Examination of Witnesses (Questions 60
- 79)
TUESDAY 17 JUNE 2003
MS BEVERLEY
LAWRENCE BEECH,
MS SARAH
MONTAGU, MS
ANNIE FRANCIS,
MS BELINDA
PHIPPS, MS
LOUISE SILVERTON
AND PROFESSOR
WILLIAM DUNLOP
Q60 Julia Drown: The Department will
always be concerned about having to put money into anything but
the NCT has said that the existing model is probably more expensive,
so we could at least encourage the Department of Health that there
should be a one-off to make changes.
Ms Silverton: And to consolidate
those changes. We already know that there are changes going to
happen to some maternity units. This is an opportunity to try
them out as lower-tech units and to have a much more mixed economy
than we do at the moment and also to look at what is happening
in Wales with their Normal Labour Pathway.
Ms Montagu: One of the problems
with Changing Childbirth was, while everyone very much liked the
ideas that were in it, the schemes that were set up were supposed
to be cost neutral. This was very difficult to achieve obviously.
We need to look at pump priming schemes, for instance, latching
into things like Sure Start. Some of the very successful Sure
Start midwifery one to one teams run for a length of time and
they can be picked up by the service as a whole. We need to be
taking a rather more long term view and putting a certain amount
of money in in order to have schemes that achieve the critical
mass that will then be able to carry on within the system.
Professor Dunlop: It is quite
difficult to predict how much money we might save by transferring
care from one environment to another. The costs of Caesarian sections
are quite difficult to calculate because there are costs involved
in setting up the maternity unit in which you can do Caesarian
sections from which you cannot escape. It is quite a complicated
area. It is not nearly as straightforward as people will tend
to suggest, so I would not place too much reliance on persuading
the Department of Health that it would save money.
Ms Phipps: I have worked in three
sections in my working life, the commercial sector, the public
sector and now the charitable sector. Based on the way all three
work, the received wisdom is you need to have a vision if you
want to change something. That is well accepted. However, I do
not think the NHS has a strong vision for what maternity care
should be and could be. If you have a strong vision, it acts as
an attractor and everybody moves towards it. Something needs to
happen at the very top to have that vision accepted across the
whole NHS. Managers fundamentally are responsible for the system
and they need to set the system up so that it is likely to achieve
the vision that we have. We do not have a system that works that
way. Maternity is not taken enough notice of. Eighty per cent
of the births ought to be in midwives' hands and do not need any
significant intervention. We need a system that gives power to
midwives for the majority of births. Obviously obstetricians need
power and money to because 20% of women definitely need obstetric
support. The way we work now does not work like that. One thought
is the Maternity Trust idea but there must be other ways of achieving
this. It would be very wrong to go to the front line and expect
the front line to work harder when they are working quite hard
enough already. If we do go to the front line and ask them to
change without a vision, without changing the structure, it will
not work. If we change the structure slightly and create an attractive
vision, we can go to the front line, but they will need change
teams and pump priming money. I do not think longer term we should
put more money in because we know there is money in there that
is not being used appropriately. We need to expand the choice
for women to make sure that women can access low tech, cheaper
to run services more easily. We know from the Albany practice
that the very women who need individual support now get it because
they have access to an Albany midwife. For women who do not have
a good grasp of English, women who are new to this country, women
who are disabled or very young, the Albany practice gives them
something that we find it very difficult to give them in the system
in which we work. I would say do not do Changing Childbirth again.
It did not work. You need to do something more at the top. We
need to measure outcomes, not activity, so let us measure how
many women have a normal birth. Let us make sure we keep a grip
of mortality and morbidity and let us measure some of the long
term outcomes so that we do not become very short term focused.
We also need to measure breast feeding because it is a significant
public health issue that we do not have the breast feeding rates
that we should.
Ms Francis: When you are looking
at the financial implications of change, I agree that when you
are trying to set up birth centres or midwifery led units, initially
there may well be greater cost but we are saying we should look
beyond that to the longer term. There has been a lot in the press
recently about the huge increase in type two diabetes linked to
obesity. If you look at breast feeding, both for mothers and babies,
there is a strong correlation between breast feeding rates and
reduced rates of obesity. If you could have a long term vision,
you would then have massive savings.
