House of Commons - Health

Select Committee on Health Ninth Report

3. Choice in where care is provided

43. According to the Association of Radical Midwives and AIMS, choice for women in maternity services depended to a large extent on where they lived. In a few areas women had access to "primary level models of care" such as the Albany Centre, or the Sheffield One to One caseload service, or the Torbay centre where a supportive manager was in charge of a team of skilled, dedicated one to one midwives.[30]

44. Rather less than 2% of births currently take place in free-standing birth centres. In the view of the Birth Centre Network, this is partly because such centres have arisen unsystematically, meaning that coverage is very patchy. Only around 57 birth centres exist in England, and large parts of the country have no access to such centres at all. Access to such centres seems likely to reduce further, according to the Birth Centre Network UK: a number of centres are now under threat of closure, such as The Malmesbury Unit in Wiltshire or three units around the Scarborough consultant unit, those at Malton, Bridlington and Whitby.[31] Yet a good deal of research validates the suggestion that community-based intrapartum care of healthy women results in lower rates of analgaesia, lower rates of caesarean section, makes women feel more in control and generally results in a better experience of birth.[32]

45. The NCT pointed out that women in London had access to only one free-standing midwifery unit, the Edgware Birth Centre in North London. While a second is planned for the Central Middlesex Hospital, which is in North West London, even in the capital most women cannot choose to give birth in a free-standing midwifery unit.[33]

46. The Nursing and Midwifery Council acknowledged that the NHS had made "great strides" in meeting women's requests for more personalized maternity services but felt that much more could be achieved by a fundamental shift in philosophy. They contended that the dominant perspective currently was one of "normality in retrospect", that is to say an approach favouring the detection and anticipation of problems before they arose. Such an interventionist culture went hand in hand with the majority of maternity services being based in acute settings.[34] Midwives were trained to treat birth as a normal, physiological event for the majority of women, but such an approach was inimical to the "problem orientated" acute settings where so much care was delivered. The Council called for cost-benefit analysis to be conducted on maternity units based in acute settings as against birth centres and home births.

47. We asked the Department what steps they could take to ensure the viability of community services. Dr Ladyman told us that the configuration of services was a matter for local trusts and Strategic Health Authorities to determine.[35] Catherine McCormack, midwifery adviser to the Department, explained that one of the reasons that these units closed was because they were "under-utilised".[36] As part of the reconfiguring hospitals project the Department was looking at ways of marketing the service to women to ensure greater uptake. We believe that it is equally important to inform GPs about the benefits and safety of community based care.

48. The most fundamental reason for the closure of so many birth centres is that there remains broad faith in the notion of centralised services as being safer and more cost effective. Like our predecessor committee we have not seen any evidence to support such a stance. It is not only birth centres that have been under threat: a number of midwifery developments were closed, for example the BUMPS project in Leicester, despite evidence of good outcomes. One problem may be that such schemes and centres are closed because they are an identifiable part of the budget and can easily be lopped off, a point Baroness Cumberlege made in evidence to us.[37] We accept that local configuration of services is a matter for local determination but given that pregnant women are not able to travel long journeys to give birth, if midwife led units are not available local choice is severely constrained.

49. In costing proposed closures the Department should ensure that local health services take into account the full and long term costs and benefits of the services being considered, including the likely impact on the recruitment and retention of midwives, on breastfeeding rates, postnatal depression rates and reduced intervention and caesarean rates which these units tend to achieve. We believe, as did our predecessor committee, that there should be a presumption against closure of smaller maternity units because without them the shift in attitude which they wanted and we want to see will be very much harder to deliver.

50. We believe that our recommendations above, calling for a shift towards midwife bookings, greater autonomy for midwives in delivering services and sufficient priority given by trusts to maternity issues would reverse the worrying medicalisation of birth reported to us.

