APPENDIX 3
Memorandum by the Royal College of Midwives
The Royal College of Midwives (RCM) represents
over 95% of the UK's practising midwives, and has over 37,000
members. It is the world's oldest and largest midwifery organisation.
It works to advance the interests of midwives and the midwifery
profession and, by doing so, enhance the well-being of women,
babies and families.
This is the RCM's third submission to the sub-committee's
inquiry into maternity services. It sets out an ideal—woman-centred
care—and looks at the main barriers to women's choice and
control that exist in maternity services at present.
1. WOMAN-CENTRED
CARE
1.1 "Woman-centred care" is the
term used for a philosophy of maternity care that gives priority
to the wishes and needs of the user.
1.2 The fundamental principles of woman-centred
care are:
— ensuring women are equal partners
in the planning and delivery of maternity care;
— recognising the service is there
to meet their needs and wishes, rather than those of staff or
managers;
— giving women informed choice in terms
of the options available during pregnancy, labour and the postnatal
period, such as who provides care, where it is given and what
it contains;
— giving women continuity of care and
carer so they are able to form trusting relationships with those
who care for them; and
— giving women control over the key
decisions affecting the content and progress of their care.
1.3 Policies to achieve woman-centred care
began a decade ago with the publication of Changing Childbirth
(Department of Health, 1993), and the present Government endorses
this approach to maternity services. In a debate in the House
of Lords in January, Lord Hunt of Kings Heath stated: "The
Government, of course, remain committed to the principle of establishing
a high-quality woman-centred maternity service."1
1.4 There is a gap however between policy
and reality. There are very real barriers to choice and control
being exercised by women.
[1]2. BARRIERS
TO CHOICE
AND CONTROL
Midwife shortages
2.1 There is a shortage of midwives in the
NHS and that shortage is widespread. The 2002 Annual Staffing
Survey of senior midwifery managers, conducted by the RCM, revealed
that overall and long-term vacancy rates are the highest we have
recorded since the survey was first carried out in 1996, with
more units that ever carrying unfilled posts. Vacancy rates had
increased in every region of England with the exception of London,
where vacancy rates were already high. Vacancies remaining unfilled
for three months or longer (long-term vacancies) accounted for
59% of all vacancies in England.
2.2 A shortage of midwives limits the amount
of information a woman can receive. Even a well-intentioned midwife
facing stressful demands on her/his time finds that s/he is unable
to spend as much time as needed with a woman to explore the choices
open to her. Additionally, lack of staff can result in no continuity
of care and so there is little chance of a trusting relationship
being built up between woman and midwife, which might facilitate
an informed discussion about the content and progress of their
care.
2.3 A shortage of midwives also impacts
upon the choice open to women. Home births offer an excellent
example.
2.4 About 555,000 births took place in England
in 2001-02[2],
of which about 2% were at home. In a House of Lords debate in
January, the Government accepted that "many more women would
have wanted a home birth but that circumstances made that difficult."[3]
Indeed, research conducted in 2000 suggested that around 20% of
women would at least like more information about the option of
giving birth at home, but that this information and the support
to make it a real possibility are not always available[4].
2.5 It is undeniable however that in parts
of the UK women are still experiencing difficulty in arranging
a home birth. Often when there are insufficient midwives available
to support both the hospital and the home birth services, women
who have planned for a home birth have been asked to deliver in
hospital instead. However, if one-to-one care in labour is achieved
it should not matter where that labour takes place.
2.6 In these instances, the service is working
to meet the needs of managers and not the needs and wishes of
women. Indeed, the woman in this circumstance possesses neither
choice nor control over her maternity care. Care given before
and around the time of birth and shortly after is pivotal to a
couple's transformation into parenthood and can deliver long-term
health benefits (eg better breastfeeding rates).
2.7 The RCM believes that the Government
must commit itself not only to the principle of woman-centred
care, but also its effective implementation.
2.8 Midwives are the experts in normal pregnancy,
childbirth and postnatal care. Effective implementation of woman-centred
care requires the development of and support for innovative models
of service delivery. Midwifery-led care, where midwives act as
the lead professional, with good liaison and referral links to
medical colleagues, are popular with women, cost-effective, and
deliver good outcomes.
2.9 However, continuing improvements in
care are difficult to achieve where midwifery is under-resourced,
understaffed or midwives demoralised. Successful implementation
of woman-centred care depends on commissioners and managers recognising
the role and value of midwifery care, and investing in this care
with appropriate resourcing, fair pay, family-friendly working
conditions, and support for midwifery leadership.
The medicalisation of birth
3.1 Giving birth should be a natural experience
for most women, and yet how women are treated during pregnancy
and childbirth has been medicalised, particularly since births
were transferred to the hospital setting during the 1970s.
3.2 A good example of the increased medicalisation
of birth is the caesarean section (CS) rate[5].
This is rising rapidly. More than one-fifth (22.3%) of births
in England in 2001-02 were by CS, which was higher than ever before.
The rate was fairly stable during the 1980s (increasing only marginally
from 9% in 1980 to 11.3% in 1989-90), but has risen rapidly in
recent years. In the last 10 years for which figures are available
(up to 2001-02), it increased from 12.9% to 22.3%.