Q61 Dr Taylor: Do you think the opportunities
for choice for women have improved in the last 10 years?
Ms Beech: Absolutely not. Choice
is an illusion. The majority of women are conned into thinking
that they have a choice. What they have is a specific menu that
is offered to them. If they choose within that menu, that is fine.
If they choose outside that menu, they have an enormous battle
to get what they want.
Ms Francis: With CNST and the
tighter protocols and policies, there is an ever more restricted
choice.
Professor Dunlop: Either you say
there is more choice within a menu or you say there is not. I
think there is a wider menu now available than there was ten years
ago. I would not agree that there is no choice. There may not
be sufficient choice. I would not dispute that but I do think
women have more choice now.
Q62 Dr Taylor: Could the addition
of patient fora improve the way actual mothers and potential mothers,
feed into the service?
Ms Phipps: They are not patients.
Patient fora are not the thing to deal with maternity. You are
dealing with well women going through a major, life change. The
NHS has a brilliant system of involving users. MSLCs are a fantastic
way of involving users because they are multidisciplinary teams
of people who are given a reasonable amount of clout. The user
representatives, if the MSLC works well, should be involved in
not just what colour should the wallpaper be but the strategic
direction of the service they are going to use. It is important
for MSLCs to continue and to be strengthened.
Q63 Dr Taylor: I would agree with
you that they are not patients but they are users of the health
service.
Ms Phipps: Maternity is so very
different from everything else. There are very few other parts
of the health service where you are changing status from a woman
to a mother from a man to a father. That is a significant life
change. The only equivalences are getting married or that sort
of thing.
Q64 Dr Taylor: As this is the Government's
main aim in user involvement, rather than patient involvement,
I would have thought that it is absolutely crucial for you to
get people interested in maternity care involved with patient
fora.
Ms Phipps: The NCT will do that
as well but fundamentally one of maternity's problems is that
it runs alongside other services which are life and death, fascinating,
with lots of research, cardiology, heart transplants. Maternity
is different. This is all about normal people having an everyday
but very special life event. It is overwhelming when you sit in
a room with the most horrifying chronic or acute situations and
all you have done is have a baby. It does not match up.
Q65 Julia Drown: Louise, in your
evidence you talked about the problem of MLSCs and some being
disbanded and funding issues, needing to get more people with
disabilities, people in ethnic minorities and so on.
Ms Silverton: There are concerns
because the statutory basis of the funding for MSLCs was with
the health authorities. As an unintended fallout off of the demise
of health authorities, the requirement to fund MSLCs fell off.
A number of primary care trusts are seeking not to fund MSLCs
because they simply do not have to. That is a big concern. MSLCs
are patchy. Some of them are brilliant. Some of them are of very
doubtful use and effectiveness. Perhaps we ought to learn from
the ones that are effective. We have talked about the professional
patient but how do you get the hard to reach people to come forward,
to find out what the experience of a Bangladeshi person in Tower
Hamlets is of using maternity services? How do you get someone
with restricted mobility or someone who has a sight impairment?
How do you make sure that they are represented? The College of
Health has done some excellent work on involving hard to reach
groups, particularly in maternity services.
Q66 Julia Drown: If there were any
magic solutions, we would like to hear them. In the RCOG's evidence
you questioned whether the remit was right for MSLCs.
Professor Dunlop: There is enormous
variability. Some are quite effective; many are not.
Ms Phipps: The NHS could make
use of market research. There has been talk about over-use and
focus groups but market research has a very valuable part to play
in reaching people who would never come to an MSLC meeting, whose
voices would never be heard. You can do quantitative surveys or
small qualitative surveys among specific groups to give you fascinating
information. That needs to be fed in via something like the MSLC
and taken notice of. You do not always have to have individual
representatives round the table in an MSLC meeting. These sorts
of committees can be very intimidating for the hard to reach groups.
