Select Committee on Health Ninth Report

1. Introduction

1. Introducing a House of Lords debate on maternity services in January this year, Baroness Cumberlege said:

Every woman is unique; every baby is unique; every birth experience is unique. That is why it is so important to give a woman and her partner choice: choice of place of birth; choice of style of care; and choice of professional who is going to accompany them in this unique and special journey.[1]

2. The intervening years between Changing Childbirth and the debate in the Lords had witnessed many changes in society: more women were entering higher education; more were entering the professions; and more of them were single parents and sole wage earners. Yet, in the view of Baroness Cumberlege, choice remained "a luxury".

3. Following the then Health Committee's Second Report of Session 1991-92, an Expert Maternity Group chaired by Baroness Cumberlege, then Parliamentary Under-Secretary of State at the Department of Health, undertook a review of maternity services which made recommendations for reform through Changing Childbirth (1994). Changing Childbirth insisted that maternity care should be woman-centred and that choice, continuity and control should inform the development of services. One of the three main principles adopted by Changing Childbirth made the case for choice as an integral element of good quality maternity care:

The woman must be the focus of maternity care. She should be able to feel that she is in control of what is happening to her and able to make decisions about her care, based on her needs, having discussed matters fully with the professionals involved.[2]

4. The principles of Changing Childbirth were welcomed by many midwives, doctors and users of the service who, according to the Royal College of Midwives (RCM), had already been working towards a more woman-centred approach to care, a "remodelled maternity service based on the needs and wishes of those using it."[3] Changing Childbirth was adopted as Government policy in 1994, when an Implementation Team was set up, and pilot projects were established around the country. The RCM reported that some service providers responded rapidly to inform women about the choices they could make in terms of their maternity care.

5. In March 1997, the Audit Commission published its report First Class Delivery—Improving Maternity Service—England and Wales which was the first large-scale audit of maternity services since the implementation of Changing Childbirth.[4] The Audit Commission found that national policy had focused on making maternity services more 'woman-centred': giving priority to information, choice and flexibility, ensuring continuity of carer, and listening to women's views. As the Department noted, "90% of women surveyed were pleased or very pleased with the way they were treated during pregnancy and childbirth."[5]

6. However, although many women were satisfied with the care that they had received, the Audit Commission reported that many women wanted more and better information about services and about options for care. The Audit Commission report indicated that information was particularly important in antenatal screening. During labour, the Audit Commission found that some women did not feel involved in key decisions. It recommended that trusts, managers and professional staff should provide the information that women needed to understand what was happening to them, including information on the options for pain relief.

7. At the RCM Conference on 2 May 2001, the then Secretary of State for Health, the Rt. Hon. Alan Milburn MP, announced a £100 million fund for maternity services which was intended to "ensure that pregnant women have more choice and access to improved maternity services."[6] He went on to assert that "choice for women cannot be there when there are shortages of midwives in too many parts of the country. Mr Milburn made an explicit link between choice in maternity services and the appropriate level of care which promoted healthy outcomes for babies:

Today I am setting a new ambition for the health service: modern maternity services as the foundation for giving each and every child in our country the very best start in life. Maternity services that give women and families more choice over the care they receive so that every child, regardless of background or circumstance, has the best possible start in life.[7]

8. On 12 December 2002, we appointed a Maternity Services Sub-committee, and the present inquiry into choice in maternity services is its final contribution. The Sub-committee announced this inquiry on 14 May 2003 with the following terms of reference:

The Sub-committee will examine the degree of choice and control a woman has over her maternity care.[8]

9. On 17 June we took oral evidence from representatives of the Association for Improvements in Maternity Services (AIMS), the Independent Midwives' Association, the National Childbirth Trust (NCT), the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM). On 24 June, we took evidence from the Baroness Cumberlege and from Dr Stephen Ladyman MP, Parliamentary Under-Secretary of State for Community Care, Department of Health, and his officials.

10. In addition to these sessions we received 24 written memoranda from a variety of trusts, professional bodies, pressure groups and users which were invaluable in helping us form our conclusions. We are most grateful to all who presented written or oral evidence.

