Select Committee on Health Ninth Report

4. Choice in how care is provided

70. Each year over half a million women give birth in England. For most women, being pregnant and having a baby are 'normal' experiences, that is to say they do not involve medical procedures. The WHO estimates that between 90 and 95% of births worldwide are normal. Yet within England "only about half of women (53%) had a spontaneous labour and delivery, without induction, the use of instruments or caesarean section".[50] What makes this last statistic even more depressing is the figure has steadily fallen from 63% in 1991-92, around the time of our predecessor Committee's inquiry and Changing Childbirth.[51]

71. Changing Childbirth identified ten indicators for success, all of which can have an influence on informed choice in maternity care:

  • All women should be entitled to carry their own notes;
  • Every woman should know one midwife who ensures continuity of her midwifery care— the named midwife;
  • At least 30% of women should have the midwife as the lead professional;
  • Every woman should know the lead professional who has a key role in the planning and provision of her care;
  • At least 75% of women delivered in a maternity unit should know the person who cares for them during their delivery;
  • Midwives should have direct access to some beds in all maternity units;
  • At least 30% of women delivered in a maternity unit should be admitted under the management of a midwife;
  • The total number of antenatal visits for women with uncomplicated pregnancies should have been reviewed in the light of the available evidence and the RCOG guidelines;
  • All front line ambulances should have a paramedic able to support the midwife who needs to transfer a woman to hospital in an emergency;
  • All women should have access to information about the services available in their locality.

72. Of the ten indicators of success identified in Changing Childbirth all of which can have an influence on informed choice in maternity care, our evidence would suggest that significant but not complete success has been achieved with three of them: on women holding their own notes; on the number of women delivered in maternity units being admitted under the management of a midwife; and on reviewing the number of antenatal visits for women with uncomplicated pregnancies. The latter is expected to be reinforced by NICE guidelines.

73. There has been some progress with another two indicators: midwives having direct access to some beds in maternity units (but certainly not in all the ways envisaged by the report); and on information available to all women about local services (but here there is still a significant way to go to achieve good practice nationally).

74. Our inquiry did not cover ambulance services which is covered by one of the indicators and the remaining four were about continuity of care and the lead professional for maternity services. There is still a long way to go to achieve the real continuity of carer envisaged by the report of ten years ago and we hope our report will help to achieve this.

75. The key issues affecting choice in the clinical delivery of care are rooted in two extremely different models of provision. The most highly medicalised pregnancies might involve a series of separate scans and tests, induction of birth, electronic monitoring of the fetus during labour, use of analgaesia such as epidural anaesthetic and then, in almost a quarter of cases, a caesarean section. In contrast, the most 'normal' births would eschew scans and tests, avoid fetal monitoring, make no use of analgesia and favour vaginal birth wherever possible.

76. The tension between these two models of care ripples through the evidence we have received in this inquiry. While it is fair to say that the majority of the submissions we have received in this inquiry have argued for a shift away from the first model of care towards the second—and indeed such an approach was sanctioned in Changing Childbirth—it is equally pertinent to point out that most maternity care in England today much more closely follows the medical model of care.

Scans, tests and procedures

77. According to the Department, all women will be offered at least one ultrasound scan usually from 10 weeks onwards, "to check the size and age of the fetus".[52] Besides this, women are "usually offered a range of screening tests to establish whether the baby is developing normally".[53] These might include:

  • serum screening, used to assess the risk of Down's syndrome and spina bifida (usually offered at 15 weeks onwards);
  • amniocentesis, also offered from 15 weeks and used to detect chromosomal abnormalities such as Down's syndrome - this test involves a risk of miscarriage so is normally offered to "those women at a higher risk of having a Down's syndrome baby if a woman's serum test was screen positive"; when there is a family history of chromosomal abnormalities; or when abnormal findings have been picked up on the utrascan;
  • chronic villus sampling, offered between 11-14 weeks to detect some inherited disorders such as Down's syndrome, sickle cell anaemia and thalassemia - this has a higher risk than amniocentesis of miscarriage so "is only offered to women whose babies are at risk".[54]

78. The Department suggested "a woman can choose whether she wants the tests" but according to the NCT too little is made of their optional nature. Moreover not all tests are available through the NHS in all areas. So nuchal translucency screening for Down's syndrome is available in some but not all areas.[55] The NCT also told us that miscarriage rates following invasive testing are also reported to vary significantly. Echo, the fetal heart charity, also pointed to an inequality in the detection rates of congenital heart disease through ultrasound screening from 3% to 68%. The Department should investigate and take action if there is such a variation.

