Text attached of the Hansard report of the debate.
It's rather long (15 A4 pages) but a very good read!
Ishbel
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Maternity Care
11 am
Mr. Nicholas Winterton (Macclesfield): I am very pleased to have the
opportunity to discuss with colleagues the implementation of good practice
in maternity care. First, I must declare an interest as an honorary
vice-president of the Royal College of Midwives, a position that I hold
with great pleasure and pride. As many hon. Members will be aware, in 1991
and 1992 I had the honour and privilege to chair the Select Committee on
Health when it undertook an in-depth inquiry into maternity services. As
the Select Committee's 1992 report says, the inquiry was instigated,
by hearing many voices saying that all is not well with the maternity
services and that women have needs which are not being met.
Paragraph 33 of the report says:
Given the absence of conclusive evidence, it is no longer acceptable
that the pattern of maternity care provision should be driven by
presumptions about the applicability of a medical model of care based
on unproven assertions.
It would be proper for me to pay public tribute to the Select Committee's
advisers who were: Caroline Flint, a well-known independent midwife; Mrs.
Rosemary Jenkins of the Royal College of Midwives; Dr. Naren Patel,
consultant obstetrician at Ninewells hospital, Dundee; Professor Osmund
Reynolds, a close personal friend for many years, who was Professor of
neo-natal paediatrics at University college and Middlesex school of
medicine; Professor Philip Steer, Professor of obstetrics and gynaecology
at Charing Cross and Westminster medical school; and another personal
friend, Dr. Luke Zander, senior lecturer in the department of general
practice at the United Medical and Dental School of Guy's and St. Thomas's.
All those people were vital to the production of the Committee's report. I
should like to express my appreciation, these many years later, for the
tremendous support that I received during the inquiry as Chairman of that
Committee from all Committee members. To mention just one, the hon. Member
for Preston (Audrey Wise) was, with me, the driving force behind the
inquiry. I hope that hon. Members will allow me to say that I wish the hon.
Lady, who is in hospital at the moment, a full and speedy recovery.
The future reconfiguration of maternity units is currently under
discussion, which I believe provides an opportunity to reshape the
provision of maternity care in the United Kingdom. Where trust mergers are
unavoidable, resources must be directed in such a way as to enhance the
quality of maternity care. This is an opportunity for the Government to act
on the growing research evidence that demonstrates the huge advantages of
midwifery-centred care in the provision of maternity services.
Following the Health Committee report in 1992, an expert committee chaired
by Baroness Cumberlege, a health Minister at the time, considered the
implications of the Health Committee's recommendations. In due course a
report called "Changing Childbirth" was published, setting targets for
implementation and recommendations for good practice. On page 1, the report
said:
19 Apr 2000 : Column 209WH
The Select Committee concluded that a medical model of care should no
longer drive the service and that women should be given unbiased
information and an opportunity for choice in the type of maternity
care they receive, including the option, previously largely denied to
them, of having their babies at home or in small maternity units.
As the Chamber knows, "Changing Childbirth" became policy for the maternity
services in England in 1994 and remains the policy today.
The report called for fundamental changes in the maternity services, based
on three principles--the importance of involving women in making informed
decisions about their care, making maternity services accessible and
attractive to all women and having public involvement in the monitoring and
planning of maternity services. A key to putting those principles into
practice was reinstating more autonomous midwifery practice and enabling
midwives to provide continuity of care. Time and again when we were taking
evidence from mothers to be, they talked about the importance of the
continuity of care--having women cared for by a named midwife through the
whole of pregnancy, for labour and birth, when possible, and in the early
weeks following birth. It was recommended that midwives be organised into
small groups, working between community and hospital. An explicit target
was to have 75 per cent. of women cared for by a midwife whom they have got
to know for labour and birth. That is something that I feel strongly about,
as did the Health Committee at the time.
The Royal College of Midwives has supported "Changing Childbirth" since its
publication and throughout its implementation and remains committed to the
principle of a woman-centred care structure. It is no longer appropriate
for maternity care to be for the convenience of consultants and doctors; it
is there for the mothers and babies.
In a new year press release the Minister for Public Health stated:
Maternity services are at the heart of the service that women and
babies of this country want and deserve.
In the opinion of some of the user organisations, this is now an issue not
of choice but of public health. In the nearly 11 years since "Changing
Childbirth" was published, maternity care has, sadly, not moved towards the
ideals embodied in the report. Indeed, and I say this with some regret, for
most women the likelihood of a normal birth with a known midwife is even
less now. The centralisation and medicalisation of birth in large obstetric
units has intensified rather than declined. Caesarean section rates since
"Changing Childbirth" have increased to over 30 per cent. in some hospitals
and have recently shown signs of rising still further. This is a major
cause for concern.