Its hard to expect one single person to represent the views of
many. The only way you can reach people is to talk to lots and
lots of people with disability, put their views together and make
sure they are taken on board by the NHS using something like the
MSLC.
Professor Dunlop: I strongly support
the idea of consumer research. There is far too little of it done.
As we said in our evidence, there was some work done on a pilot
basis by Tina Lavender as part of the Maternity and Neonatal Workforce
Working Group which produced some answers which we were not expecting.
I do not think we can read too much into but it certainly needs
to be followed up.
Ms Francis: One of the things
that came out of that particular piece of research that I saw
as well was that women do not necessarily know what their choices
are. That is our argument. There is a degree of low expectation
within the maternity services. When women have gone through our
care and when we discharge women at 28 days, one of the most frequent
comments that we get is, "We could not believe how fantastic
that whole experience was." When we are asking them about
their choices, we need to be sure that they are understanding
what their choices are.
Q67 John Austin: Someone was talking
about the number of drop-outs in the training of midwives and
you mentioned bursaries. We are aware that midwives' training
is funded in a different way from other university courses. Is
it materially different? Are there particular problems in the
way it is funded and do training employers have access to other
means of financial support through the social security system
that other students have?
Ms Silverton: We have two ways
of funding students. Those who are on undergraduate programmes
for the most part are on the student loan system and are paying
fees. They are subject to the usual problems of all those students
plus, for the most part, they are working many more hours than
the traditional undergraduate in mediaeval history, to quote the
Secretary of State. However, the majority of students who are
on an NHS training basis are on a bursary of about £5,000
or £6,000 a year. This unfortunately removes some of their
eligibility for things like top-up loans. They cannot get free
school meals, for example, so it does create problems when accessing
funding. We find particularly as our students do not tend to be
18 year olds as they come into midwifery—many of them are
single parents and of far more mature years—they cannot
survive. The drop out rate is towards the end of the second and
into the third year, when they have almost finished. Unlike student
nurses who are similarly funded, they do an awful lot of on-call
because they want to work with their midwife and provide continuity
of care and to attend home births. They are working many more
hours so the ability to get a job in McDonalds, for example, is
not there. They also travel a very long way on their placements
and although travel costs are reimbursed we have had instances
of students being up to £4,000 in debt because they have
not received their travel allowance. There are bizarre systems.
If you are based at home and are moved to another unit for part
of your experience, you do not get your cost of rent in that unit
paid. In the west country, students are going 80 to 90 miles a
day for clinical placements and this results in them driving every
day. I do not think people have looked properly at this. We are
not arguing for a salary. We think students need the very minimum
of between £10,000 and £12,000 a year to survive and
to be able to concentrate on their training programme. Then we
are not wasting money on giving them two years' training and then
they have to leave because they cannot afford it.
Q68 John Austin: You mentioned that
many of them will be single parents.
Ms Silverton: They are parents.
They do get an allowance if they have dependents but if they have
a partner the partner's income is taken into account. This seems
extremely unfair where you have a low earning partner who essentially
is managing to keep the student midwife and supporting the NHS
in doing so.
Q69 John Austin: What about provision
of childcare support?
Ms Montagu: It is hugely difficult
for student midwives and often that is the straw that breaks the
camel's back. Some students are single parents and if you are
going to be called out at two o'clock in the morning it is not
easy to get childcare. It is easy to get childcare cover nine
to five but not at three o'clock in the morning. A lot of students
end up being unable to find childcare that is affordable or manageable.
They never finish their courses because of that.
Q70 Sandra Gidley: I ought to declare
an interest because I was quite heavily involved in NCT many years
ago. One of the things that concerned me particularly about NCT,
although it was mostly brilliant, was we only seemed to reach
the white, middle class women on average. It was very difficult
to expend any sort of provision out towards other women who could
not afford classes and who maybe lived in areas where there was
not an NCT. I also saw last week in The BMJ an article
saying that the articulate patient took up too much time and deprived
other people of time. Have we reached a situation where choices
are available for white, middle class women but are probably not
relevant to disadvantaged groups?
Ms Silverton: It should be even
more relevant.
