APPENDIX 6
Memorandum by the Royal College of Obstetricians
and Gynaecologists
1.0 INTRODUCTION
1.1 The Royal College of Obstetricians and
Gynaecologists considers that it has an important role in advocating
health policies which will enhance its aim of setting standards
to improve women's health. In addressing this role, it has worked
closely in recent years with women's consumer groups and has established
a Consumer's Forum which provides advice on a wide range of College
policies. The Chair of the Consumers' Forum has a seat on the
RCOG Council and representatives chosen by the Forum sit on all
of the major committees of the College. The name chosen for the
Forum reflects the College's view that its policies must reflect
the needs of all women, not only those who have been ill. Thus
the Forum has had strong representation from lay groups, such
as the National Childbirth Trust and the Association for the Improvement
of Maternity Services, with an interest in the development of
maternity services for women having normal as well as complicated
pregnancies.
1.2 The National Service Framework for Children's
Services will include maternity services. Development of the Framework
has provided the College with a further valuable opportunity to
collaborate with these lay organisations and also with colleagues
in the Royal College of Midwives, which shares aspirations for
the provision of an effective, safe and flexible system of maternity
care. Officers of the RCM and RCOG meet frequently and there is
cross representation on the Councils of both Colleges. The RCOG
acknowledges with pleasure the development of this close and harmonious
relationship, which has strengthened greatly in recent years.
1.3 Other medical royal colleges have important
roles to play in the development of maternity services. Of particular
importance are the Royal College of Paediatrics and Child Health
and the Royal College of Anaesthetists. These Colleges are also
involved in the discussions leading to the development of the
National Service Framework and are consulted regularly by the
RCOG. It is important to recognise that their perceptions of maternity
care may differ in some respects from those of the RCM and RCOG,
in that their members tend to become involved in maternity care
when clinical problems develop. Their contribution to these discussions
therefore tends to focus on the safety aspects of childbirth.
The RCOG acknowledges the importance of this viewpoint but also
recognises that childbirth is a natural process and that medical
intervention can often be avoided, to the advantage of the mother
and her family.
1.4 There is currently considerable concern
about rates of medical intervention in childbirth. In particular,
it has been suggested that rates of Caesarean Section in the United
Kingdom are inappropriately high. It was because of this concern
that the RCOG was a major force behind the National Sentinel Caesarean
Section Audit.[7]
This was the most comprehensive analysis of Caesarean Section
ever undertaken and it provides valuable insights into clinical
practice in the United Kingdom. The RCOG has previously commented
to the Committee on its importance. Of note in this context is
the fact that many consultants regarded a caesarean section rate
of 20% as being "too high". It is therefore evident
that obstetricians are aware of the need to restrict medical intervention
wherever possible.
2.0 CHOICE IN
MATERNITY SERVICES
2.1 The RCOG recognises and respects the
right of women to exercise choice in relation to childbirth. It
acknowledges that one of the roles of health professionals is
to provide information to help inform women's choices. Unfortunately
there are still major deficiencies in the provision of health
care data in relation to maternity services. It is therefore difficult
to provide comprehensive, accurate information upon which women
and their families can base decisions about optimal care. The
RCOG has previously provided evidence to the Committee about these
deficiencies and about the apparently increasing trend for women
to be looked after in settings where data collection is particularly
poor.
2.2 It is important to recognise another
major information deficit. There is very little well-researched
information about women's preferences in relation to maternity
care. An attempt was made to remedy this deficiency by the Maternity
and Neonatal Workforce Working Group,2 which commissioned a project
led by Dr Tina Lavender (Reader in Midwifery, University of Central
Lancashire). Some of the findings of this pilot study (attached)
were unexpected and challenging. The College considers that this
important work should be developed further.
2.3 An important feature of this study was
the fact that relatively few women were offered choice in deciding
on their place of birth. Although the report did not indicate
strongly that a large proportion of women would choose to deliver
in other than a hospital setting, it is important to establish
the economic and logistical consequences of a substantial movement
of maternity care in this direction. This is of particular importance
in view of the current crisis in midwifery staffing.3 In this
context, it is important to recall the aspiration of the Secretary
of State for Health of 100% midwifery support in labour.4
2.4 In its evidence to the Maternity and
Neonatal Workforce Working Group, the College accepted the likelihood
that there would in the future be more freestanding midwifery
led units. This development is welcomed by many organisations,
notably the Birth Centre Network, which advocates a substantial
expansion in these facilities.5 It is important to recognise that
there is as yet very little objective information about the functioning
of such units, both in terms of logistics and safety. The RCOG
strongly endorses the Network's advocacy of a national data collection
system encompassing such births.
2.5 An individual's choice of health care
may not be that advocated by clinical advisers (medical or midwifery)
nor espoused by the National Health Service. There may appear
to be undesirable health or financial implications. Any debate
on this subject must address the responsibilities of individual
health care workers and of the health care provider under these
circumstances. The Expert Group on Acute Maternity Services in
Scotland (EGAMS) made the following observation:6 "It is
not always possible to meet women's first choice in relation to
their care at childbirth, particularly in some of Scotland's very
remote areas. This may also present challenges for services in
more populous areas where the pattern of maternity services sometimes
reflects past practices, rather than current clinical priorities.
EGAMS nevertheless wanted to find means of ensuring that, as far
as possible, care delivered to women meets their needs and is
close to their home and family, without compromising safety."
There are already examples of work in various parts of Scotland
developing the theme of providing informed choice for women against
this background.7 The College endorses the sentiments expressed
by EGAMS and suggests that the Committee should adopt a similar
balanced and pragmatic view in addressing this important subject.
3.0 RECOMMENDATIONS
3.1 Women and their families should be encouraged
to exercise choice in deciding upon their care during pregnancy
and childbirth.
3.2 Collection of data relating to the provision
and outcome of healthcare in maternity services should be substantially
improved.
3.3 Further information should be collected
about women's preferences in relation to maternity care.
3.4 The economic and logistical consequences
of significant alterations in the provision of maternity services
should be established.
3.5 The Subcommittee should take account
of the work already carried out by the Expert Group on Acute Maternity
Services in Scotland in this area.
4.0 REFERENCES
1. Thomas J, Paranjothy S. Royal College
of Obstetricians and Gynaecologists Clinical Support Unit. National
Sentinel Caesarean Section Audit Report. RCOG Press, 2001.
2. Department of Health. Report to the Department
of Health Children's Taskforce from the Maternity and Neonatal
Workforce Group—January 2003. http://www.doh.gov.uk/maternitywg/report-jan03.pdf
3. Royal College of Midwives. Submission
to the Health Committee Maternity Services Sub-committee. First
Inquiry: Provision of Maternity Services. February 2003.
4. Alan Milburn. Speech to Annual Conference
of Royal College of Midwives, Torquay. 2nd May 2001.
5. Birth Centre Network. Birth centres—the
key to modernising the maternity services. A briefing paper for
the All Party Parliamentary Group on the Maternity Services. 2001.
6. NHS Scotland. Implementing A Framework
for Maternity Services in Scotland. Overview Report of the Expert
Group on Acute Maternity Services. http://www.show.scot.nhs.uk/publications.
Scottish Executive, 2003.
7. Mahmood T. Personal communication. 5
June 2003.
June 2003
7 Department of Health Children's Taskforce from the
Maternity and Neonatal Workforce Group-January 2003.http://www.doh.gov.ik/maternitywg/report-jan03.pdf. Back
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