House of Commons - Health

Select Committee on Health Eighth Report

4. How can barriers to access be overcome?

Assessing the needs of disadvantaged women and their babies

118. Policy makers and service providers alike are impeded in their work to improve access to maternity services for women from disadvantaged groups by the weakness of the evidence base. The needs and wishes of these women are not known and so services are ill-prepared to meet them. Christine Gowdridge from the Maternity Alliance told us that "a lot of the evidence on which services have been planned has been skewed by the fact that they have not necessarily asked the right women." In particular, she pointed out that user surveys often did not include women whose first language was not English because services could not "afford to survey them."[101]

119. However, there is much that maternity care teams can do at local level to gain an understanding of the needs of disadvantaged women and their babies, and also to strengthen their relationships with different communities.

Consultation at individual level

120. In the first instance, maternity services should engage with women, and respond to their needs as individuals at the earliest opportunity. The RCOG argued that women with learning disabilities should have access to pre-pregnancy advice, and that women should be involved in planning the "packages of care and support" that would be necessary to enable them to bring up a child.[102]

121. The RCM emphasised the importance of involving women in their care at the earliest possible stage so that services and equipment could be adjusted to meet their needs:

Adjustable equipment will increase the independence of women with disabilities and will reduce staff workload, therefore the right equipment and forward planning are crucial.[103] Prior to admission the woman should be given an opportunity to visit the maternity unit and check that facilities are appropriate to her needs, including familiarising her with the environment and giving her an opportunity to meet other staff.[104]

122. Simone Baker from the DPN agreed that women should be closely involved in all decisions about their maternity care. She emphasised the importance of assessing and then responding to a woman or a family's need over acting on assumptions. Mrs Baker told us that "a disabled person does not need you to do everything for them, they need you to wait to be asked."[105]

Consultation at community level

123. Changing Childbirth tackled the issue of access to maternity care and recommended that every District Health Authority should have a Maternity Services Liaison Committee (MSLC) with user representation reflecting the ethnic, cultural and social mix of the local population. Involvement of users in planning and evaluating services was proposed as a way of improving access and developing appropriate service provision.[106] Jo Garcia from the NPEU told us that MSLCs "have been fantastically useful and they are also the place where women using the service can have a real input … it is very often a layperson chairing the committee and they have been incredibly important."[107]

124. We were encouraged to hear this endorsement of MSLCs. As part of our first inquiry, into Provision of Maternity Services, we heard from service users representing 15 maternity units across the country. Nearly all of the service users were members of their local MSLCs and as such they spoke with confidence about a range of work being carried out to ensure that maternity services took full account of women's needs and wishes.

125. However, we heard from other quarters that women in some areas were not adequately served by active MSLCs, despite the publication of Department of Health guidelines on the role and organisation of MSLCs.[108] The RCOG told us that although these guidelines were intended to "emphasise the role and place of the MSLC" across the country, the activity levels and efficiency of MSLCs continued to vary widely.[109]

126. Some of our witnesses concurred with the RCOG that MSLCs found it difficult to find appropriate lay and user representatives from minority and disadvantaged groups.[110] One factor which might partially explain this difficulty is the financial burden of arranging childcare and/or travelling to MSLC functions, and in a written submission to our inquiry, the Centre for Nursing and Midwifery Research at the University of Brighton called for service users to be paid for formal participation at events such as trust meetings.[111]

127. Jo Garcia told us that it was "difficult to get … any reimbursement for lay people on the committees", and further that this and every other aspect of the running of MSLCs depended "entirely on the local health authorities' approach." She told us that reforms to restructure the health service, namely the transition to PCT-led commissioning, could threaten the effectiveness, and even the existence, of MSLCs:

In some places, they are continuing to function well but in other places, the change in service structure means that it is not clear where they should be based. There is a lack of clarity right now about what they should be doing … all the learning and skills and confidence that has been built in gradually with these committees and lay people need to be kept in order that that role can continue.[112]^,[113]

128. User involvement is vital to the effective planning of services and monitoring of access to care. We recommend that the Department should ensure the continuation of MSLCs in the context of NHS reforms. The role of MSLCs in relation to the Patient Advice and Liaison Service (PALS) and in relation to new patient forums and other mechanisms to involve the public in health service provision needs to be clarified. The expertise of the Commission for Public and Patient Involvement in Health should also be used to support MSLCs.[114]

