Examination of Witnesses (Questions 1
- 19)
TUESDAY 17 JUNE 2003
MS BEVERLEY
LAWRENCE BEECH,
MS SARAH
MONTAGU, MS
ANNIE FRANCIS,
MS BELINDA
PHIPPS, MS
LOUISE SILVERTON
AND PROFESSOR
WILLIAM DUNLOP
Q1 Julia Drown: Good afternoon. I
welcome you as our witnesses to our third inquiry into maternity
services, as a sub-committee of the Health Committee. In this
inquiry we are going to be focusing on choice, but we will also
bring together some of the work we have done in our two previous
inquiries, one of which is coming out tomorrow. We are going to
try a vast area with you this afternoon, and I am anticipating
a vote at four o'clock, so we will probably have to finish at
that point. Brevity in questions and answers will be much appreciated.
Thank you all for your written evidence. I want to start off by
looking at some of the lessons that we would have hoped to have
learned from the Changing Childbirth report, which is nearly
ten years old now, and ask you a bit about that. Then, we are
going to go on and cover staffing issues, home births, litigation,
who should lead on maternity care, the roles of independent midwives,
caesareans, and if we have time there is a host of other questions
that we would like to put to you. Changing Childbirth was
very widely welcomed when it came out ten years ago. It is clear
from our work so far that there were a number of recommendations
that have not been implemented across the country, and the reality
of women-centred care is not to be found everywhere. I wanted
to know from you why that is, and throw in a particular example.
The RCOG, in its evidence, talked about issues to do with disability
and said that if these recommendations had been properly implemented
across the country, there would not be problems now. We heard
from a disabled mum who said she had to argue to get height-variable
cots, and, after much discussion, she managed to get them in her
area, but did not feel she had managed to get them in place beyond
that. Why do we still have those problems?
Ms Phipps: As a representative
of a user organisation, I think it is worth saying that I do not
think the NHS has learned the trick of putting itself in the shoes
of the user of the service very well. There is an interesting
example from Disney—I know a commercial organisation—where
it was discovered that the reason why the cleaning ladies were
discovered to be very good was because when they finished cleaning
a room, they lay on the bed, sat on the loo and lay on the bath,
and looked at the room from the user's perspective. Therefore,
they cleaned to maximise benefit for the user. The NHS is not
very good at that. Although we have Maternity Services Liaison
Committees, I do not think they are as powerful or as much listened
to as they could be, although they are probably the best forum
that we have. When you work in the NHS, as I have as a Chief Executive,
it becomes very day-to-day, and you focus on the latest piece
of paper you have from the NHSE or whatever else is the latest
issue. It is very easy to lose sight of the fact that birth is
a once, twice or perhaps three times in a lifetime experience
and is pivotal for the people going through it. Your everyday
working life is somebody's for-ever memory. The NHS just has not
got that, and I do not think society supports it in thinking from
that point of view.
Professor Dunlop: There are a
number of issues. First of all, Changing Childbirth, which
we supported in general, was quite an aspirational document, and
not all the aspirations were easy to achieve. Secondly, I do not
think there has been much resource put into maternity services
during that period of time, and particularly in relation to midwifery
staffing, we could have done with a lot more resources. Many of
these things did depend on numbers in midwifery, for example.
Thirdly, there has not been any clear guidance given by the Department
over this period; and now that we have the opportunity of the
national service framework, I hope that will be remedied.
Ms Montagu: I would agree that
funding did not follow Changing Childbirth recommendations,
which would obviously have helped to implement some of the things
that were proposed in that. Some were put into action. Where funding
was put in, it tended to be put in and very often directed more
towards the hi-tech end, because you can spend an awful lot of
money on a new scanning machine, when perhaps the money could
have been put into more one-to-one midwifery care, but it does
not have quite the same whizz-bangery effect as a new ultrasound
machine or whatever, but it has a more profound effect in terms
of the kind of care that that midwife would then be able to give.