3.3 Intervention, however, is not limited
to CS operations. In 2001-02, only about half of women (53%) had
a spontaneous labour and delivery, without induction, the use
of instruments or caesarean section. Ten years previously that
figure was 63% and five years previously it was 58%. The decline
in spontaneous labour and delivery is steady. Other examples include
restrictions on food and drink and continuous fetal monitoring.
3.4 Intervention has potential health implications
for both mother and baby and so this rise cannot logically be
as a result of women exercising more choice and control over their
maternity care, certainly if it is informed choice. Indeed research
shows that such interventions reduce normal outcomes.
3.5 It can be argued that fear of litigation
is a factor in encouraging maternity care to be practised defensively,
with medicalisation and intervention seen as preferable to the
promotion of normality. Other factors also contribute, such as
midwife shortages and practice norms (both mother and maternity
care staff have become educated and socialised to view medicalised
birth as perfectly normal and perhaps even desirable).
3.6 The RCM believes that there is a need
to reverse the medicalisation of maternity care. There must be
a clear promotion of a philosophy of normality in maternity services,
with the resources to support that philosophy.
3.7 And that is being achieved in some Trusts
at present. In maternity units in which women are given the support
they need to have a normal birth, such as at the Royal Shrewsbury
NHS Trust, intervention rates are low[6].
3.8 In Shrewsbury, the CS rate is comparatively
low at 12% in 2001-02. This is the result of a long-term strategy
of promoting normality in childbirth, which is an approach the
RCM would support. In this Trust, a quarter of births take place
at home or in low-risk midwife-led units. For mothers with babies
in the breech position or who have previously had a CS delivery,
where most hospitals would opt for a CS, the Royal Shrewsbury
provide women with the opportunity to achieve vaginal births.
3.9 This approach—where pregnancy
and birth is treated as a normal physiological process in which
medical intervention is unnecessary unless there are clear indications
otherwise—results in less intervention. Most women do not
have this style of care open to them and so are not free to choose
it. We need sufficient numbers of midwives to provide antenatal
preparation and support in labour.
PCTs and the target culture
4.1 Although Primary Care Trusts commission
NHS services for localities, there is a major concern that their
understanding of maternity services is limited. As a result the
type of service being commissioned from Trusts is not necessarily
delivering choice and control for women.
4.2 This is compounded by the fact that
there are no waiting lists in maternity services. When a woman
goes into labour, she needs care. This makes maternity services
a lesser priority than many other parts of the NHS because there
are no politically-sensitive or media-friendly targets attached
to it. There is of course an incentive for PCTs to concentrate
on those aspects that are measured and targeted and for which
they will be held most accountable by Government and by the media.
4.3 This is compounded still further by
the approach taken by some PCTs towards Maternity Services Liaison
Committees (MSLCs). These are independent advisory committees
made up of maternity care staff and user representatives set up
originally to advise health authorities on local maternity services.
The abolition of health authorities and the creation of PCTs meant
that there is no longer an obligation to maintain or listen to
the views of MSLCs. As women who use local maternity services
sit on MSLCs, their disappearance would further diminish the "voice"
of women over the provision of services locally.
4.4 The weaknesses in PCTs relating to the
commissioning of maternity care needs to be addressed as PCTs
bed down within the new NHS structures.
4.5 The politically-sensitive target culture
existing in the NHS skews the priorities of PCTs, which has a
knock-on effect on what maternity services are commissioned for
local women. This needs to be changed.
4.6 PCTs should be obliged to maintain MSLCs
as a means of relaying the voice of women who use maternity services
to those responsible for commissioning those services. This would
help to ensure that women are equal partners in the planning and
delivery of their maternity care.
First point of contact
5.1 A midwife is the professional with the
most knowledge and experience of how to care for women during
normal pregnancy, labour and the postnatal period.
5.2 Many women however see their GP as a
first point of contact when they become pregnant. The GP normally
refers the woman to the nearest maternity unit for consultant-led
care. Whilst the GP has knowledge and experience of how to care
for women during pregnancy, the GP is not the best person to whom
women should turn.
5.3 Midwives should be the first point of
contact for all pregnant women. A culture needs to be developed
where women think to turn to a midwife first and not their GP.
This would be better for women and would help to take an unnecessary
strain off GP surgeries, but it would require that midwives are
accessible and women know how to contact them, whilst midwives
need to be prepared for this changing role. How this is achieved
needs to be examined.
June 2003
1 House of Lords Hansard, 15 January 2003,
c294. Back
2
NHS Maternity Statistics, England: 1998-99 to 2000-01.
Department of Health. April 2002. (www.doh.gov.uk/public/sb0309.pdf). Back
3
House of Lords Hansard, 15th January 2003, c295. Back
4
Singh D and Newburn M (2000) Access to maternity information
and support: the needs and experiences of pregnant women and new
mothers. NCT: London. Back
5
NHS Maternity Statistics, England: 2001-02, May 2003, NHS
Maternity Statistics, England: 1998-99 to 2000-01. Department
of Health. April 2002. (www.doh.gov.uk/public/sb0309.pdf). Back
6
Information for this example is taken from Postnote Number 184:
Caesarean Sections. Parliamentary Office of Science and
Technology. October 2002. Back
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