129. Even where MSLCs operated on a secure organisational basis, we heard that some still failed to represent or even register the experiences of women from disadvantaged groups. Diane Jones from Newham Healthcare told us that although local MSLCs could play significant roles in maternity services:

The service users' representation does not actually reflect the Newham population. What we tend to have are women from the NCT group, many middle class white women who run the MSLC, so it does not accurately reflect other women from the community.[115]

Maggie Elliot from Queen Charlotte's and Chelsea Hospital described the problem in the starkest of terms: "you are not going to get somebody that is subject to domestic violence on the MSLC."[116]

130. Jenny McLeish from Maternity Alliance argued that service planners needed to acknowledge that current provision was not based on an accurate profile of local communities, and take immediate steps to rectify this:

If an area is really serious about hearing the views of its full local population and reflecting them, they cannot simply rely on voluntary committees and groups of people who are confident to come to groups and speak the language of the group in doing that … they have to do much more by way of local health assessments and needs assessments to work out who they have in their population who is not being heard.[117]

131. Maternity services in some areas have recognised that women from disadvantaged or marginalised groups may not be able to make a case for specialist care through mechanisms such as MSLCs. Diane Jones told us that other ways of "hearing the voices" of disadvantaged women were being explored, and Maggie Elliott commented that Queen Charlotte's and Chelsea Hospital used their complaints system, inviting those who made complaints to become involved in service development. She reported that the service had made contact with a Somali woman in this way. In general, she told us, "you tend to have to go out to these women as opposed to them coming to you."[118]

132. Outreach work is a key factor in making an assessment of the views and needs of disadvantaged groups. Diane Jones emphasised this in telling us that the maternity service at Newham was proactive in seeking entry to established community forums where staff could seek views on maternity care, and in developing cassette tapes to raise awareness that women could make their views known to the maternity services.[119]

133. MSLCs can be a powerful way of involving users in planning and developing maternity services but it is important that MSLC membership reflects the ethnic and social diversity of the local population as far as possible so that the needs of disadvantaged groups are accommodated. Lay members of MSLCs should at least be reimbursed for the child care and travel costs incurred when they attend meetings.

134. We were encouraged by the work of service providers who actively sought the views of women and families from disadvantaged groups by becoming involved in forums established by minority communities, and we are keen to ascertain whether this work could be replicated in other areas. We recommend that the Health Development Agency should gather and disseminate evidence of best practice in this area.

Training staff to provide appropriate care

135. Another strategy to ensure that maternity services provide appropriate care for the whole community involves the promotion of awareness of the needs of disadvantaged groups through specific training programmes.

136. In order to provide an appropriate level of care, the Centre for Nursing and Midwifery Research argued that:

Midwives need more support and training … trusts, supervisors and educationalists need to recognise that this work is challenging and that it needs extra resources, to undertake training of this sort.[120]

137. Maggie Elliott from Queen Charlotte's told us that existing training programmes for midwives working with disadvantaged women were "excellent" but that enabling midwives to undertake the courses could be difficult, owing to lack of resources and flexibility in terms of staffing. She insisted that in-post training was essential, even if student midwives now received training in meeting the needs of disadvantaged women and babies:

Certainly students who come out of midwifery education programmes will have had that education, one hopes, during their training, but it is all the midwives who trained 20 years ago that we need to get to as well.[121]

138. The Centre for Nursing and Midwifery Research told us that the involvement of service users who were themselves representatives of a specific group or community, as "expert educators", greatly enhanced student learning, and "the development of empathy."[122]

139. Simone Baker from the Disabled Parents' Network endorsed this view in telling us how she spoke to trainee midwives about her own situation and experience[123] but she acknowledged that "a lot of mothers would not want to do that."[124] Jenny McLeish from Maternity Alliance told us that where a woman's experience had been particularly distressing, she might be reluctant to recount it or to answer questions about it, and that a more sensitive approach in these instances might be to support the woman in compiling a case history which could then be made available for discussion.[125]

140. Domestic violence is a particularly sensitive area in relation to training of maternity care staff, not only because pregnant women and new mothers may be reluctant or unable to discuss abuse, but also because members of staff may themselves have been subjected to domestic violence. According to the RCM, maternity care staff require the support of policies and guidelines in caring for women who are affected by domestic violence[126] and the RCOG incorporated guidance on identifying abuse and managing care for those affected in its Trainee's Log Book.[127] The Department acknowledged this requirement in 2000 as it published Domestic Violence: a resource manual for Health Care Professionals but while we understand that the guidance was widely welcomed, neither the RCOG nor the Maternity Alliance could judge how widely the manual was being used.[128]