Ms Silverton: I am not going to
differ with anything my colleagues have said. One of the key problems
is that there were never any specific targets. There were aspirations
but we do have a target-driven NHS. At the moment, because the
maternity service does not have targets, then there is nothing
bringing it to the attention of the primary care trusts. More
importantly, to some extent we have got the maternity services
the wrong way round. They are based mainly in the acute trusts,
which are geared towards treating people with time-limited illness
episodes and coping with waiting lists. Perhaps if we were to
look at childbirth as a life event, which for some women will
need medical intervention, then looking at it from a more normality
and community-based mode would help to take it out of the acute
trust and put the ball in the court of the women.
Q2 Dr Taylor: It is remarkable that
you have brought that up so early, because we were talking about
that just before you came in. It seems to us that it is something
that should be under PCTs rather than under the acute trusts.
I have a dream myself, with these foundation trusts about to come
in, that PCTs should be foundation PCTs, and the whole shooting
match should be run by local people as a foundation trust. I would
be interested in your comments of the practicality, Professor
Dunlop, of PCTs rather than acute trusts running it.
Professor Dunlop: I think a lot
of midwifery care could be delivered at PCT level, but I do not
think that will be easy for secondary care. I think for acute
care, especially since we are living in a situation where a marked
re-configuration of maternity services is taking place, it would
be very difficult for that to be delivered at primary care level.
Therefore, I think there still ought to be some relationship between
the two. There does need to be some sort of overarching co-ordination
of services, and that really is what the NSF should be addressing.
There needs to be some sort of managed network which will allow
both primary care and secondary care services to integrate effectively.
Q3 Dr Taylor: Our impression is that
there is very little co-ordination at the moment between primary
and secondary care. Is it any better in the obstetric field?
Professor Dunlop: Not a lot, in
that primary care tends to be predominantly dominated by general
practitioners, who actually do not deliver much obstetric care.
The best practitioners of primary care obstetrics are midwives,
who are often not employed by general practitioners.
Q4 Julia Drown: Would the RCOG object
to even the acute part, the secondary care part of maternity services
actually being under the management of the PCC, which happens
in Bath, as I understand it?
Professor Dunlop: That is an unusual
situation with a relatively small acute trust, and I think you
would have to look at that in the context of the neontenatal care
services and obstetric anaesthetic services and so on. I doubt
if it could work for the larger trusts.
Ms Beech: I think one of the major
problems with maternity care at the moment is that midwives do
not have any power, and I do not see that they are going to get
any power on PCTs either, unless there is a system that will enable
senior midwives to be involved at senior management level and
have real power within their area. There is not a recognition
either, I think, of the professional status of midwives. They
all talk about midwives being the primary whatever, but when it
comes down to it, so many midwives are required to fit into protocols
and guidelines that are very clearly, closely defined by another
professional group. Unlike GPs—you do not closely define
what a GP will do. One of the problems of looking after normal
birth is that there is such a range of normality that it inhibits
midwives from thinking clearly about this particular woman in
these particular circumstances. Unless we have midwives carrying
their own caseloads and being responsible for it, and not on this
system of teams and centralised care, we are not going to get
that kind of change, because where those units that have introduced
change and have provided the kind of care that many women want—like
Torbay for instance—they have got strong midwifery leadership.
The tragedy is that the midwifery leaders leave and then it goes
back to the old system. AIMS has been involved in maternity care
since the 1960s, and we see the same thing happening time and
time again.
Q5 Julia Drown: You are saying that
where it is a midwifery-led unit, that is good and you would support
that; but where it is being run on a team basis, the midwife's
voice is still not heard.
Ms Beech: It is where all the
midwives are integrated into one system of care, and where they
do not have very senior managers running it in the first place;
and so you end up with hospital-based midwives having to go out
to look after a woman at home, and they are very insecure about
it. Many of the trusts have not introduced any kind of further
training for the midwives. It is very unfair on the midwife who
has worked thirty years in a labour ward suddenly to be told,
"oh, you are going to do normal birth now; go out to Mrs
Smith".
Q6 Julia Drown: We will be coming
on to some of these things.