Ms Montagu: It is not that it
is not relevant; it is not available.
Ms Silverton: If you look at the
Albany practice, they are looking after a group of socially deprived
women who are getting one to one midwifery care and a lot of social
support which will be improving their outcomes. I am not arguing
against providing care for the articulate middle class because
of course you do get the cascade down from that but something
needs to be done to make sure that choice is available for all
women and you do not simply assume that because a woman does not
speak English, hospital care is best for her. If she is at home,
she has her family around her and she does not feel so isolated.
That is what we should strive for. Also, if we are looking at
employing maternity care assistants, in the same way as the midwives
should reflect the local population, it is easier with maternity
care assistants who live locally to make sure that they match
the local population as well so that the women are cared for essentially
by their own community.
Professor Dunlop: We do tend to
assume that the needs of white, middle class women are what the
service should cater for. I am not suggesting it should not but
there is some evidence to suggest that other women may choose
other things and the service does not necessarily provide them.
The Tina Lavender Study highlighted that. It came up with some
results that people were not expecting and that is why I said
we need to support market research.
Ms Francis: As independent midwives
one of our biggest difficulties is that we have to charge to offer
the model of care that we give, which is why we feel so strongly
about it being offered as an option within the NHS. We believe
you would then address that inequality of access. If it was offered
as an option to any woman wanting it, you would then be able to
offer that model of care to those who could not afford it.
Ms Beech: Because AIMS has a helpline,
we are approached not just by middle class women but also by working
class women. We can tell that from their accents and where they
are living. We have not found that they are asking for anything
significantly different from what middle class women are asking
for. The difference that we perceive is that some professionals
take a different attitude towards them and presume that because
they are inarticulate, working class or whatever they do not give
them the information and they find it a lot more difficult to
get the information. When they come to us, they are quite surprised
at the amount of information that they can get and they act on
it. They do not act any differently from middle class women. They
have the same aspirations and the same beliefs. They want a fit
and healthy baby and they want to be able to have an influence
on the care that they have and the care that is appropriate to
their needs.
Ms Phipps: The Tina Lavender Study
did look at groups of women that were not white and middle class.
The common theme was all women were wanting a level of control,
to be involved in the decision making. For those groups that are
harder to reach it is true too, which is all the more reason that
we should offer a range of models of care, particularly the ability
for women to choose their place of birth. I think the NHS is woefully
inadequate in providing interpreters. I was talking to one deaf
woman. She needed somebody who could speak to her in her own sign
language rather than having to mouth and shout at her when she
is having contractions. This is an issue for all organisations,
the NHS and the NCT. White, middle class women have insufficient,
proper, informed choice. Women who are disadvantaged or excluded
in some way are far worse off; yet they want the same things.
Q71 Sandra Gidley: When it comes
to breast feeding, there is a class divide. It is something that
concerns a number of people because most of us would sign up to
the fact that breast feeding is a good thing. Bearing in mind
that you often do what friends and neighbours do, is there anything
we can do to improve the breast feeding rate?
Ms Phipps: Yes. We should cease
to have advertising of formula in this country. We should implement
fully the WHO code. We know that, particularly with young or disadvantaged
women, poor women, peer support works really well when you have
somebody in your road or that you know who has breast fed. They
can sit and talk to you and it becomes a group thing and you feel
supported in doing that. We should train our midwives much better.
Many of our midwives arrive on the wards having had very little
breast feeding training, certainly nothing like the two years
that a breast feeding counsellor working for the NCT gets. Those
are just three things for starters and there are so many factors
that affect or are affected by breastfeeding what we really need
is a strategy.
Q72 Sandra Gidley: Would people agree
with that? There is a big drop off rate. The support you get in
the early days which is often hospital based or local midwives
based is crucial. Do midwives have enough training?
Ms Silverton: I do not think midwives
have enough time. You need to be able to sit with a woman for
more than half an hour for the first breast feed to explain to
her the physiology of breast feeding, to explain how she will
know the baby is attached properly. You then need to do it perhaps
twice more so that when the baby is five to six weeks old and
that women is feeding every two hours, she thinks herself not,
"I do not have enough milk" but "My baby is having
a growth spurt." If women are not given the information,
if they do not understand the physiological basis of breast feeding,
you undermine the process. We say breast feeding is natural but
being natural does not mean it is easy. It has to be learned.
