Select Committee on Health Written Evidence


APPENDIX 48

Memorandum by the Association of Radical Midwives (MS 57)

SUMMARY

  1.  That the report produced by the Winterton Committee and the subsequent Cumberlege Report ("Changing Childbirth") are both still as valid today as they were 10 years ago.

  2.  That the current piecemeal data collection and audit across maternity services needs coherent direction and an holistic compass. It also needs to include qualitative as well as quantitative data.

  3.  That the provision of training should be based in normality and should be centred in midwifery led units and on community.

  4.  That the current staffing structure within the maternity services reflects the needs of the medical profession, not the needs of childbearing women.

  The Association of Radical Midwives has been in existence for over 25 years and at present has over 1,500 members, both in the UK and overseas. The majority of members are midwives or student midwives but a significant number are consumers or others concerned with standards of maternity care.

Although its membership numbers are relatively small, the Association has had and continues to have a significant impact on the midwifery profession. Ideas and proposals from the Association have subsequently been taken up and incorporated into new policies and schemes throughout the maternity services.

  1.  That the report produced by the Winterton Committee and the subsequent Cumberlege Report ("Changing Childbirth") are both still as valid today as they were 10 years ago.

  1.1  Although some slow and patchy progress has been made towards the goals set out in those reports, much still remains to be done. Although it is claimed in some quarters that Changing Childbirth has "failed", it has in truth never been properly implemented. In many areas where continuity of care schemes were set up along the lines advocated in Changing Childbirth, these important initiatives have been allowed to wither away. Although the report was accepted as official Government policy, there was no concomitant funding and the various schemes were expected to be cost neutral, funded from within existing budgets. Even where pilot schemes showed excellent results, the schemes were very rarely rolled out across an entire service. The short-term approach to budgeting did not allow the start-up costs to be absorbed as the expected benefits from reduction in caesarean section rates, lower use of analgesia, increased breast feeding rates would not appear in the same year's budget. In contrast, the "pump-priming" approach used in many Sure Start projects has shown that judicious investment in start-up costs can successfully set a project rolling and pay off in long term sustainability.

  1.2  The few schemes that have been set up and that continue to run along these lines show how successful such projects can be. The Albany Midwifery Practice has achieved impressive results in an area of high socio-economic deprivation and the Weston Shore project in Southampton has shown a significant impact on such markers as the caesarean section rate. The growth of Birth Centres, such as the Edgware Birth Centre or the five free-standing units that contribute to the Royal Shrewsbury's caesarean section rate of 12%, show what autonomous midwifery practice can achieve.

  1.3  We would also commend to the attention of the Committee the debate on the Maternity Services which took place in the House of Lords on the 15 January 2003. The debate showed an impressive grasp of the issues and the challenges facing the maternity services today. The statements that "the maternity services are in a mess", that "this crucial service is going backwards", that midwifery staffing levels show "critically high levels of vacancies" are no more than the truth. The debate highlighted the problems caused by the medicalisation of childbirth. It also made clear that one of the key issues in the current crisis is the effects of the fear of litigation on care in childbirth, an issue to which we shall return.

  2.  That the current piecemeal data collection and audit across maternity services needs coherent direction and an holistic compass. It also needs to include qualitative as well as quantitative data.

  2.1  Data collection varies from unit to unit; there is no unified system across the NHS and hence it is virtually impossible to get an accurate picture of the whole of the maternity service. Although the crude data is usually accessible such as how many births happen, how many instrumental births, how many caesareans and so on, the lack of consistency makes it hard to answer such an apparently simple question as how many normal births there are, as different units may have different definitions of "normal". "Normal" birth can be used to refer to everything from a completely physiological birth with no pain relief to a birth that was normal only in that it proceeded via the vagina rather than being a caesarean but included major interventions such as induction, augmentation, epidural, episiotomy and a managed third stage. The difference in impact, both on the mother and on the child, of a birth from one of these two extremes, is huge.

  2.2  In order to acquire a more accurate picture of the impact of such interventions in childbirth, data collection needs not only to be consistent but also to focus on more than the bare outcomes. It needs to include the knock-on impact on other services, so that for example the savings in paediatric budgets as a result of increased breast-feeding rates can be traced to its source. It needs to include not only obvious statistics, such as the £5-7 million extra costs to the NHS of each 1% rise in the caesarean section rate but also the smaller but cumulatively large effects on NHS spending due to morbidity deriving from supposedly "minor" interventions such as episiotomy or from postnatal depression as a result of a traumatic birth experience.

  2.3  Qualitative data is as important as quantitative data. Many units collect small amounts of qualitative data in "patient satisfaction surveys" at or around the time of birth and the data produced tend to show only marginal differences for different patterns of care. Such surveys have been used in support of comments such as "women do not care who is actually present at the birth, so long as the midwife is competent and caring". However, qualitative data collected later, eg six months after birth, often show a more nuanced picture and give a more accurate reflection about how women truly feel about the way they are currnelty treated by the maternity services and in particular how much difference the presence of a known and trusted midwife can make.

  2.4  The current emphasis on computerised data collection, while useful, has the potential to further diminish the contribution of qualitative data. The reductionist approach fostered by a computerised system fails to take into account the far-reaching impact of the experience of childbirth. Many computerised systems aim to reduce every possible event in a childbirth episode to a standardised term, so that it can easily be incorporated into a database. This can diminish the individuality and richness of the event and threatens to render invisible the woman's own experience.