Home birth

51. For normal low risk women, research shows that home birth is as safe as hospital birth and results in less intervention and less morbidity for mothers and babies. At the RCM Conference on 2 May 2001, the then Secretary of State for Health, the Rt. Hon. Alan Milburn MP used the availability of home birth as an example of the iniquities which limited choice in maternity services:

In some areas home births are widely available to women; in others they are not. Our standard must be an end to the lottery in childbirth choices so that women in all parts of the country, not just some, have greater choice including the choice of a home birth.[38]

52. We support the Secretary of State's policy goal of making home birth more widely available but are disappointed that nothing has been done directly by the Department to achieve this over the two years since his statement. It may be that it is expected that the NSF will achieve this and if so we would welcome that but we believe action could have been taken on this independently of the NSF.

53. Currently around 2% of births are home births. While this is broadly comparable with the figures in other socio-economically comparable countries it is hugely below the highest rate in Europe, that prevailing in the Netherlands which has for many years recorded a home birth rate of around 30%.

54. What the figure for home births in England does not reveal is the amount of unmet need amongst women who want to have home birth but feel they do not have the opportunity to do so, and those who are wrongly advised against home birth on spurious grounds. Dr Tina Lavender's study, cited in paragraph 13 above, indicated that half of the women surveyed had not even been given the option of a home birth.

55. Little robust evidence exists to quantify the extent of unmet need. Beverly Beech, Chair of AIMS, referred to a study conducted in York some time ago which suggested that around 20% of women would choose home birth if given "free choice".[39] She maintained that there were trusts in England who "really vigorously oppose home birth".[40] Further, she felt that many GPs were "woefully under-informed about home birth". The RCM cited a more conservative estimate from an NCT survey which indicated that around 20% of women would at least like more information so as to be able to consider the option of home birth. A further indication of the potential for greater uptake of homebirth is the very wide geographical variation in home birth statistics, which range from 0.3% to 6.1% of maternities resident to health authorities.[41]

56. Belinda Phipps for the NCT suggested that home births were not "well integrated" into the NHS. According to the NCT, some GPs were opposed to birth at home.[42] While the NCT contended that, overall, booked home births involve less midwifery time than those in hospitals and were only half as likely to involve caesarean section, in their view home birth was still often regarded as a luxury, "add on" service. They noted that the Chelsea & Westminster Hospital had recently suspended its home birth service.[43]

57. Some support for the notion that the Department did take the view that home birth absorbed greater resources than consultant units came in remarks that Dr Stephen Ladyman MP, the newly-appointed Minister with responsibility in this area, made to us:

If I put my sort of managerial hat on—and I will be brutally honest here, so do not leap down my throat when I say this—but if I was responsible for service in one of those areas of London where we have approaching a 15 per cent vacancy rate for midwives, I might, as a manager, be thinking to myself; it is going to be pretty damn difficult to offer home births as a routine in this area and my priorities might have to be somewhere else initially until I can deal with the midwife recruitment issue in my area.[44]

58. This view which is shared by some in maternity services is not backed by any evidence presented to us. Indeed promoting a home birth model may aid rather than detract from the recruitment of midwives. If one to one care is to be achieved in labour it should make little difference whether that care is provided at home or in hospital, but there does need to be a political will to give this choice for women. It may be that it is necessary to try and build up a critical mass of home birth numbers in each area by promoting this choice in order for services to become just as easy to organise for women at home as they are in hospital.

59. AIMS suggested that trusts would typically present obstacles in the path of homebirth. They would indicate to women that it might not be possible to supply a suitably trained midwife when the labour commenced:

The commonest classic ploy is to inform the woman towards the end of her pregnancy (usually around 36 weeks) that the staff cannot guarantee, or will not be able to supply, a midwife because of staff shortages, with hints that she would be "selfish" to try to take the midwife from the labour ward. It has now become a game of brinksmanship, with women supported by us hanging on and informing the Trust that they will give birth at home, come what may, and will hold them responsible if they fail to supply care. We deal with at least one such case a week and often more. In the end a midwife is invariably supplied, but by now she is seen by the woman as representing a domineering, antagonistic system, which does not understand or support normal birth.[45]

60. We regard this treatment of women particularly at such an important stage of their pregnancy as wholly unacceptable. If trusts have staff shortages they should call on the services of agency staff and independent midwives so that women in hospital and at home do not have to face the prospect of not being properly supported in labour. The Department should ensure that via a fast-track complaint or other procedure women experiencing any pressure like this should have an immediate source of help for the situation to be resolved without delay.