11. We also, once again, owe many thanks to our excellent advisers on this and our previous inquiries: Dr Susan Bewley from Guy's andSt Thomas'Hospital, Professor Lesley Page from the Royal Free Hospital, Professor Alison Macfarlane from City University and Professor Martin Whittle from the University of Birmingham.

Defining Choice

Data on choice

12. It is extremely difficult to define the extent to which women have choice in maternity care. The Royal College of GPs noted in its submission that "little systematic data are available" about the extent to which choice is a reality.[9] The Mother and Infant Research Unit at the University of Leeds has recently completed a survey of women's expectations and experiences of intrapartum care, focusing on issues of choice and control. The survey was based on a similar survey carried out in 1987. The survey concluded:

  • There had been an overall increase since 1987 in the extent to which women felt that they had been able to make choices, in the extent to which they were involved in decision making and the extent to which they felt in control of what staff were doing to them in labour. The most important variable in feeling in control was being treated with respect and as an individual.
  • Around 60% of women, however, did not feel always in control of what was being done to them.
  • The general increase in feelings of choice and control had not yielded the improvement in psychological outcomes that might have been expected. This, the researchers postulated, might be because of the increased levels of obstetric interventions which were associated with poorer outcomes.
  • Many women chose epidurals because they lacked confidence in their own ability to cope without. The proportion of women who were "very worried" about labour pain had increased from 16% to 26% of first time mothers.[10]

13. As part of its work to consider the modernisation of maternity services in the light of the NHS Plan, the Maternity and Neonatal Workforce Group (MNWG) commissioned a project led by Dr Tina Lavender, Reader in Midwifery at the University of Central Lancashire, to undertake a rapid assessment of women's and midwives' view of the range of options for place of antenatal care and birth. Dr Lavender's preliminary findings (from a survey of about 2,300 women) included the following indications of women's preferences in maternity care, expressed during the antenatal period:

  • Little knowledge or understanding of home births. Only 8% had considered it and 50% were not offered a choice;
  • 72% wanted local antenatal care;
  • Around 68% were willing to travel for perceived higher quality of care during labour;
  • Around 33% believed it was important to know in advance the midwife who helped them to give birth while 32% thought it unimportant;
  • Around 64% stated that they would feel unsafe if a doctor were not immediately available during labour. After delivery, 45% of women felt this way;
  • Around 75% stated that it was important to have a neonatal unit in the place where they delivered;
  • 51% said they wanted 24-hour access to an epidural anaesthetic. After delivery the figure was 50%;
  • 51% agreed that it was important for them to have a midwife who can support them to give birth without medical intervention.[11]

14. Women perceived consultant-led maternity units to be busy, clinical and less personal, but they felt reassured by the availability of access to appropriate medical staff in case of an emergency. For many of the women surveyed, a midwifery-led unit on the same site as a consultant unit was believed to offer a more homely, but safe, environment. Dr Lavender attributed this to women's expectations and experience—lack of knowledge of the choices available, and perception of the safety of medical rather than midwifery-led care.

15. The MNWG, in its report to the Department of Health's Children's Taskforce, concluded that the forthcoming Children's National Service Framework (NSF) should seek further evidence on the views of women and their families about the different models of maternity care, including information on initial preferences, the 'real-life' choices which women and their families make, and how they feel about the services they receive.

16. The MNWG also called for more evidence on how women's views and preferences could be influenced by the services made available to them, by how health professionals presented alternatives to them, and by the "maternity services culture variations between NHS trusts." However, it insisted that "Good maternity care starts with the wishes of the woman herself, and her family, and aims to meet these as far as possible, whilst also ensuring the safety of both mother and baby. Different women will make different choices."[12]

17. Professor Dunlop for the RCOG told us that he "strongly supported" the idea of greater consumer research in maternity services which was an area he considered to be far too little researched.[13]

18. For most women, giving birth is a normal physiological process, not an illness. It is not clear to us that the usual methods the Department employs to measure the effectiveness of services (which must inevitably focus on clinical outcomes) are necessarily the most appropriate for maternity services. We also note the surprising paucity of evidence in this area, given that over half a million births are recorded by the NHS each year. So we would welcome the Department commissioning some more research on the fundamental needs, wishes and concerns of women in this area to gain a better picture of what women think about maternity care but also to see how they would respond to different lead carers and different birth settings.