79. For Caroline Flint, a former president of the RCM, former adviser to our predecessor Committee in 1991 and the Director of a Birth Centre, screening was a sign of "the desire to complicate pregnancy":

It sometimes appears to be the role of modern antenatal care to make women anxious. A whole industry has grown up around ultrasound scanning - which has yet to be shown to have any clinical benefits at all (despite the millions of pounds we must be spending as a country on this process), women are told that there are cysts in the baby's brain (may or may not mean anything), golf balls in the baby's heart (may or may not mean anything) etc. etc.[56]

80. Ms Flint noted that mini glucose tolerance tests are carried out on nearly all women going through London hospitals despite the fact that "this has specifically been cautioned against by the National Perinatal Epidemiology Unit". She concluded that such screening was part of the "over-medicalisation" of birth which ultimately damaged the key relationship between mothers and midwives.[57]

81. Anne Francis of the Independent Midwives' Association offered some support for the view that tests could lead to a spiral of intervention when she reported anecdotal evidence that the removal of routine admission trace use of cardiotocographs in labour at St George's Hospital Tooting had resulted in a substantial reduction in caesarean rates.[58]

82. We do not believe that simply making tests available is in itself an extension of choice. Testing and screening sometimes inhibit rational choice and sometimes encourage higher levels of intervention. We recognise that many women will want to have the tests available and support them in that choice but women do need to be fully informed of the purpose and consequence of all tests, so that tests are not treated simply as a routine part of the process of being pregnant. We recommend that the NSF should specify the minimum screening services that should be available in all areas of the country.

83. The NCT reported to us that the evidence-based guidelines on the induction of labour published by the RCOG and NICE in 2001 were being interpreted in very different ways across the country. The guidelines stated that 'women with uncomplicated pregnancies should be offered induction of labour beyond 41 weeks'. The guideline also said that 'women must be able to make informed choices'. The NCT reported that many women were not being supported to make decisions that they felt were right for them and that professionals were not respecting women's right to refuse unwanted treatment.[59]

84. We recommend that women should receive evidence-based information on the balance of risks and benefits of induction of labour at different times, so that those whose pregnancy continues beyond term can make informed decisions about whether to accept the offer of a medical induction at around 41 weeks or at any stage thereafter. Where women refuse treatment their decision should be respected.

Birth suites

85. Several of our witnesses argued that the typical hospital delivery suite limited women's choices and intrinsically favoured a medical model of care. According to the NCT, "the very act of immobilising women in a clinical environment to monitor them intensively to look for signs of pathology creates pathology as the flow, the hormones, and the behaviour of normal labour is disrupted."[60]

86. Caroline Flint put this most forcefully when she suggested that making women lie down to give birth was "the most crucial way in which labour is made more painful and more likely to need medical intervention".[61] She saw a prone labour position as creating a spiral of intervention: labour lying down was more painful; this made epidurals more frequent; this in turn triggered a higher rate of caesarean section. In the ten years during which her birth centre had run, she told us, only one woman had given birth on a bed. The issue of the design of the typical birth suite and its impact on labour seemed to Ms Flint to offer a good example of the way in which the current structure acted against informed choice. Few women were likely to question the way the hospital had set up a particular room, not least because the prone position facilitated the use of monitoring devices and pain relief. She concluded, however, that: "When women had a real choice, they do not choose to labour on a bed, it causes them too much pain".[62]

87. It does not require a huge sum of money to reorganize birth suites. The bed can be moved from the centre of the room, a rocking chair can be introduced, a mattress on the floor, birth balls, birth stools and birth pools can all make contributions. But we have heard from midwives who have had to battle to achieve even moving beds to the side of the room. The really big issue is retraining midwives to encourage movement, and making movement within labour natural and typical behaviour.

88. If the arguments of the NCT and AIMS are soundly based, and hundreds of thousands of women are being asked to give birth in wholly inappropriately designed rooms, this would be a matter of very great concern. We are not the appropriate body to judge on such clinical matters but we suggest that the National Institute for Clinical Excellence should be able to investigate this important issue as a matter of priority.


89. The NCT pointed out that some trusts allowed several birth partners to be present during birth while others only permitted one.[63] Yet a woman may wish to have a relative with her as well as a partner, or an even an acupuncturist or aromatherapist. There is some evidence to suggest that a female birth supporter in addition to a partner has a positive effect on the progress of labour.

90. We asked the Department whether there was, or should be, a Department of Health policy on the issue of partner numbers. Lindsay Wilkinson, Head of Women's Health and Maternity Services at the Department, told us that user involvement was something that would be considered in the context of the forthcoming Children's NSF.[64] The Minister thought that it was important to take into account the reasons the trust gave for restricting the number of partners to one. If it was the result of a physical constraint in the building he would want to have future buildings modified to ameliorate the problem; if it was simply a matter of entrenched, conservative attitudes he hoped that more enlightened views would be brought to bear.[65]

91. We do not think it appropriate that women are asked to give birth in rooms where there is deemed to be insufficient room for a second partner if they choose to have a second partner there. This seems to us to be a fundamental denial of choice: it is the mother who is giving birth and her choices here should be respected.

