Select Committee on Health Written Evidence


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.


  1.1  "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.


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. ( 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. ( 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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