If we look at other societies where the final act of parenting
for a mother is to assist a daughter in childbirth and to ensure
that she breast feeds well, we have lost that technique. In south
Yorkshire—I think it is Pontefract; it might be Doncaster—there
is a team where they have young women who have breast fed and
they are getting more young women to breast feed. It is becoming
acceptable to do so. Until we can remove the perception that breasts
are only sexual organs rather than being there for nourishing
babies, we have major problems. Work has been done with young
boys and they think breasts are dirty from the age of about nine.
Ms Phipps: We need some work in
schools as well. There is a section in the infant part of school
life where children of about four learn about what babies eat.
The number of displays of formula tins appearing without any concomitant
discussion of breast feeding is horrendous. It starts very early
in life.
Ms Francis: Going back to continuity
of care, one of the difficulties is that a lot of women, especially
on a post-natal ward if they are there after a Caesarian section,
for example, for a few days will have a huge number of different
midwives. We hear very often that each midwife will have their
own particular way of showing you and women end up thinking they
do not know what they are doing. It is absolutely crucial that
there are very straightforward, simple ways of talking to women
about the best way to breast feed that will give them the information
so that further on down the road, when the midwives are not there,
they will be able to continue with.
Ms Beech: Two years ago I visited
a hospital in Poland. They have a policy that no advertising material
about bottle feeding is available anywhere in the hospital and
they have a 98% breast feeding rate. I said, "What do you
do with a woman who wants to bottle feed?" They said, "That
is fair enough. She brings in her own bottles and we will help
her prepare them." It is not available and they cup feed
the babies. They do not give babies bottles.
Ms Montagu: In virtually every
maternity unit in the country, if a woman decides she wants to
bottle feed the bottles are ready mixed with milk and they get
passed out with gay abandon. If women decide they wish to bottle
feed, they can but they would have to bring in their bottles,
their teats, their powder and so on to make up the feeds for their
babies. I think we would see an instant drop. It is so often that
women say, "I would like to breast feed" and they come
out of the hospital bottle feeding. That single step of making
women bring their own bottles in if they want to bottle feed would
make a huge difference. In Birmingham, where I am based, there
are schemes called Bosom Buddies where peer support from women
living in inner city areas is supporting women who want to breast
feed and that has made quite a bit difference, particularly in
continuance rates.
Professor Dunlop: We are all very
keen to see breast feeding rates increase but it is important
to remember that we are talking about informed choice and some
women do choose not to. It is important that they feel supported.
The other thing to remark on is the marked reduction in the amount
of time women now spend in post-natal wards in hospital and therefore
the reduction of availability of support within the hospital.
If we are going to overcome this, there is a need for support
within the community to a much greater extent than we have now.
Q73 Julia Drown: Louise, you were
speaking about the time midwives spend with women. Are you satisfied
that in training midwives are being given enough training in breast
feeding?
Ms Silverton: I think they are
getting enough theory. Whether they are getting enough time sitting
near an experienced midwife to see how it is done and working
through with the woman who is breast feeding, I do not know. I
would say that is very variable. One of the reasons for suggesting
experienced maternity care assistants is that they can be trained
to support breast feeding mothers, to provide additional support
for midwives perhaps when the woman is at home. When I was a student
midwife, women who were having Caesarian sections were in for
eight days. You knew if you did not get that baby on the breast
the first day you had eight more nights and it was going to get
worse so you got good at it. I was taught by the auxiliaries who
had all breast fed their babies.
Q74 Julia Drown: What would be the
recommendation from this Committee?
Ms Silverton: Student midwives
need access to good role models and to see midwives helping women
to breast feed, but many midwives do not have the time.
Q75 Sandra Gidley: My local unit
at Southampton's Princess Anne Hospital a few years ago employed
a breast feeding specialist. I think she was a nurse originally
but not a midwife. She was a trained NCT breast feeding counsellor.