Ms Francis: I wanted to echo what
Beverley was saying. We believe that the model of care that we
offer women addresses a lot of these issues because the centrepiece
is that women make choice; and when women make the choice, that
is a very powerful starting-point. The way in which we work means
that we are very aware of the individual woman and the issues
that surround her, and what we strongly wanted to recommend is
that our model of care be offered as an option, alongside the
current structure—not having to dismantle what exists but
to offer it as a further option to those women who would like
that level of care.
Ms Phipps: On the power issue,
midwifery is a very different service from what goes on in the
rest of an acute trust. It is not generally dealt with by powerful
people in the hierarchy. If you go to an NHS trust Board meeting,
you will very rarely hear midwifery discussed, except in the context
of litigation. Of those people that sit on the board—there
is no midwife. The nursing director is rarely a midwife. The medical
director is rarely an obstetrician. The Board members do not have
any particular interest in midwifery, which means that the decisions
that the trust makes are based on sickness, not on midwifery.
For example, you will get the same sort of flooring put in across
the whole trust, even if it does not suit midwifery. Should we
put them in PCTs? The same applies because PCTs are dealing with
all the medical disciplines midwifery gets lost. I wonder whether
we would be better to have something like a midwifery trust, a
virtual body, where the board is focused on midwifery, where there
is a director of midwifery in the place of the director of nursing,
looking after the services that are located out in several different
acute Trusts. Like a specialist Trust, they are going to get a
true understanding of the range of what needs to be available
in midwifery. They are going to get good at both the end where
you do need medical intervention and the end where you need to
be very good at supporting and enabling normal birth. They are
going to be able to spend the time on the issue that Annie has
raised about making sure that women have the opportunity to use
independent midwives and to use the services that they provide;
whereas it is very much a low level, low key, not properly considered
issue, and choice is squashed as a result of that.
Q7 John Austin: You have said that
one of the reasons why things have not been driven forward has
been the absence of any targets. Throughout the rest of the NHS
we get complaints that there are too many targets, but what are
the key targets that you would like to see set in terms of midwifery?
How could they be arrived at?
Ms Silverton: There are a number
of areas that we could look at. We could look at setting targets
for the percentage of women cared for in particular models of
care—for example, the percentage that had caseload care,
where one midwife with a partner look after a defined group of
women. We could look at the percentage that have domino care,
where they have mainly community care and are brought in for birth,
or the percentages for home birth, as they have done in Wales;
or you could set percentages for the number of women who see a
midwife as their first point of contact rather than being put
into the medicalised system by seeing a general practitioner.
More importantly from the point of view of the College (RCM),
on the targets on the number of hospitals that have undertaken
BirthratePlus analysis of the requirement for midwifery workforce,
and the number of percentage of units that find the funding to
match the shortfall in midwifery numbers.
Q8 John Austin: How can you be sure
those targets are not just arbitrary and that they do actually
reflect women choosing and being empowered to make choices?
Ms Silverton: At the moment, part
of the problem is that the definition of what we mean by "choice"
is rather difficult to define. You could say that some people
may say, "choice is choosing you what I offer you",
which is a very cynical way, but unfortunately does happen. Certainly,
the issue of choice about caesarean section seems to be much more
acceptable in some circumstances than it is to choose a home birth.
We need to look at women having good advice that they can understand,
and having time to make decisions—not being expected to
make a decision there and then. The informed choice leaflets are
a very good guide to this, although they are not geared to women
from ethnic minorities and they do tend to be written at quite
a high level of understanding. If they give time for the woman
to read them and then come back to the midwife and discuss them,
having considerable time to think about what it is she wants to
do, then choice can be made real.
Q9 Dr Naysmith: We want to look at
staffing and choice and the inter-relationship between them. We
have heard from Beverley and Annie about situations where choice
for women is limited because of the way things are structured.
To what extent does the lack of choice for women contribute to
the staffing shortages?