Full implementation of "Changing Childbirth" depended to a large extent on
good midwifery practice. With the severe shortage of midwives, many of the
excellent pilot schemes that were originally set up have failed to
continue. The latest statistical analysis of the register of the United
Kingdom Central Council for Nursing, Midwifery and Health Visiting reveals
that there are 33,897 practising midwives and a further 58,286 who are
registered but not practising. That is a lamentable waste of skills and
talent.
19 Apr 2000 : Column 210WH
Sadly, since 1994, the quality of maternity care has deteriorated. Consumer
groups, including one for which I have the greatest regard, the Association
for Improvements in Maternity Service, which is known affectionately as
AIMS and is chaired by that splendid lady, Beverley Beech, is reporting
many more serious complaints from all over the country. It attributes them
to a reduction in midwifery staff, particularly in the more senior
midwifery grades--it is worth emphasising that. At the same time, it is
reporting many letters from former midwives who have left the service in
despair because they were not allowed to practice normal midwifery and
provide the normal births for which they had been trained. Instead, many
became obstetric nurses in high-tech hospital units.
Caesarean sections are a matter that causes considerable concern. Some
obstetricians now provide caesarean sections on request for women with no
medical reason to have them, thereby adding to the risk to both mother and
child as well as to national health service costs. At the same time, NHS
trusts are failing to provide proper care for those women who want and
should have a normal birth. Delivery by caesarean section carries a higher
risk, as I am sure that many hon. Members know--not least among them the
Minister--for both mother and baby. The mother has a slower rate of
recovery, a reduced chance of successful breastfeeding, an increased need
for post-natal care--which, sadly, is in short supply--and a greater risk
of complications.
One of the major risks of caesarean section comes with the birth of the
next child and any subsequent children. The mother has a greater risk of
placenta praevia when the placenta blocks the outlet, leading to
haemorrhage, an increased risk of the placenta becoming embedded in the
wall of the uterus, and the risk of life-threatening haemorrhage when an
attempt is made to remove it. There has been an increase in emergency
hysterectomies carried out after birth to save the life of the mother who
has had one or more caesarean sections for previous births. If those
caesarean sections were unnecessary, surely the resulting problems are a
high price to pay. Ironically, medical litigation costs the NHS more than
£300 million every year and obstetric claims account for more than 50 per
cent. of that total.
Good practice is the provision of a service that allows women who wish to
have a normal labour and delivery without medical assistance to do so.
There is now ample medical evidence that normal births at home are at least
as safe as hospital births. However, it is rare for women to receive clear,
unbiased advice--I say that with fervour--or to be able to choose where to
give birth to their babies. Women are not told of the risks of hospital
births, but the risks of home birth, both real and imagined, are heavily
stressed by the medical profession. AIMS receives calls daily from women
who want to give birth at home but are being persuaded into accepting a
hospital birth and now that the midwifery shortage is acute, staff are
telling mothers, "Should there be a staff shortage in the hospital when you
go into labour you will have to come into the hospital."
I turn to midwifery education. The centralisation and medicalisation of
birth in large obstetric units has resulted in a significant group of
midwives who are not confident of supporting a woman who wants a normal
19 Apr 2000 : Column 211WH
physiological birth. They can only offer drugs for pain relief and are
stressed by caring for a woman who is not immobilised by a foetal heart
monitor and connected to an epidural. In a recent AIMS journal, a
non-practising midwife, deploring the decline in good skilled midwifery
practice, commented that student midwives learn good theory in the
classrooms, but bad practice in the wards of our hospitals. AIMS hears from
an increasing number of student midwives who say that, although they are
nearing the end of their training, they have not witnessed a normal
physiological birth. Is that not extraordinary? Surely there is something
wrong with a system that allows that to happen.
At Chelsea and Westminster hospital, 80 per cent. of pregnant women are
given epidural anaesthesia. As a result, student midwives are unable to
understand and support a woman in normal labour. Such women behave very
differently from those who are given epidurals. Because of that training
failure, midwives no longer understand the natural progression of labour in
a normal, unmedicated physiological birth. Indeed, AIMS files bulge with
reports of the strategies adopted by many midwives to persuade women who
had home births to give birth in hospital.
What is the way forward? The Royal College of Midwives wants maternity
services to be orientated around primary care, and the use of midwifery-led
units to be increased. Examples of successful units include Trowbridge
hospital--which is part of Wiltshire Health Care NHS trust--where more than
600 deliveries a year take place. In inquiring into maternity services,
members of the Health Committee visited that hospital. The Edgware birth
centre recently presented the findings of its two-year project in an
evaluation report.
Hospitals in which team midwifery has excelled include Bolton
hospital--again, in my own part of the country--which is part of Bolton
Hospitals NHS trust. At the Crewe health centre--which is even closer to my
constituency and that of my hon. Friend the Member for Congleton (Mrs.
