Conclusions and recommendations
1. 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.
(Paragraph 18)
2. 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. (Paragraph 25)
3. We were concerned
to hear that some women found it hard to access maternity care
without a referral from a GP. We advised the Minister that even
NHS Direct was not giving correct advice to callers on how to
access maternity services suggesting that the only route was via
a GP. We would expect this advice to be updated. (Paragraph 28)
4. 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. (Paragraph 31)
5. 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. (Paragraph 37)
6. 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. (Paragraph 42)
7. 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. (Paragraph 48)
8. 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. (Paragraph 49)
9. 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. (Paragraph
50)
10. 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. (Paragraph
52)
11. We regard this
treatment of women [the introduction of barriers against home
birth] 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.
(Paragraph 60)
12. 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. (Paragraph 64)
13. 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. (Paragraph 65)
14. 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. (Paragraph 66)
15. 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. (Paragraph 68)
16. 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. (Paragraph 69)
17. 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. (Paragraph 78)
18. 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.
(Paragraph 82)
19. 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. (Paragraph 83)
20. 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. (Paragraph 84)
21. 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. (Paragraph 88)
22. 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. (Paragraph
93)
23. 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.
(Paragraph 97)
24. 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. (Paragraph 106)
25. The consultation
paper [Making Amends] does not explicitly address the issue
of defensive medicine, and we are not convinced that on their
own these reforms will have a significant impact on the more defensive
clinical practices that have become entrenched in maternity care
in recent years. It will take time to establish whether such a
scheme can engender a true 'no-blame' culture in the NHS, or whether
admission of responsibility for a clinical error or misjudgement
would still go hand in hand with individual clinicians being singled
out or stigmatised, an approach which may still be perceived as
being implicitly punitive. A system of collective, team-based
responsibility might be more likely to succeed in building clinicians'
confidence to report adverse incidents. Our concern is that the
defensive approach to medicine may particularly undermine giving
women choice in maternity services and we urge the Government
to implement and monitor any changes with this in mind. (Paragraph
110)
26. We therefore would
urge the Government to consider allocating some one-off resources
to maternity units wanting to make changes to their practise so
that they could carry out this work. Unlike the £100m allocation
the Government announced in 2001 for maternity services this one-off
allocation might be used more to support staff than building improvements.
This might be done in the form of a team of people who local units
could ask to be brought in to support a service either by releasing
local staff to do the work themselves and/or by helping them make
changes. Independent midwives may be a particularly useful source
of staffing for a part of these teams. (Paragraph 115)
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