That seems to have worked extremely well. Is that fairly unique
to Southampton?
Ms Phipps: No. It happens elsewhere
and it is something we would like to see more of. The NCT does
have a middle class membership but we aim to reach all women and
we probably reach every single woman in the country, directly
or indirectly, in one way or another. More and more NHS trusts
are taking on either volunteers or even paying NCT breast feeding
counsellors to come into the unit and spend however long it takes
with individual woman breast feeding for the first time. The NCT
we set up a breast feeding line and publicised it last year using
a poster of a woman with quite a lot of tattoos and piercings
and a mobile phone message. As a result, we have seen the number
of calls from mobile phones from young women rise hugely. More
and more the NCT is reaching people we would not otherwise reach,
particularly on breast feeding issues. It is very important that
women who want to bottle feed can choose to do so if that if their
wish. Bottle feeding women can only get information, by and large,
from formula companies. We need a leaflet out there which is not
produced by a formula company but by somebody independent so that
women who want to bottle feed can get objective information. Formula
companies have every excuse to send out an awful lot of promotional
material but if we had a straightforward leaflet on bottle feeding
and on the different types of formula, what has benefits and what
is irrelevant, that would help and make choices easier for women.
Q76 Julia Drown: For the purposes
of the record, there is a lot of nodding going on in response
to that.
Ms Beech: We need to take on board
the insidious nature of bottle feeding advertising. Hillingdon
Hospital, many years ago, was given a hearing testing machine
by Milupa and above the door all they had was a tiny sign that
just said "Milupa" on it. The amount of bottle feeding
of Milupa products in the area went up over 300%. It had a huge
effect.
Ms Silverton: I want to go back
to the issue of informed choice for women. Yes, we would like
women to breast feed and if we do explain to them the values of
breast feeding many of them will choose to breast feed. However,
bottle feeding well is not easy. Many midwives have not had experience
of teaching women how to make the feeds up properly. The more
babies a woman has, the less likely she is to feed properly. We
must not lose sight of the bottle feeding woman's right to be
taught how to bottle feed safely and well for her baby.
Q77 Julia Drown: The RCM sent us
some quite powerful evidence on racism, pointing out that the
experience of older midwives from minority ethnic groups might
deter younger ones from coming through. What is the solution for
us in terms of making sure there is proper support for everyone?
Do we need some champions?
Ms Silverton: Some work is being
done led by the chief nurse assisted by the College, looking at
supporting black and minority ethnic midwives, particularly midwife
leaders, because in some areas it appears there is a glass ceiling.
It is an issue of having appropriate role models. Valuing diversity
is important in the NHS. It is something that is often trotted
out but it has to mean it and it has to mean that all midwives
have access to opportunities for development, training, progress
on the basis of being a good midwife, not on any other basis.
Q78 Julia Drown: We have seen fairly
unequal access to things like birthing pools and TENS machines.
Are there any views on whether there is a big, unmet demand in
these areas? TENS machines tend to be rented or bought by individuals.
Should these be more freely available across the NHS?
Ms Francis: The problem with birth
pools is not the birth pools; it is finding midwives who feel
comfortable with water births. A huge number of women come to
us saying that is what they would like and they cannot find a
midwife able to provide that.
Q79 Julia Drown: There is an unmet
demand there and not enough training?
Ms Beech: Yes. One of the problems
is that the trusts will provide a pool and then they do not provide
a rolling programme to ensure that every midwife on the unit knows
how to deliver a woman in water. They are quite prepared to rely
on informing the woman that she has to get out of the water. I
think they are putting themselves at considerable risk of litigation
if they end up with a woman who sits in the pool saying, "I
am not moving" and the midwife says, "What am I going
to do now?" The risk managers do not seem to factor that
into their calculations when they are thinking about risk.
Ms Phipps: There are two issues.
One is the availability of pools. Every woman in labour should
have access to one and that means she has to have the midwives
around to do that 24/7, not that it is okay except for Bank Holidays
or whatever. There is a huge amount of evidence about how beneficial
water is in labour.
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