92. However, as our inequalities report demonstrated, the limitations placed on able-bodied people pale in comparison to many of those imposed on some people with disabilities. During the Sub-committee's inquiry into inequalities in access to maternity care, Simone Baker described this feeling of loss of control in its most extreme form: "people have their babies taken away from them before they are born."[66]

93. While we acknowledge that there may be problems of space and security which might limit the overall number of partners who can be present we do not think that it is reasonable that women should be limited to a single birth partner in any circumstances. Such an attitude suggests birth is being managed for the convenience of the unit rather than the mother. We look to the Department to support the view that women should not be limited to a single birth partner.

Birth pools

94. Birthing pools are popular with women and can now be found in the great majority of maternity units. There is clear evidence to support the suggestion that many women find them a great benefit and comfort when giving birth. However, several of the submissions we received suggested that the mere existence of a birthing pool by no means guaranteed that a woman would have access to such a facility when it came to her labour or that she would be able to make as much use of the pool as she might wish.

95. The Association for Improvements in Maternity Services (AIMS) used the introduction of birthing pools as an example of where supplying women with insufficient or irrelevant information could restrict choice, arguing that although many hospitals now had a birthing pool and might advertise this as part of the 'choices' they offered, in many units pools were used very infrequently. AIMS reported how women who asked to use pools were too often told that the pool was unavailable (being cleaned, needing maintenance, or needing sterilisation). AIMS argued that "the crucial piece of information, therefore, was not whether the unit had a pool, but how many women gave birth in it the previous year".[67]

96. According to Beverley Beech for AIMS, another problem arose from some midwives not knowing how to deliver a woman in water and resorting to asking the woman to get out of the pool to give birth even when this was against her wishes.[68] Sarah Montagu, for the Association of Radical Midwives thought that such an attitude was completely inappropriate and symptomatic of the distortion of values in maternity care:

It struck me as quite bizarre that it seems optional for management that if midwives from a unit feel that they do not want to support women in water, they do not feel they can force the midwives to train to look after women in water. If a midwife said, "I do not feel I want to look after women having epidurals or Caesarean sections" the managers would tell them not to be stupid and that it was part of their job.[69]

This assertion prompted Professor Dunlop of the RCOG to query whether a water birth could be characterised as a "normal labour" rather than, as he presumably believed, "a form of intervention".[70] Midwives responded by saying that unlike other interventions there were no side effects or complications associated with a water birth. Such a clash of attitudes well sums up the debate about normal versus medical models of care.

97. We believe that if maternity units have pools, as most now do, a woman giving birth should have a reasonable expectation that the pool will be available for her use except in cases where demand is abnormally high. Efforts should be made to ensure that maintenance is organized so as to restrict as little as possible the hours which the pool may be accessed. We think it is unacceptable that midwives should be uncomfortable in dealing with mothers using birth pools: this is a matter that should be addressed in training and through professional development. We agree that it should not be acceptable for midwives to be unable or unwilling fully to support women using birth pools.

Caesarean section

98. In our first report, we discussed the issue of rising rates of caesarean sections in considerable detail.[71] Around 63% of caesarean sections are classified as "emergency procedures". Health professionals and academics vary in their explanations for the rise in numbers of emergency caesareans, which include the use of continuous electronic fetal monitoring, the use of protocols which specify that labour must proceed to a set timescale, and the de-skilling of both midwives and junior doctors in 'normal' birth. Given nearly all women who have no need for a caesarean section prefer not to have one and given the evidence that the current rise in caesarean sections does not improve outcomes in maternity services, the rising rate of caesarean sections suggests women are not being able to follow what would be their choice of delivery method.

99. The Department's evidence to us suggested they wished to resist getting involved in whether the rising caesarean rate was a good or bad thing. They told us they were "well aware of the debate", that there was "not sufficient evidence or medical consensus about the desirability and what the optimum caesarean section rate should be" and that the National Sentinel Caesarean Section Audit "did not show that caesarean section is unsafe".[72] However the evidence does suggest that if it is not clinically indicated vaginal births are safer than caesareans and have fewer long term adverse consequences for women. The evidence we received suggested a consensus that more needs to be done to tackle the rising rate and the variation in rates across the country and we would again urge the Department to tackle this issue.