Ms Phipps: Most women want to
have a baby and come out of the experience physically and mentally
whole, in a good state to be a parent. For most women, that means
a straightforward vaginal birth. That is the option that is most
likely to give that outcome. When enabled to choose that and when
they have the information in front of them that shows them in
order to achieve being physically and mentally whole at the end,
a straightforward birth is the most likely to do it, women choose
those sorts of services. We have seen that in other countries:
women voting with their feet for midwifery services that are very
good at increasing straightforward birth. That, overridingly,
is what women want. If we are going to measure anything, we need
to measure those outcomes and measure our ability to enable women
to have a straightforward birth. It is a treble win, because not
only is straightforward birth better for the vast majority of
women, but it is also cheaper for the NHS and it is a much nicer
way for the vast majority of midwives to work. Midwives enjoy
being able to spend time to getting to know a woman, and feeling
a sense of achievement, as the woman does, in getting to the stage
of having a baby and being able to look back on the experience
as a positive, joyful experience rather than a traumatic horrible
memory that she would like to forget. We know what works. We know
that independent midwifery works; we know that birth centres work
and that home birth works. Those are the very choices that are
not easily available for women at the moment.
Q10 Dr Naysmith: I am trying to get
at whether because they are not available, that in itself reduces
the number of staff available.
Ms Beech: It is not a question
of reducing the numbers of staff available. The problem is that
most women do not have normal births and they do not get it in
the hospitals—Sue Downes' research showed that only one
in six first-time mothers have a normal birth in large centralised
consultant units. It gets very demoralising for the midwives;
they are not happy about the kind of care that they are having
to provide that does not enable women to have these kinds of births.
They are not able to go out and help the women deliver at home
because many of the trusts are very antipathetic towards home
birth, and the midwives become disheartened and discouraged. One
midwife said to me recently that she was leaving midwifery. We
asked her why because she was such an experienced midwife—a
lovely midwife. She said: "I am not prepared any longer to
continue abusing women in these large centralised units and I
am giving it up." That is a terrible indictment, and there
are thousands of midwives who feel similarly.
Ms Francis: What we understand
is that there are between 5,000 and 7,000 registered, qualified
midwives currently not practising. One of the reasons for that
is because of the way in which care is given to these people in
these systems. Those midwives have expressed an interest in working
in the independent area. If we were to offer that, we believe
that you would solve the staffing crisis, or would certainly work
towards solving it.
Professor Dunlop: Can I say that
none of us wish unnecessary intervention in maternity care, and
that includes our college. However, when we say that we know things
work, I actually disagree with that. We have very little knowledge
about maternity services, and I think that is a major defect that
somebody ought to be putting right. The NHS statistics for 2001-02
have just been published, and there is some improvement in data
collection from NHS hospital deliveries from 57% in 1989-90 to
70% in 2001-02. This is data that is usable, interpretable data.
When you look at home deliveries, there has been a decline from
only 20% in 1989-90, to 14% in 2001-02. I do not know how anyone
can say we know what is happening in relation to home confinement
because I certainly do not know. One could hypothesise that one
does not have data from 86% of pregnancies which may have gone
terribly wrong. We just do not know.
Ms Montagu: I would agree that
data collection is important, but there quite a large number of
very robust studies which reflect the outcomes of one-to-one care,
and the importance of having a known, trusted carer throughout
a pregnancy and a birth, and the difference that that makes. I
very much second what Beverley was saying. I am frequently rung
up by midwives who are desperately frustrated at the kind of care
that they end up having to give, and the processes by which women
have come in, ostensibly normal, and end up with birth that is
definitely not normal, that is predicated by the way in which
the hospital system works. Midwives just cannot stand having to
collude in that kind of care any longer, and they give up and
leave. Those are the very midwives that you want to keep.
Q11 Dr Naysmith: What kind of evidence
do you think is needed in order to provide for women? Is it not
simply enough to say that there is a fairly large number of women
who have births that do not require intervention, and many of
them are at home and trouble-free; or are you looking for a bit
more scientific evidence?
Professor Dunlop: We want to be
able to audit what is happening in the National Health Service,
and I cannot do that. We cannot do that with the data we have.
We are drawing conclusions about home confinement and about free-standing
midwifery-led units that are not based on substantial evidence.
The number of women having births under these circumstances is
small, and there are not properly conducted studies. I do not
accept that the studies are robust enough.
