[22]
If a woman wants or needs to be cared for in an acute hospital
setting, she should also be offered a choice of different acute
units since, as our previous inquiry demonstrated, the type of
care a woman is likely to receive can vary greatly from hospital
to hospital, and even between different consultants in the same
unit.
29. The difficulty in effecting a culture change
was encapsulated in a memorandum submitted by Elizabeth Key of
Preston Lancashire. Ms Key explained to us she was writing in
an individual capacity since the organisations she was representing—the
North West Lancashire Maternity Service Liaison Committee (MSLC)
and Preston Community Health Council (CHC)—had either been
abolished or were about to be abolished. Ms Key's MSLC arranged
for a local group of midwives and mothers to draft a short pamphlet
setting out information on maternity services for distribution
to pregnant women. The health authority would not fund its production
but eventually local CHCs met the bill, which was under £400.
None of the local Primary Care Trusts (PCTs), according to Ms
Key, would support the leaflet. Ms Key told us they were "not
happy" with the wording but were unable to supply "specific
examples or alternatives".[23]
Only one out of four local maternity units was prepared to issue
it: this unit agreed to supply a copy of the leaflet to every
mother booking there.
30. We ourselves were supplied with copies of the
leaflet, Choices for Maternity Care. The leaflet is short
and seems to us factually accurate. We can only surmise that the
units and GPs might have objected to the way the leaflet encourages
home birth as a "safe" option for women with uncomplicated
pregnancies, and describes consultant led care as a choice "especially
suitable for women with particular health or pregnancy related
problems".
31. Clearly we have only heard one side of this story
and we would not want to apportion blame to units or GPs for not
circulating the pamphlet without knowing their reasons. What we
can say is that the organisations supporting the choice pamphlet
are now disappearing, and that whatever the rights and wrongs
of the matter, it is clear that local staff and patient groups
were not able to co-operate and reach a consensus. For
our part, we do think it appropriate that women should be encouraged
to contact midwives as their first port of call and to at least
be aware of their right to have a home birth without seeking "the
GP's permission". This could be done by ensuring all GP receptionists
and hospital units know of the appropriate midwife to refer women
to, by notices in GP practices advising women on how to contact
midwifery services directly and by local telephone directories
having a contact for midwifery services.
32. Witnesses told us of their concern that, with
PCTs now responsible for commissioning the majority of healthcare
in England, these bodies lacked representation from midwifery
or obstetrics.[24]
The RCM told us that the "limited understanding" of
maternity services within PCTs was a "major concern".[25]
Belinda Phipps for the NCT felt that PCTs were unlikely to be
orientated to dealing with maternity issues:
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 a director of nursing, looking after the services that are
located out there.[26]
33. In addition, there are few places where there
is midwifery representation at Trust Board level. Thus there is
very little visibility for central issues relating to maternity.
Yet maternity care is different in nature to general health care.
The majority of patients looked after in general acute trusts
are chronically or acutely ill, whereas pregnant and labouring
women are usually perfectly well. Offering care to women from
a separate organisation devoted exclusively to maternity care
would reinforce the message that pregnancy and birth are normal
life events rather than illnesses, and may help counter the medicalisation
of birth we have heard described. We would however be wary about
suggesting more organisational change such as the setting up of
new maternity trusts but we were attracted by the model in Bath
where maternity services are run via the community PCT rather
than the acute trust. In this regard, it is interesting to note
the example of the Netherlands where around 40% of women give
birth without ever having seen a specialist obstetrician since
so much care is rooted in sophisticated systems of primary care.
34. Running services from the PCT might make an appropriate
division of care between primary and secondary care more likely.
They would fit well into the PCT agenda of public health and reducing
inequalities. We would expect PCTs to operate a primarily community-based
service, with the majority of women expected to receive their
antenatal care in the community, and their intrapartum and post
natal care in a birthing centre (either attached to secondary
care provision, or stand-alone) or at home. It could manage secondary
maternity care for women who experience complications, and have
access to 24 hour cover for obstetric or paediatric emergencies.
35. Whether in an acute trust or PCT we would encourage
managers to ensure sufficient attention is given to maternity
issues. Our evidence suggests action is needed in many areas to
achieve this. It may be that whilst maternity care is predominantly
located in acute units, the community aspects of services and
the voice of midwives will never be heard equally to the medical
and acute parts of the service. We can see how much easier it
would be for users to approach a PCT to recommend shifting beds
from an acute unit to the community - or to replace beds with
a home birth service, so we would recommend PCTs having the power
to take over maternity services where they feel their communities'
needs are not being met.
