et al. Relation of
infant diet to childhood health: seven year follow up of cohort
of children in Dundee infant feeding study. BMJ 1998, 316; 21-25.
32. Duncan B, Ey J, Holberg CJ, Wright AL,
Martinez FD, Taussig LM. Exclusive breast-feeding for at least
4 months protects against Otitis Media. Pediatrics. 1993; 91:
667-669.
33. Pisacane A, Graziano L, Zona G. Breastfeeding
and urinary infection. J. Pediatrics, 1992; 120: 87-89.
34. Breastfeeding or bottle feeding: Helping
women choose. MIDIRS Informed Choice leaflets, 1999.
35. Lucas A, Cole T J. Breastmilk and necrotising
enterocolitis. Lancet, 1990; 336:1519-1523. Narayanan I,
et al. Randomised controlled trial of the effect of raw and holder
pasteurised human milk and formula milk and of formula supplements
on incidence of neonatal infection. Lancet, 1984; 8412: 1111-1113.
36. Ball TM, Wright AL. Health care costs
of formula-feeding in the first year of life. Pediatrics 1999
Apr; 103 (4 Pt 2): 870-6.
37. Wilson AC, et al. Relation of
infant diet to childhood health: seven year follow up of cohort
of children in Dundee infant feeding study. BMJ 1998, 316; 21-25.
Early nutrition in preterm infants and later blood pressure: two
cohorts after randomised trials. Singhal A, Cole TJ, Lucas A.
Lancet, 2001; 357: 413-19.
38. Mortensen EL et al (2002). The
association between duration of breastfeeding and adult intelligence.
JAMA 287: 2365-71. Anderson W.A, Johnstone B.M, Remley D.T.
Breastfeeding and cognitive development: a meta-analysis. Am
J Clin Nutr 1999; 70: 525-535.
39. Armstrong J et al (2002). Breastfeeding
and lowering the risk of childhood obesity. Lancet 359:
2003-04. Gillman MW, Rifas-Shiman SL, Camargo CA, Jr., Berkey
CS, Frazier AL, Rockett HR et al. Risk of overweight among
adolescents who were breastfed as infants. JAMA 2001; 285(19):
2461-7.
40. Mayer EJ, Hamman RF, Gay EC, Lezotte
DC, Savita DA, Klingensmith GJ. Reduced risk of IDDM amongst breastfed
children. Diabetes, 1988; 37: 1625-1632.
41. Breast cancer and breastfeeding: collaborative
reanalysis of individual data from 47 epidemiological studies
in 30 countries, including 50302 women with breast cancer and
96973 women without the disease. Lancet 2002; 360(9328): 187-95.
42. Heinig MJ, Dewey KG. Health effects
of breastfeeding for mothers: a critical review. Nutrition
Research Reviews, 1997; 10: 35-56. Gwinn et al, Reduced risk
of ovarian cancer. J Clin Epidemiol 1990, 43: 559-68. Cummings
RG, Kleinberg REJ. Breastfeeding and other reproductive factors
and the risk of hip fractures in elderly women. Int. J Epid. 1993,
22(4): 684-691.
43. UNICEF UK Baby Friendly Initiative.
Baby Friendly hospitals show strong increase in breastfeeding
rates. Baby Friendly News No 6, July 2000.
44. Singh D, Newburn M. Postnatal Care
in the Month After Birth. London: National Childbirth Trust,
2000.
45. Renfrew M et al. Enabling women
to breastfeed. London. The Stationery Office, 2000.
46. Ingram J, Johnson D, Greenwood R. Breastfeeding
in Bristol: teaching good positioning, and support from fathers
and families. Midwifery 2002; 18; 87-101.
47. MacArthur C, Winter HR, Bick DE, Knowles
H, Lilford R, Henderson C, Lancashire RJ, Braunholtz DA, Gee H.
Effects of redesigned community postnatal care on women's' health
four months after birth: a cluster randomised controlled trial.
Lancet. 2002 Feb 2; 359(9304): 378-85.
48. O'Hara MW, Swain AM. Rates and risk
of postnatal depression—a meta-analysis. Int Rev Psychiatry
1996; 8:37-54.
49. Sharp D, Hay DF, Pawlby S, Schmucker
G, Allen H, Kumar R. The impact of postnatal depression on boys'
intellectual development. J Child Psychol Psychiatry 1995; 36:
1315-37.
50. Scottish Intercollegiate Guidelines
Network (SIGN) guideline, Postnatal Depression and Puerperal Psychosis,
June 2002.
| 