141. Because of the particular sensitivity and importance of maternity services we recommend that trusts should ensure that maternity care staff and PALS officers have access to sufficient opportunities for training with particular reference to the problems of mothers with disabilities or mental health problems, those from minority ethnic communities, those who live in poverty, and those from other disadvantaged groups. If there were to be a 'specialist' in maternity units to help such mothers, service users might not suffer from the ignorance and prejudices of some staff that were reported to the Committee.

142. We were encouraged to hear examples of good practice in promoting access to specialised services and continuity of care for women and families from disadvantaged groups through guidance and training programmes. However, our witnesses expressed doubt that this good practice could be spread unless sufficient resources were made available to create opportunities for recruitment and training of midwives in adequate numbers. Maggie Elliott from Queen Charlotte's and Chelsea Hospital told us that "we are not able to do as much as we would like to do because we just do not have the resources and staffing to do it."[129]

Providing specialist services in hospital and in the community

143. In the course of our inquiry we heard evidence of innovative practice in improving access and service provision for women and families from disadvantaged groups and we list several examples of such practice below. We note that, as a great many of our witnesses told us, much of the specialist work undertaken with disadvantaged communities is driven by small teams of committed staff or is even "the result of one individual being concerned."[130]

144. We are keen to see the good practice implemented by these teams and individuals, spread across the country. While local projects are, by necessity, inextricably linked to their specific groups, communities and areas, the principles which inform the projects (for example, the provision of targeted and continuous care in an appropriate environment) may be applied elsewhere.

sGood practice in provision of targeted services

Access to appropriate care for those from minority ethnic groups

145. Although women from minority ethnic groups who live in areas where the minority ethnic population is low may face greater difficulties in gaining access to maternity care than women in other areas, we heard that in some cases individual services, or individual midwives, rose to the challenge of meeting women's needs:

they are so motivated because this is the first person they have encountered in that situation and they feel really compassionate and get really involved and they have the most fantastic personalised service.[131]

146. The RCOG went on to cite examples of good practice in the provision of services to meet the needs of specific groups, such as special clinics for African women affected by female genital mutilation based at the Whittington Hospital, London, Guy's and St Thomas' Hospital, London, and at the Central Middlesex Hospital. The RCOG also drew attention to an open access family planning service in Wandsworth where the minority ethnic population also had direct access to midwifery services.[132]

Access to appropriate care for those from the travelling community

147. Maternity services at Queen Charlotte's and Chelsea Hospital identified travellers as a particular group of women who did not attend for antenatal care, the barrier to access being a lack of trust between travellers and health professionals. Lesley Spires outlined the rationale behind a project to improve access to care for travellers:

If … [the women] get to know individual professionals then they are more likely to trust the service that they are getting and to access it and to believe in the people who are giving it.[133]

148. 'One to one' midwives developed such strong relationships within the travelling community that a visit to the site became "more of a social event, people come and say hello." Lesley Spires was keen that the success of the One to One project should be replicated elsewhere:

I think it is an achievable aim to go and address the issue of the travelling community, particularly the worst ones with poor attendance. If you are providing care in the community you have 100% attendance rate and that is what we got.[134]

149. We recommend that local health services should liaise with local authorities and other agencies to update information about traveller sites within their areas. User representatives from local travelling communities should be involved in planning any special measures for service provision. We further recommend that PCTs should identify a co-ordinator for travellers, to facilitate transfer of health records, especially maternity records and notification of health professionals.