Q12 Dr Naysmith: I was about to ask
you about evidence from overseas, somewhere like the Netherlands,
where there is a significant number of home confinements: is that
evidence not good enough?
Professor Dunlop: No, it is a
totally different system and a totally different population with
different ethnic mix and a different history. There are lower
perinatal mortality rates in Sweden where there are virtually
100% hospital births.
Ms Phipps: But they are low-tech
hospital births. There are many more normal births in Sweden.
Professor Dunlop: I have no problem
about why, it is the conclusion that home births are safer and
that is illogical.
Ms Phipps: And in Holland as well
because there they have a 33% home birth rate and they have extremely
good mortality figures. I would agree that statistics that are
provided by the NHS are not good enough, and we do need them to
be accurate so that we are not working in the dark. However, there
are a number of good studies, including studies on home birth,
that show that it is as safe, if not safer than hospital birth
for a low-risk normal pregnancy. That has been shown over and
over again, and we really do not need to go back and question
that data; it exists. In addition, if you saw as many birth stories
as I do, you would see that it is rare to see a home birth where
there is either a poor experience or a medical problem resulting
from that home birth. We know, just by looking a home birth, that
you half your risk of a caesarean section or other intervention.
So there is very good data. I know that the NHS data set is not
very good, and we need to address that, but these are two different
issues.
Ms Silverton: There is some good
data on the midwife-led units and birth centres, and also on home
births, which is collected locally. The problem is that they do
not fit in with the NHS statistics, because of the way in which
they need to be calculated and collected. For example, home births
do not have a hospital number. Then it does not appear anywhere
on the system. However, we do know that the data is there, and
that for women at low to moderate risk of complications, their
outcomes are as good, if not better, given they do not have interventions
at home. To return to the question of shortages and the effect
on models or types of care, it is a chicken-and-egg situation
because where midwives can plan their own model of staffing, this
might result in a very mixed economy in the trust with many different
models of staffing. The midwives are much happier to work in that
way, and they feel that, like the women, they have got control.
The midwives follow the women rather than staffing the unit and
having fixed shifts. What they do hate, once they have established
themselves as caseload midwives or four-in-a-team midwives, or
whatever it is, is then being dragged off to plug gaps somewhere
else. That really upsets them. Mavis Kirkham's work for the college
on why midwives leave certainly showed that this was one of the
things that undermined their satisfaction. We also need to look
very clearly at the demographics of midwifery. Twenty per cent
of midwives are over fifty. Given that all NHS midwives can retire
at 55, we have a huge problem looming. The number of training
places has increased, but not sufficiently. Again, we could argue
that there are not sufficient normal births for the students to
get experience of, and more worryingly there are not enough midwives
out there to act as mentors and to provide the correct role model.
The idea is that we want to socialise midwives into doing a woman-centred
model of care, and not a much more medicalised, almost an assembly
line type of care, which unfortunately occurs somewhere. We are
also worryingly losing not only student midwives because they
cannot survive on the bursary, but we are also losing newly qualified
midwives in their first year who find that they cannot cope with
the pressures of looking after two or three women simultaneously.
Ms Phipps: Women want that as
well.
Q13 Dr Naysmith: I do not mean to
deprecate the evidence you are giving, but everywhere we go as
politicians at the moment, we hear that university lecturers,
for instance, constitute an aging profession, and if we do not
do something about it we will not have any—and the same
for teachers and almost every profession. GPs are a bunch that
are also supposed to be—
Ms Silverton: I think we could
encourage them to stay longer if they felt they were giving the
right sort of care.
Q14 Dr Naysmith: Is it right that
people can just select the best bit, the nice bit they want to
do about their profession, and not do some of the others?
Ms Silverton: If you take a group
of a hundred midwives, you will find that a significant proportion
like hi-tech labour wards. They love it.