36. In order to make an informed choice over what
maternity services to use, women need to be made fully aware of
the different options open to them, and be given helpful information
about the advantages and disadvantages of each, from their very
first contact with a health professional. They should be given
written as well as verbal information, time to consider their
options fully, and opportunities to discuss areas of uncertainty
with health professionals and to visit units and meet staff, before
making a choice. Given the time constraints most GPs work under,
it does not seem realistic to expect them to provide such intensive
and specialist support to pregnant women, and it seems obvious
that community midwives would be better placed to provide this
sort of support to women, working in conjunction with GPs and
obstetricians. Women should not be under pressure to decide on
where to give birth early in their pregnancy.
37. We therefore
recommend that, as part of the Children's NSF, the NHS should
ensure that each pregnant woman has at least one initial 'booking
appointment' with a community midwife who has in-depth knowledge
of local services, and who has received special training to help
newly pregnant women with this type of decision-making. Women
whose first contact is with their GP should be referred automatically
to a community midwife.
38. The Nursing and Midwifery Council observed that
independent midwives found it "increasingly difficult to
continue caring for a woman who has been transferred into a maternity
unit", deprecating the policy of maternity units assigning
other midwives, usually unknown to the woman, to her on entry
to the unit.[27]
King's College Hospital NHS Trust contracts with an independent
midwifery practice, the Albany Practice in Peckham. The Albany
Practice, which has been mentioned as a centre of excellence by
witnesses in all our inquiries, does contract with independent
midwives, but its practice here is very much the exception, not
the rule.[28]
39. The Independent Midwives Association argued that
the current hegemony of the medical model of care in maternity,
where the bulk of activity takes place in hospitals, involving
women first referred by their GP, could only be overturned by
radical measures. It suggested moving toward the model of care
used in New Zealand whereby midwives operate as independent contractors,
much the same way as most GPs, dentists and opticians do in the
UK, and are paid a set fee per woman.[29]
In New Zealand it is estimated that approximately half of all
pregnant women use an independent midwife. The Netherlands, which
has the highest home birth rate in Europe, uses a similar system
of independent contracting with midwives. However, the health
systems in New Zealand and the Netherlands differ substantially
from that in England.
40. We feel that calls for extending the independent
contractor model to encompass all NHS midwifery practice would
not be so vociferous if NHS community midwives were properly supported
to use their professional skills in accommodating the choices
of individual women. We would expect that giving community midwives
a stronger role in maternity care would share the advantages put
forward by independent midwives, particularly in recruitment and
retention. But achieving this stronger role may not be easy. It
may be that the option of independent midwifery would work well
and the Department or individual PCTs, particularly those where
choice is currently limited for women, may want to pilot this
approach as an addition to current services.
41. Whether or not such a model is adopted, women
who choose to employ and pay for an independent midwife should
not face difficulties in using a trust's facilities, and trusts
and local independent midwives should be expected to forge good
working arrangements. All trusts should ensure they have established
arrangements for using independent midwives where they are paid
for by the woman, where they face staff shortages or where they
cannot meet individual women's wishes, for example for those areas
which do not support homebirths, water births or a higher risk
birth where a woman makes an informed choice to avoid intervention.
The Department must ensure that Trusts can access appropriate
insurance cover in these circumstances.
42. We recommend
that the Government uses the opportunity presented by its forthcoming
NSF as an opportunity to recast maternity services to the advantage
of both women and their carers. We feel that the current delivery
of maternity services, which is generally led by acute general
hospitals, over-medicalises birth. Through the NSF, PCTs should
be given a lead role in ensuring there is choice and community-led
services for women, wherever they live.
20 Provision of Maternity Services, paras 12-20. Back
21
Provision of Maternity Services, para 16. Back
22
Q 125 Back
23
Appendix 10, para 2.2 Back
24
Q 4 (Beverley Beech) Back
25
Appendix 3, para 4.1 Back
26
Q 6 Back
27
Appendix 15, para 7 Back
28
Q 38 (Louise Silverton) Back
29
Appendix 7, para 20 Back