Access to appropriate care for women who live under threat of domestic violence

150. As Jenny McLeish from Maternity Alliance argued, maternity services "cannot act alone" in tackling domestic violence. Other support services, and safe places, must be available so that the maternity care team can refer women for specialist help. However, maternity services could work to improve care for women subject to domestic violence by ensuring that:

all midwives are equipped with whatever local knowledge there is to support women effectively, to know how to ask women in a non-threatening way, and to make sure that all women are seen without their partner at least once.[135]

151. The Maternity Alliance described how some services had been driven to use unconventional techniques to give women an opportunity to disclose domestic violence. In one case, the maternity care team suspected that a non-English speaking woman, was at risk of domestic violence. The woman's husband acted as her interpreter and so the maternity care team arranged for a professional interpreter to "go and hide in the women's loo" in order that the woman could speak freely.[136]

152. Diane Jones, a consultant midwife based in Newham, explained to us that discussion of domestic violence could contribute to a positive experience of maternity care:

they are not offended by it, they are actually quite glad that somebody is asking those questions. It is just a forum for them to speak about what is happening in their lives. They may not want to do anything about it but the fact that somebody has listened to them in a non-judgemental way shows women, the few I have had contact with, it is beneficial.[137]

153. As part of its work on domestic violence the Government should ensure that the Department of Health addresses the issue in the context of maternity services across the country. For women who have been abused and raped, there may be particular issues which need to be addressed in maternity services. We recommend that the Department should take steps to ensure that special training programmes are made available to all maternity staff across the country so that women subject to rape and domestic violence receive appropriate care.

Advocacy and interpreting services

154. Specialist interpreting and advocacy services, which enable women from disadvantaged groups to understand what is available to them, to participate in planning their own maternity care, and to gain access to health and social services, provide a model for maternity services. The principles of advocacy work can be used in meeting the needs of women who are disadvantaged for all kinds of reasons, not just those from minority ethnic or cultural groups, or those who do not speak English. Interpreting and advocacy services extend beyond "making medical procedures understandable to women" into "establishing a forum or a vehicle for women to express their own needs."[138]

155. My Diep, a community worker, interpreter and advocate for women from some of the Asian communities in East London, confirmed that her work involved more than an interpreting service for women but that she was also engaged in "explaining the health care system in the country to them and encouraging them to use the services, and how to use the services."[139]

156. We heard from the Maternity Alliance that according to findings of recent research, the services of advocates, helped women to make fuller use of the maternity services:

They felt more confident and reassured, able to ask questions and make choices and reported positive experiences of maternity care when supported in this way.[140]

157. However, we also heard concern that such positive outcomes were difficult to achieve, and that service providers themselves encountered barriers to access in relation to maternity services. Diane Jones, a consultant midwife from Newham noted that in an area where approximately 60 core languages were spoken it could be difficult to provide access to health advocates. She reported that the trust was undertaking work to recruit healthcare assistants from different communities, and to train them to provide advocacy support.[141]

158. Advocates may be impeded in their work by the extension to them of negative attitudes towards disadvantaged women and families. Carolyn Roth from Women's Health and Family Services told us that:

Advocates have had experience of being treated rather disrespectfully themselves by health professionals, so there are even attitudes that are projected onto the group of workers that are actually negotiating services on behalf of women. I think there is a need for awareness on the part of health professionals about the needs and backgrounds and the lives of the people that they are serving … somehow it has to be valued as an essential part of the care that the women are getting rather than an optional extra which can be dispensed with if it does not suit the professional.[142]

159. We recommend that all maternity services should consider recruiting healthcare assistants from minority ethnic communities, and developing training programmes so that these assistants can provide advocacy support for women and families.

Working with the voluntary sector

160. We heard throughout our inquiry that a great many health professionals did not have expertise in providing maternity services for those from disadvantaged groups, and that they lacked specialist cultural or, in the case of women with disabilities, physiological and medical, knowledge. Simone Baker from the DPN told us that health professionals such as GPs could not be expected to be able to provide immediate advice in all cases but she pointed to peer support groups and voluntary sector organisations as valuable sources of the information required by prospective and new parents.[143]

161. The RCOG highlighted the importance of the work undertaken by organisations outside the NHS:

Many of the patients have contact with voluntary sector organisations and self-help groups who can advise and anticipate the problems that may be encountered and it is important that the doctors and midwives take advantage of the help that is available.[144]

162. Perhaps the most important role of these organisations is to provide a direct service to women and families. Simone Baker underlined the value of a direct specialist service to those who have urgent need of advice and support. She argued that while peer support and voluntary organisations should not replace statutory service provision:

Volunteers, grass roots organisations … can react much quicker than statutory service providers. In the case of somebody who is pregnant or who has just had a baby and might have a disability, and, on top of that, might just have become a single parent, they are not really going to want to sit around and wait three weeks for an appointment, they are going to need some help immediately.[145]

163. All health professionals, including PALS officers, who become involved with a disabled mother who is either planning to become pregnant, receiving fertility treatment or who is already pregnant, should know how and where to obtain specialised information about the problems with pregnancy, delivery and baby care associated with particular impairments.