Ms Phipps: And some people need
that sort of care, and they deserve midwives that love giving
that sort of care. They deserve the full attention of the obstetricians
rather than obstetricians spending time with women that really
ought to never come through the doors of a hospital. We have actually
got it wrong. In order to safeguard the lives of women and babies,
which we all want to do, we have forced many more women, without
giving them proper choice, through the doors of hospitals, where
actually they are subject to care they do not need, which costs
the NHS money, which alienates midwives and reduces our obstetrician
time. We need to be much better at helping sort out which women
do need that sort of hi-tech care, and making sure they have the
information they need so that they know why this is being suggested
to them and they can make decisions about it, and making sure
that women that have the opportunity to have a straightforward
birth get the support they need and know what sort of services
will help them get that.
Q15 Dr Naysmith: I did raise the
question of what lessons we can learn from overseas. Are there
any other lessons that we can learn, perhaps the use of maternity
care assistants?
Ms Francis: I feel that the question
of research is a real red herring. We do not have enough to research
to show that the lesser the level of unnecessary intervention,
the better the outcome; because Margaret Tew's work addresses
all the statistics that are available, and has a very clear conclusion,
which is that historically obstetric intervention has not improved
the overall safety of the mother and baby. It is very easy to
look at the continuing arguments about how you collect data, but
the absolute fundamental situation is that women do better in
either birth centres or at home, in the low-tech areas. Perhaps
rather than restricting criteria into birth centres, we should
be looking at making criteria into consultant-led units so that
only those women with high risk or the problems go in, so that
we turn the whole situation around on its head.
Q16 Dr Naysmith: Has there been an
increase in the numbers of women who want to deliver their baby
at home or in free-standing midwifery-led units?
Ms Beech: There was a study done
in York many years ago that showed that if you gave women free
choice of where they wanted to have their babies, 20% would choose
it. That was at a time when they were very much restricting home
birth. If you give women choice, as the Albany practice has done,
a far greater percentage of women will choose to have their babies
at home. We have trusts in this country that really vigorously
oppose home birth. You can pick out which trusts they are and
where they are. We get constant letters and e-mails and requests
from women who are trying to get their way round the system because
they have been told for various reasons, many of them spurious,
that they do not qualify any more. I had a woman ring me yesterday
who said she has been told by her trust that they have already
booked their quota for home births in an area that only has a
2% home birth rate, and therefore she cannot book her home birth.
Q17 Dr Naysmith: That would suggest
that there are not enough resources and facilities.
Ms Beech: They are spending their
money on hi-technology care—ultrasound for just about everybody—and
it is very questionable whether every woman needs an ultrasound
examination. Instead of putting the money into the more low technology,
it is "paint the walls, put up the curtains" and spend
money on yet more technology.
Q18 Dr Naysmith: I wish they would
do that in my local hospital!
Ms Phipps: If you look at the
process, before a woman is even pregnant, she has been exposed
to multiple images of hospitalised/medicalised/on-your-back birth,
and she may not even realise that home birth is a possibility.
If she does know it exists as a possibility, she may not know
that it is as safe, or safer, than hospital birth if she is normal
and low-risk. The most common place for a pregnant woman to go
to is still to her GP—89%—despite the fact that the
midwives are there for normal birth. She may tentatively say to
the GP, "I am thinking of having a home birth", and
GPs are woefully under-informed about the safety of home birth.
They are working on pre Marjorie Tew data on home birth. They
do not understand the benefits. They may say, "you are not
allowed; I will not let you; you cannot stay in my practice"—they
may just suck their teeth, and that is enough to put a woman off.
You have eliminated choice already up-front. If a woman actually
has to struggle and argue and present her case and listen several
times to the disbenefits of home, is that choice? No, it is not.
Does she get a clear explanation of the benefits of home birth
and the disbenefits of home birth; the benefits of a hospital
birth and the disbenefits of a home birth? No she does not.
Q19 Dr Naysmith: Who should provide
that?
Ms Phipps: The midwife.
Professor Dunlop: I am sad that
this is degenerating into an exercise in territorial issues because
I actually think there are much more important issues to address,
and that is how we develop maternity services as a group, as a
team, as a country. We require the whole spectrum of care.
Ms Beech: But we are not getting
it at the moment. That is the problem.
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