61. In the view of AIMS, many midwives lacked the confidence or experience to carry out home births. They told us that the NHS insisted on entry to hospital for some women who were judged to be at risk. This has resulted in some very high risk women labouring and giving birth alone at home. Sometimes they have not even had their partner present for fear that he will be threatened with prosecution, even though the law does not allow for such a prosecution. This is of huge concern and emphasises the importance of providing adequate midwifery services in the place of a women's choosing, even if that is not the place of birth that the relevant professional would advise.

62. Another issue sometimes cited is the requirement of some trusts to have a second midwife in attendance for home births. Usually a second professional attends for second stage or near the time of birth: this may be a midwife or doctor so that there is at least one person who has neonatal resuscitation skills who can support the baby if needed while the other staff member supports the mother. Louise Silverton from the RCM told us that a second pair of hands would not have to be a fully trained midwife. This model is adopted in the Netherlands where a maternity care assistant supports a birth and often goes on to support a family with postnatal care.[46] Even allowing for the second person at the second stage of birth where that is needed, the well recognised workforce planning tool Birthrate Plus shows that overall booked home births involve less midwifery time than hospital births because they tend to be quicker and involve fewer interventions.[47]

63. Although some independent midwives always practice in pairs, many support home births without a second midwife or assistant as they work with the woman's birth partner(s). This is consistent with Nursing and Midwifery Council rules. Where they do practice alone, independent midwives would always have a 'back-up' - a midwife who would be available, if needed, to attend a long or difficult labour.

64. Rather than perceiving home births as a potential drain on scarce resources we see them as a gateway to promoting normal birth and a spur towards midwife recruitment and retention. We endorse AIMS' recommendation that all trainee midwives should be obliged to attend a minimum of three home births as an essential part of their training. We believe that this would help tackle prejudice against home births amongst health professionals, But we also believe it would be very beneficial if GPs and consultant obstetricians attended a similar number of home births to give them insights into the process and to provide for a more informed and rational debate.

65. Home births, we believe, would be far better supported if there was a general principal of continuity of carer, an issue we raised in our first report but reiterate here.

66. There may be scope for creating the post of maternity assistant to help deliver services in the community. Such a person could also assist in the role of educating and informing pregnant women and in neonatal and postnatal support in areas such as breast feeding as happens in Hythe, Hampshire and Lymington.

Choice in consultant units

67. Many women will want to proceed with births in consultant units. Dr Lavender's study indicated that the majority of women liked to have a doctor in immediate attendance and around half wanted immediate access to epidural anaesthetic. However, a decision to opt for care in a consultant unit should not, in our view, curtail a woman's right to choose the most appropriate setting.

68. 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 where this is practical. As our previous inquiry has shown, the type of care a woman is likely to receive can vary significantly from hospital to hospital, and even between different consultants in the same unit. That inquiry recommended that individual consultant data on, for example, the caesarean rates of different consultants, together with national and local comparisons, should be given to all users.[48]

69. Professor Dunlop, for the RCOG, thought there would be "no problem at all" with such a recommendation provided that the data took account of the different case mix of units, and we accept that this is an important requirement.[49]

30 Appendix 2, para 1.2; Appendix 4, para 24.1. Back

31 Appendix 11, para 4.3. Back

32 See Cochrane review cited in Ibid., para 5.4.2. Back

33 Appendix 5, para 2.4 (ii). Back

34 Appendix 15, para 4. Back

35 Q 136 Back

36 Q 136 Back

37 Q 106 Back

38 Department of Health Press Notice 2001/0212. Back

39 Q 16 Back

40 Q 16 Back

41 Provision of Maternity Services, p 11. Back