APPENDIX 1
Memorandum by the Department of Health
1. INTRODUCTION
1.1 Historically options and preferences
of individuals have often been determined by the service itself
rather than by the individuals. Providing prompt, high quality,
convenient services which respond to patients needs is central
to the NHS reform programme.
1.2 Increasingly patients and public have
access to more information about health, treatments and the service
and so can and will make choices about when and where they wish
to be treated. Extending choice and developing more responsive
services enables the NHS to meet those needs and shape the service
around the patient.
1.3 It is arguable that women have more
choices in their use of maternity services than many other users
of NHS services. This paper sets out some of the choices women
and their families currently have and policy and action being
taken to extend choices in NHS maternity services.
2. CHOICE—WHAT
EXISTS NOW?
Antenatal care
Location of antenatal care
2.1 Many women can choose to have some or
most of their antenatal care provided in the community rather
than having to travel to hospital. Many Sure Start projects have
been at the forefront of providing maternity care and support
to pregnant women, new mothers and their partners & families
at the heart of otherwise disadvantaged communities—in settings
which are easily accessible.
Antenatal/parentcraft classes
2.2 Most women are offered antenatal or
parentcraft classes and these usually start about eight to 10
weeks before the baby is due. In some cases these classes are
tailored to particular groups, eg pregnant teenagers or those
whose first language is not English. The number of different antenatal
classes varies from place to place. Classes may be run by the
local hospital, local midwives or health visitors, or by the GP
or health centre. Women can chose which type or location of antenatal
classes from those available in their area in consultation with
their GP or midwife. A woman can also choose to pay for private
antenatal classes run by the National Childbirth Trust.
Antenatal Screening and other tests
2.3 All women will be offered at least one
ultrasound scan usually from 10 weeks onwards to check the size
and age of the fetus. As well as this, women are usually offered
a range of screening tests to establish whether the baby is developing
normally or not. A woman can choose whether she wants the tests.
The screening tests include:
2.4 Serum screening—this is normally
offered at 15 to 20 weeks and is used to assess the risk of having
a baby with spina bifida or Down's syndrome.
2.5 The diagnostic tests are:
Amniocentesis—this is offered at 15 weeks
onwards and can be used to detect chromosomal abnormalities such
as Down's syndrome. This test involves a small risk of miscarriage
so is not performed routinely. It is offered to those women at
a higher risk of having a Down's syndrome baby if a woman's serum
test was screen positive. It is also offered if she had a family
history of chromosomal abnormalities and also in circumstances
when an abnormal finding on ultrasound scan is seen.
2.6 Chronic villus sampling (CVS)—this
is offered between 11-14 weeks and can detect some inherited disorders
for example Down's syndrome, sickle-cell anaemia and thalassemia.
It carries a higher risk of miscarriage than amniocentesis so
is only offered to women whose babies are at risk.
INTRAPARTUM CARE
Place and type of birth
2.7 Many women are offered a choice of places
to have their baby. This may include a free-standing birth unit
run by midwives, a midwife-led birth area located within or alongside
an obstetric unit, a high-tech (obstetric-led) hospital or the
option of having a baby at home. The decision would be made together
by the woman with her doctor or midwife. Some factors which may
limit these choices will include: the facilities or staff which
are available locally, an individuals likely need for particular
facilities (for example a paediatric intensive care unit) or other
choices such as the type of pain relief they want to have available.
Pain management in labour
2.8 Most women are offered choices around
pain relief. The choice will be made following discussions with
the midwife or doctor. This may include gas and air, epidural
anaesthetic, a transcutaneous electrical nerve stimulation (TENS)
machine, or non-interventionist management of pain through breathing
techniques. Some women also choose to involve alternative or complementary
practitioners and techniques such as aromatherapy and massage
although the woman usually funds these.
Birthing positions
2.9 Women in labour should be encouraged
by their midwife to find a position that they prefer and one which
will make labour easier. Positions can vary. Some women choose
to remain in bed with their back propped up with pillows, or stand,
sit, kneel or squat. If a woman is too tired she can choose to
lie on her side rather than her back and if backache has been
a problem then kneeling on all fours can help. Women may be able
to try these positions at their antenatal classes or at home to
find the most comfortable position and their midwife can offer
advice both before and during labour.
Caesarean Sections
2.10 Despite the image of the executive
woman who wishes to plan the exact date and time of the birth
of her baby a recently commissioned audit of caesarean section
found that maternal request as reported by the clinician was the
primary indication for performing only 7% of caesarean sections.
2.11 The report of the National Sentinel
Audit of Caesarean Sections was published on 26th October 2001.
The results of the audit have been referred to the National Institute
for Clinical Excellence to develop clinical guidelines on the
use of caesarean sections. This will cover clinical indication
for caesarean section, the optimal timing of the operation and
conditions where caesarean section should not be the first choice
of the method of delivery.
Postnatal care
Length of hospital stay following the birth
2.12 This is often negotiable. A woman who
has had an uncomplicated birth may be able to choose to be discharged
six hours after the birth or to stay a day or more in hospital.
Women who have had a complicated birth, for example a caesarean
section, will stay in hospital longer. According to the latest
Maternity Statistics* a typical hospital delivery starts on the
day of delivery, with the woman and baby discharged the following
day. However, where interventions occur, these have a marked effect,
particularly on postnatal stay—women with instrumental deliveries
typically stay in hospital for one or two days after delivery
and women delivered by caesarean section typically stay for three
or four days.