An illusion of choice?

19. There is a danger, as our inequalities report would suggest, that choice in maternity services is really a choice for the articulate middle classes. Maggie Elliot, Director of Midwifery and General Manager at Queen Charlotte's and Chelsea Hospital also maintained that emphasis on choice for some women created barriers to access for others:

It can be quite difficult sometimes to provide specialised services for women who cannot speak up because the women who can speak up demand them. It is sometimes going against the political climate that is going on at the time.[14]

20. However, the Disabled Parents Network indicated that choice and services for disadvantaged groups were not mutually exclusive concepts. The organisation argued that:

Disabled women are not always given the same choices as other parents, for example, decisions about the type of birth or anaesthesia and mode of delivery are taken by professionals without adequate discussion with the woman or her partner. Informed choice is often not an option for disabled women due to assumptions and decisions made by professionals.[15]

21. Diane Jones from Newham Healthcare told us that while making choices and participating in decisions was "quite an alien concept for some women" at the outset of care, it was possible to develop an understanding which would allow women to become involved in their own maternity care choices:

When you first meet with them and expect them to make choices and decisions about what tests they may want to have or how to feed their baby, it may be quite a new concept when they have never made those types of decisions for themselves in the first place … when you do have a midwife who is part of your care all the way through, that is something that can be developed and encouraged as you go along and she might have an understanding of what we mean by wanting to empower her, to give her responsibility for her care.[16]

22. Even for women who are not disabled, the extent to which choice is a real choice was questioned by several of our witnesses. Asked if she thought that the opportunities for choice for women had improved over the last ten years, Beverley Beech, Chair of the Association for Improvement in Maternity Services (AIMS), replied:

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 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.[17]

23. Belinda Phipps for the NCT thought that the threat of litigation created a culture of fear and defensive medicine which made trusts "nervous" and made them fail to provide "objective" information:

From a woman's point of view, we worry hugely when there is an apparent feeling of choice but actually the information is not being provided. I think there is some evidence that the fear of litigation may bias what is made available to women so that women have informed compliance rather than informed choice.[18]

24. As Louise Silverton of the RCM told us, choice can be difficult to define: "some people may say, 'choice is you choosing what I offer you'".[19] Choice is clearly only genuine, meaningful and beneficial if women and their families have appropriate and unbiased information available to them to help them to make informed choices. At what stage they receive this information, and in what circumstances, is also crucial to the process of informed decision-making. There is an important distinction between a clinician advising one course of action and the reasons for and against it and recommending that action, and setting out a choice of actions and the advantages and disadvantages of each and leaving a woman to make the decision. Adopting the latter approach would reinforce women-centred care and might discourage legal claims because it would be clearer that any action was the choice of the woman rather than the clinician.

25. We note the Leeds University research which suggested that high levels of intervention in care had militated against better psychological outcomes being achieved as a consequence of greater choice. The Department needs to ensure that women are given a genuine and informed choice, and not the illusion of choice that some of our witnesses suggested was currently the case.

1   HL Deb, 15 January 2003, cols 267-68. Back

2   Department of Health, Changing Childbirth: Report of the Expert Maternity Group, 1993. Back

3   Royal College of Midwives Journal, vol 1 no 2, February 1998. Back

4   See Back

5   Health Committee, Provision of Maternity Services, Fourth Report 2002-03, HC 464, p 82. Back

6   Department of Health, Press Notice 2001/0212. Back

7   IbidBack

8   Health Committee Press Notice 23, Session 2002-03. Back

9   Appendix 21, para 3.8 Back

10   Appendix 18, para 2 Back

11   The Maternity and Neonatal Workforce Group, Report to the Department of Health Children's Taskforce, January 2003, Annex B. Back

12   The Maternity and Neonatal Workforce Group, Report to the Department of Health Children's Taskforce, January 2003. Back

13   Q 66 Back

14   Health Committee, Inequalities in Access to Maternity Services, Eighth Report 2002-03, HC 696, Q 100. Back

15   Ibid., para 204 Back

16   Ibid., Q 129 Back

17   Q 61 Back

18   Q 26 Back

19   Q 8 Back

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