164. In order to provide an appropriate level of care for disadvantaged women and families, health professionals should have ready access to expert information, and to sources of further support. We recommend that the Health Development Agency should collate available research and evidence on work with disadvantaged groups, and create a central database of voluntary organisations working at local and national level.

Working with other health and social services

165. In examining the barriers which prevent disadvantaged women and their families from gaining full access to maternity care, we heard that for a great many disadvantaged groups, care can be fragmented if health and social services professionals do not collaborate in providing care during pregnancy, childbirth and the postnatal period.

166. In a great many cases, care for pregnant women with severe mental health problems forms a vivid illustration of the fragmented and incoherent approach to provision of maternity services which can prevent women from receiving the care and support that they need. Jenny McLeish from Maternity Alliance described this problem and went on to suggest one step towards a solution:

You have one group of people who know a lot about mental illness and nothing about maternity and another group who know a lot about maternity and nothing about mental illness. Actually, what you have to do is get them round a table once a month and then they can provide really good care … it is about liaison between the different agencies involved in someone's life.[146]

167. Lesley Spires described as "fortunate" the way in which the maternity care team at Queen Charlotte's was able to communicate with the mental health team in the trust. Diane Jones reported that at Newham, the maternity service was "trying to come to some agreement" with the mental health team on issues related to postnatal depression.[147]

168. The RCOG felt that the problems of mental health provided another example of the case for effective co-ordination of inter-agency care[148] and outlined how the 'inter-agency' approach to provision of maternity care could be used to help women from other disadvantaged groups:

The [minority ethnic] groups provide examples of the requirement for multi-professional education of carers and identification of specific health and social carers to be lead professionals and to use their added knowledge to act as a resource for the whole team.[149]

169. Southampton University Hospitals Trust told us that they had addressed the issue of poverty and homelessness "as part of the maternity services strategy". Midwifery group practices were established in areas of socio-economic deprivation and these practices worked in partnership with Sure Start projects. According to the Trust, this partnership promoted inter-agency work to tackle issues such as housing, benefits, domestic abuse, mental health, smoking cessation and other aspects of culture or lifestyle which might prevent a woman from gaining full access to maternity services.[150]

170. Simone Baker confirmed that, like women from other disadvantaged groups, "what most disabled parents would love" in terms of access to maternity services would be an integrated approach to care:

Some kind of cohesive joined-up service provided to them that involved everybody in their maternity care, so GP, health visitors, midwives and … social services.[151]

This approach to care, which would involve the social services at an early stage might help to alleviate the anxiety felt by some disabled parents and parents-to-be about intervention by social services.

171. An identified 'lead' professional, appointed to oversee care for women with disabilities would be able to provide practical and logistical support, allowing a pregnant woman to focus on her health and on that of her own baby. Simone Baker described the role of this professional as:

Somebody working with you right from that very early stage and actually saying "don't worry about the cot, I'll sort that" or "don't worry about your husband coming to stay with you."[152]

172. The RCOG identified the appointment of a Disability Advisor at Liverpool Women's Hospital NHS Trust as an example of good practice and recommended that:

it may be appropriate for each tertiary centre to appoint a midwife co-ordinator for women with disabilities in the region, to act as a consultant and a resource for advice.[153]

173. We recommend that local maternity services should appoint a lead health professional to ensure that women and families who have needs specific to physical or mental health, or social circumstances are provided with appropriate services. The role should involve liaison within a multi-disciplinary health and social care team, provision of care for individual women, advice on plans and policies within units, co-ordination of advocacy and interpreting services, including British Sign Language, and training and support for colleagues.