  2.5  Data on staffing levels already shows vacancies at an all time high. It is often forgotten that these statistics frequently include staff on long term sick leave and almost certainly include staff with high levels of sickness and staff on maternity leave, who are still counted as part of the establishment. This means that the already bleak picture of staffing levels is even more threatening, as the pressure on those staff remaining increases further.

  3.  That the provision of training should be based in normality and should be centred in midwifery led units and on community.

  3.1  Currently, midwifery and medical training are centred on obstetric units and hence, by definition, on obstetric birth. We would propose that the basic assumptions of training should be turned on their head so that the fundamental place of training should be where "normal" birth is the norm. Both midwives and doctors should spend the major part of their training based in midwifery-led units, in birth centres and on the community so that their base line skills support and facilitate normal birth. If obstetric units were seen as the "add-on" rather than the norm, this would at a stroke demolish the current inexorable drive towards medicalisation of child-birth.

  3.2  Likewise, the current trend towards having community midwives come in to the obstetric unit for updating should be reversed, with labour ward midwives coming out onto community or into peripheral units to "refresh" their experience of normal birth. While every midwife needs to be conversant with all the skills he or she may need in an emergency situation, the primacy of childbirth as a normal, physiological event should be continually reinforced, especially among those who rarely get the chance to see a truly spontaneous normal birth. The skills that would hence be brought into and maintained within midwifery would then be those that promote normalisation.

  3.3  The return of midwifery skills and normal childbirth as the focal point of training may reverse current drop-out rates within midwifery education. Many students fail to complete the course as they become disillusioned with the amount of intervention they see on the average obstetric unit labour ward. Issues such as student hardship and the virtual impossibility of paying for childcare to cover shift and night working on a student loan also need urgently to be addressed to halt the attrition in student numbers.

  3.4  The promotion of normalisation and of midwifery skills requires strong midwifery leadership, not just within the service but also at a Trust level. It also requires clinical leadership, perhaps from within the existing structure of supervision which at its best can be a strong support both to midwifery practice and also to women's choice.

  3.5  High standards of education and training also require the implementation of research based care. It is sad but true that research advocating the abandonment of patterns of care that are known to have an adverse impact, such as continuous fetal monitoring, is repeated over and over again, despite being robust and well designed, with only patchy implementation, whereas research that is not so rigorous but which advocates the introduction of an intervention, such as the Hannah breech trial, is swiftly and almost universally adopted.

  3.6  Such defensive practice is usually driven by fear of litigation. The current trend towards introduction of Clinical Negligence Scheme for Trusts-driven guidelines is often not evidence based. Rather, the main motivating force is not improved standards of care but reduction of exposure of the Trust to litigation. The steady increase in litigation tends to imply that this is a misconceived idea and may be diminishing choice and increasing morbidity, without improving outcomes either for the Trust or for the woman and child. We feel that the introduction of no-fault compensation for birth injuries is vital to preserve the autonomy of the midwifery profession from fear-driven practice.

  4.  That the current staffing structure within the maternity services reflects the needs of the medical profession, not the needs of childbearing women.

  4.1  There appears to be a contradiction in the ways in which the maternity services are developing which continually pulls the service different ways. On the one hand, there appears to be recognition of the value of midwifery led care and of the outcomes seen in midwifery led units and birth centres. On the other hand, there are constant calls for the closure of such units and the concentration of services in ever larger regional units with ever increasing numbers of obstetric consultants. In some recent reports, there have been claims that the changing demographics of childbirth demand increased surveillance and increased intervention, a claim which does not appear to be borne out by the evidence. Rather, the increased number of consultants appears to lead to increased intervention as the medicalisation of the normal continues.

  4.2  In order to reverse this trend, the work of such bodies as the RCM's Institute for Normal Birth needs to be promoted so that concepts such as that of "salutogenesis", the facilitation and elicitation of health and wellbeing, can be allowed to operate.

  4.3  Again, midwifery-led and community based services need to be seen as the norm and as the basis of the service. At the moment, in times of staff shortage, community staff are pulled in to cover the obstetric unit, rather than vice versa. This leads to situations such as woman expecting home birth being told they must come in to the obstetric unit to give birth, community midwives being told they are booking "too many" home births and community based services, such as early labour assessment at home, which is well known to reduce unnecessary admissions to hospital, being abandoned in order to cover the unit.

  4.4  Further data on long-term recruitment and retention of midwives working in caseloading schemes such as the Albany or Weston Shore, or in areas such as Nottingham, where community staff are employed by a different Trust and therefore cannot be used to cover the shortages of staff in the acute unit, need to be compared with units where staff are continually moved from one area to another and have little control over their working environment.

  4.5  We would argue that the well-researched benefits to women of the kind of care advocated by Changing Childbirth have been subsumed by the need to maintain the medicalised approach. The use of expensive technology and invasive methods, highly useful for the small minority of genuinely high risk mothers and babies but of dubious benefit if not actively dangerous for the vast majority of normal healthy women, continues. The caesarean rate continues to rise. The cost of the maternity services continues to spiral while the incalculable cost to the nation's women continues to be exacted. We look forward to the Committee's responses on these issues.


 
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