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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