Providing continuity of care

Continuity of carer

174. There is evidence that one-to-one support during pregnancy can improve physical and mental health by helping disadvantaged women to cope with their difficult circumstances. Our attention was drawn to one study which reported that women who were supported in this way were less likely to feel unhappy during pregnancy and six weeks after birth they were more likely to be breastfeeding, less likely to have introduced solid food too early, less likely to be feeling physically unwell, and their babies were less likely to have had worrying health problems.[154] A follow-up study found that the benefits of these health outcomes could still be perceived in the children seven years later.[155]

175. During our inquiry witnesses identified as models of good practice in supporting pregnant women and mothers with mental health problems, those which provided continuity of carer, one-to-one midwifery, or midwifery provided by a small group of midwives. Jenny McLeish from Maternity Alliance told us that this kind of service, where the same midwife or midwives would "see the woman right from the beginning, see her at home, deliver her baby and then follow her up at home", would enable maternity services to monitor the woman's mental health throughout the pregnancy and to detect and respond to any problems.[156]

176. Lesley Spires, Head of the One to One midwifery group based at Queen Charlotte's and Chelsea Hospital confirmed that:

If women in these groups do have a named midwife they can identify with there is going to be a more trusting relationship between them and more disclosure in these kinds of situations and also better co-ordination of the other services they require.[157]

177. Maggie Elliot, Director of Midwifery and General Manager at Queen Charlotte's emphasised that the One to One scheme was a community-based service, with "one midwife providing total care". For the women served by the scheme (young mothers-to-be, and women from the travelling community amongst others), access to continuity of carer was "not just a concept [but] … a reality."[158] However, Mrs Elliot also reminded us of the impact of midwifery shortages on community midwifery care, as described to us by witnesses to our first inquiry:

What currently happens is that at times of high workload because of the safety issues the staff from the community tend to go to labour wards, so there is a shift of resources from the community to the labour wards. Where we are, our community service is probably one of the least resourced parts of the service. Yes, we need more midwives, we absolutely do. If we had more midwives we could provide more caseload practice to individual groups which would vastly improve outcomes.[159]

178. Maternity teams which have developed community-based continuity of carer schemes for women from disadvantaged groups, have been successful in improving access to maternity care and in achieving positive health outcomes for mothers and babies. We recommend that providing continuity of carer schemes for women from disadvantaged backgrounds should be a particular priority for maternity services.

Woman-held notes

179. Where it is impossible to provide continuity of carer, some degree of continuity of care may be preserved by the use of woman-held notes which would allow health professionals access to a woman's medical history, to information about any pre-existing conditions which might affect her pregnancy, and about the maternity care (or lack thereof) that she had received. The RCM argued that beyond the vital function of passing on medical and health information to maternity care staff, woman-held notes could also help a pregnant woman to become involved in discussing and making decisions about her own care:

all pregnant women … should be invited to carry their own notes and take a full and active role in decisions about the nature of their care. Women should be asked what they want included in notes about their condition so that this information does not have to be continually repeated to new carers.[160]

180. Diane Jones told us that use of woman-held notes was effective in helping to sustain care for women from transient populations because women were "more than likely" to bring their notes with them when they made contact with maternity services in a new area.[161] Women themselves may be less likely to lose their maternity records than hospitals.

181. However, we are aware that maternity services in some areas do not provide woman-held notes and a written submission to our inquiry from the Centre for Nursing and Midwifery Research identified further problems with the current system. According to the Centre, the value of woman-held notes in encouraging women to become actively involved in their maternity care was diminished because they were "rarely adapted to meet the literacy and comprehension needs of women with learning difficulties and those for whom English is not their first language." The Centre raised the concern that this problem could be exacerbated by the introduction of the Electronic Patient Record (EPR), which could lead in turn to the development of a "digital health divide." [162]

182. Although the use of woman-held notes does not address the problem of identifying and reaching those women who do not make any contact with maternity services, they are a valuable way of passing on information which may be crucial to the provision of appropriate care for women from transient populations and for women who see a variety of health professionals during their maternity care. Given the concerns expressed by witnesses during our first inquiry in relation to maternity care records, and to the Electronic Patient Record (EPR) in particular, we recommend that the Department should clarify whether the EPR will affect the use of woman-held notes and how it will be adapted to facilitate provision of appropriate services for disadvantaged women and their babies.

101 Q 2 Back

102 Ev 59 Back

103 For further discussion of how planning, involving patients themselves, can reduce staff workload and unnecessary hospital stays, see Health Committee, Third Report of Session 2001-02, Delayed Discharges, HC 617. Back

104 Ev 68 Back

105 Q 59 Back

106 Department of Health, Changing Childbirth: report of the Expert Maternity Group, 1993 Back

107 Q 23 Back

108 Department of Health, Maternity Services Liaison Committees: guidelines for working effectively, 1996 Back

109 Ev 57 Back

110 Ibid. Back

111 Ev 61 Back

112 Q 23 Back