(* The bulletin, number 2003-9, was published
on 16th May 2003, and has been placed in the Library and is also
available on the Department of Health website at http://www.doh.gov.uk/public/sb0309.htm)
Midwife/ health visitor visits
2.13 Midwives have a statutory obligation
to provide postnatal care to the mother, whether at home or in
hospital, for at least 10 days and up to 28 days after the birth.
However the patterns and content of post natal care can vary from
area to area. Usually once a woman is at home with her baby their
GP or midwife will visit them in their home until the baby is
about two weeks old. This may be every day or less frequently
depending on local practice. After that the health visitor will
visit the woman and baby at home for a period of up to 28 days
after the birth. Again the number of visits can vary depending
on local practice.
3. POLICY AND
ACTION BEING
TAKEN TO
EXTEND CHOICE
The Maternity Module of the Children's National
Service Framework
3.1 The Children's NSF—has one module
dedicated to maternity services. The maternity module has sub-groups
making recommendations around pre-birth, birth, post-birth, user
involvement and inequalities and access. One of the key themes
of the maternity module of the NSF will be around extending choice
around the following areas
— Extending choice of place of birth—for
example making home birth a real option in places where this is
not really supported.
— Extending choice of carer—the
choice of midwife only care throughout the whole period of pregnancy
and birth.
— Encouraging innovation in location
of antenatal care—especially for hard to reach groups. For
example providing antenatal services alongside clinics for drug
users, taking clinics and classes into community halls.
— Extending choice in postnatal care—individualised
packages of care, looking at evidence around extending midwife
led care for some women. Extending the length of time a woman
can be cared for by a midwife after the birth of her baby. Currently
this is only about 10 days but there appears to be good evidence
that extending this in particular cases to six or even 12 weeks
can improve outcomes, for example reduced postnatal depression,
and user satisfaction.
— Looking at information women, partners
and families need to help them make their choices. How this can
be offered in way women find the most informative and accessible.
£100 million capital allocation
3.2 In 2001 Alan Milburn announced a £100
million capital allocation for improving facilities in maternity
units to be spent over two years. The money was allocated to improve
quality of maternity unit surroundings and to promote choice for
a woman and her family by extending options for places to stay,
when and what to eat and drink, for example.
Other examples of how the money was spent included:
— Single rooms for women in early labour—where
partners can also stay
— Counselling and quiet rooms—mothers
and fathers making difficult choices may prefer time to reflect
away from busy areas
— New home from home areas—more
women can choose more comfortable birth environment
— New birthing pools—extending
birth options for women
3.3 The £100 million was allocated
on the basis of individual bids submitted by maternity units after
consultation with local staff and users. Over 200 units across
the country received a share of this investment. The money is
already being spent throughout the country with many building
and improvement projects underway and new equipment on order.
All projects are due to be completed in 2003.
Recruitment and retention of midwives
3.4 The government has made a commitment
to increase the number of midwives working in the NHS. The target
is to have 2,000 more midwives working in the NHS by the end of
2006 than there were in 2000.
3.5 There are 700 more midwives working
on the wards than there were in 1997. As increases in training
and return to practice initiatives bear fruit there will be further
increases.
3.6 Since 1996-97 the number of midwives
entering training each year has increased by 226 (14%) and latest
figures suggest a further increase of around 300 in the current
financial year. Increases in the number of students entering training
will provide the basis for growth beyond 2006.
Local Maternity Guides
3.7 The Department of Health is producing
100 local maternity guides with Dr Foster—filling the gap
between unit or trust level information and national (largely
health information/promotion) publications. The local information
will make it easier for women and their families to compare units
and services in their area. The information will be available
to everyone but is being designed particularly to appeal to lower
socio-economic groups, with celebrity and other real-life stories
in a popular magazine format. These magazines will allow all women
to compare local units more easily, and will encourage them to
consider the choices available throughout pregnancy and birth.
4. DISADVANTAGED
GROUPS AND
CHOICE
4.1 The maternity module of the Children's
NSF is specifically looking at services and choices for disadvantaged
groups through the Inequalities and Access Sub Group. The User
Involvement Sub Group will emphasise the importance of ensuring
user feedback and involvement from all service users, not just
those who are most vocal.
4.2 The maternity module will address extending
choice in the provision of antenatal care by encouraging innovation
in location of antenatal care—especially for hard to reach
groups. For example by taking antenatal clinics and classes into
more accessible locations such as community halls. It will emphasise
that services should be inclusive and flexible enough to meet
the needs of all women and will recognise that women from more
vulnerable groups may require different patterns of services and
places of care than have been traditionally provided. This innovation
need not only include physical location of care but by providing
continuing care and support over the telephone, by text or email
so women have quick access to help-line services or their midwife.
4.3 Information is key to being able to
exercise choice and control over maternity care. All women should
be provided with the information they need, in methods or languages
they can understand, to help them make decisions together with
their healthcare professional. This is a key aim of the maternity
module of the NSF. Disadvantaged groups are often unable to access
information that will help them make choices over their maternity
care. The local maternity guides that are currently being produced
by the Department of Health and Dr Foster are being designed to
raise awareness of the options open to them in their local area.
5. CONCLUSION
5.1 Maternity services are already at the
forefront of service user choice. Choice in all aspects of maternity
care provision is an important issue that is being addressed in
the maternity module of the Children's NSF. The National Service
Framework will encourage Primary Care Teams and Trusts to push
further at the boundaries, breaking down barriers to ensure each
woman, her partner and their family, have a range of realistic
choices throughout pregnancy, birth and beyond. The aim will be
to make the service even more flexible and responsive to the needs
and wishes of mothers, fathers, their babies and their families.
June 2003
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