100. Elective caesarean rates have risen, in part, perhaps, because of the increasing inclination of obstetricians to perform a caesarean for a breech or a twin birth. It is not within our remit to comment on the efficacy or safety of different clinical practices. However, many witnesses have argued compellingly that the increase in the caesarean rate reflects the effective removal of informed choice from a large number of women who would have preferred to be given the option to give birth naturally.

101. Informed choice here may be compromised in two ways. First, choice may be restricted if units implement policies effectively prohibiting certain types of clinical practice, for example vaginal breech births, or vaginal birth for twins. For example, in our first inquiry we found that around two thirds of women were not being offered the turning round of a breech baby.[73] Applying predetermined clinical policies will often mean that women will only receive information about that hospital policy, and finding out about possible clinical alternatives will be very difficult. Secondly, although different clinical choices may be offered to the woman during delivery (for example between opting for a caesarean section on the basis of a trace abnormality, and taking a 'wait and see' approach), the options may be presented in such a way that the woman feels that the only decision which is 'allowed' is that favoured by the health professional advising her. This is clearly particularly important given the extreme vulnerability of women giving birth and given the natural tendency of many people to defer to 'experts'. While the lead health professional, whether a midwife or an obstetrician, has a professional duty to give advice based on what he or she judges to be the most appropriate course of action, it is vitally important that the woman is able to receive clear and unbiased information about the risks and benefits of both, so that she can make an informed choice.

102. A birth story printed in the Daily Telegraph to coincide with the publication of our first report, illustrates well how information can contribute to positive experiences and outcomes: Jane Dawson knew that her baby was breech, and after an unsuccessful attempt to turn the baby, and discussions with her clinicians, Ms Dawson chose a planned caesarean, and reported that "Knowing all the options and being talked to as an equal partner in the birth team was crucial. I felt I was well cared for".[74]

103. The evidence we have received suggests that women-centred care would be best achieved by the Government adding to the weight of opinion we have heard in favour of an increase in normal births. We recognise that for some women—probably less than 20%—medical interventions including caesareans are desirable and will improve outcomes. But given that the national rate of interventions is now well above this we would like to see maternity service managers setting themselves objectives to increase normal births as part of an audit cycle. This could include actions to improve facilities, control and choice for women in the birth environment, to ensure women receive one to one support during labour and training to promote normal birth to all staff. NICE guidelines and the forthcoming NSF should emphasise that birth is a physiological process to be facilitated and not a medical problem and should reflect this consensus to see an increase in the normal birth rate.

Choice in neo-natal and post-natal care

104. First Class Delivery noted that women made more negative comments about hospital postnatal services than any other aspect of their maternity care. It recommended that trusts should have flexible policies on length of stay and that they should consult women about their postnatal care. The report also recommended that trusts should provide support, information and practical help so that parents of babies in neonatal units could be involved in their baby's care.

105. The NCT drew our attention to a range of problems in postnatal care.[75] In their view, while the length of stay of a woman in hospital had been "cut dramatically" over the last few years, there was no evidence that there was adequate support in the community to replace in-hospital care. The NCT pointed out that some women might want more support in, for example, breast feeding in the days after birth, and that it was wrong always to assume that someone would be there to support a woman at home. They noted that in busy consultant units women were seldom offered choice as to length of hospital stay, whereas in smaller midwifery led units length of stay after birth was often four or five days, and breast feeding rates (and confidence to breast feed) were often high.

106. We hope that the NSF will include choice for women on the length of time they can stay in hospital or in a midwife-led unit after birth and allow for flexible support in the community for up to eight weeks from midwives and health visitors working as a team.

50   Appendix 3, para 3.3 (RCM). Back

51   IbidBack

52   Appendix 1, para 2.3 (Department of Health). Back

53   Ibid., para 2.4. Back

54   Ibid., para 2.6. Back

55   Ibid., para 2.2; Appendix 5, para 2.2. Back

56   Appendix 15. Back

57   IbidBack

58   Q 48; cardiotocographs measure fetal heart rate relative to the woman's contractions. Back

59   Appendix 5, para 2.3. Back

60   Appendix 5, para 1. Back

61   Appendix 14. Back

62   Appendix 14. Back

63   Appendix 5, para 2.6. Back

64   Q 133 Back

65   Q 134 Back

66   Inequalities in Access to Maternity Services, Q 70. Back

67   Appendix 4, para 16.2. Back

68   Q 79 Back

69   Q 80 Back

70   Q 80 Back

71   For the Committee's discussion of the fraught issue of choice in caesarean section, see Provision of Maternity Services, paras 90-104. Back

72   Provision of Maternity Services, Ev 162. Back

73   Provision of Maternity Services, Q 48. Back

74   The Daily Telegraph, 24 June, "Pleasure, pain and complicated deliveries". Back

75   Appendix 5, para 4. Back

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