Winterton), and is part of the Cheshire Community Healthcare NHS trust--the
caesarean section rate has been reduced significantly. I applaud that
statistic, the hospital, the midwives and other clinicians involved at
Leighton hospital.
The current shortage of midwives in maternity units is a problem in terms
of recruitment and retention. If depreciation in services is to be avoided,
that shortage must be addressed by health authorities and, if I may say so,
the Minister in particular. Education and training must also be emphasised.
Salford provides a good example of a comprehensive training school.
Students there experience deliveries from a variety of backgrounds. The
recent practice of recruiting consultant midwives is an encouraging
development that should be extended throughout the United Kingdom. If the
theoretical training of student midwives is to be reinforced and supported,
they must be provided with a thorough grounding and understanding of normal
birth.
The education system should be linked to stand-alone midwifery birth
centres, and I hope that the Minister will comment on that. A
community-based service that supports case-load midwifery was introduced in
Professor Lesley Page's one-to-one midwifery care
19 Apr 2000 : Column 212WH
scheme. I have met Professor Page and I have the greatest respect for her.
Her contribution to maternity services is outstanding.
The Minister and hon. Members will know that one-to-one midwifery was
established in November 1993 in the Hammersmith Hospitals NHS trust, at
Queen Charlotte's and Chelsea hospital, and Hammersmith hospital, so that
the "Changing Childbirth" principles could be put into practice. Each
midwife has a case load of 40 women. Sensibly, each works with a partner
and, so that they can cover holidays and so forth, they get to know the
women in each other's case load. Partnerships are organised in group
practices of six to eight midwives, which allows allocation of case load,
mutual support and a forum for peer review of practice. Again, those are
sound procedures. The one-to-one midwives survey geographical catchment
area includes low and high-risk women. If the woman's pregnancy is low
risk, the midwife manages the care, but if it is high risk, an obstetrician
does so, although, importantly, the one-to-one midwife will continue to
provide midwifery care.
The education system should be linked to a home birth service in which all
midwives are supported and enabled to practise autonomously, should they
wish to do so. For many years, midwives in independent practice have been
able to provide a high-quality service for the women whom they attend--they
are often high-risk women who are unwilling to have a second hospital
birth. In order to practise autonomously and to fulfil their role to its
fullest extent, those midwives have had to practise independently and,
sadly, outside the NHS. It is time that their contribution to maternal and
child health was recognised and those dedicated midwives were supported
within our splendid NHS. The situation in New Zealand shows that an
independent model in the health service would enable all women--not simply
those who can afford the fees or those for whom the midwives provide
charitable care without payment--to benefit from real choice, control over
their body and continuity of care. That restructuring of care would enable
obstetricians to focus on and develop quality of care for high-risk women
and those who choose to give birth in a high-tech unit.
Several initiatives have had excellent outcomes, including the one-to-one
midwifery practice, which I discussed earlier, and the Edgware birth
centre. During the two-year evaluation period between 1 September 1997 and
31 August 1999, 387 women had their babies at the centre, which was in line
with the targets that had been set. In that period, 727 women booked into
the centre; 19.4 per cent. transferred ante-natally and 12 per cent.
transferred during labour.
I am delighted to say that women who planned to deliver at the birth centre
during the evaluation period recorded very high levels of maternal
satisfaction, which is crucial when women give birth. They also had need of
far fewer interventions than women who were in the same risk category but
who delivered in hospital.
I hope that the Minister will bear with me while I give some statistics. In
relation to planned caesareans among low-risk women, there were
interventions in 3.3 per cent. of cases in local hospitals and in only 0.3
per cent. of cases in birth centres. The national figure, which includes
all women and covers the period 1996-97, was 8 per cent.
19 Apr 2000 : Column 213WH
In relation to inductions among low-risk women, there were interventions in
16.8 per cent. of cases in local hospitals and in 7.3 per cent. of cases in
birth centres, which is significantly lower. The national figure, which
includes all women and covers the period 1996-97, was 20 per cent.
In relation to epidurals among low-risk women, there were interventions in
30.7 per cent. of cases in local hospitals and in only 11.4 per cent. of
cases in birth centres. The national figure was 19 per cent.
In relation to episiotomies among low-risk women, there were interventions
in 18.9 per cent. of cases in local hospitals and in only 5.1 per cent. of
cases in birth centres. The national figure was 20 per cent.
In relation to the use of forceps among low-risk women, there were
interventions in 5.1 per cent. of cases in local hospitals--the figure for
the use of the ventouse in that category was 9.5 per cent.--and in birth
centres the relevant figure was 2 per cent. for forceps and just 1.9 per
cent. for the ventouse, which is the vacuum extractor procedure. The
national figure was 11 per cent. Some of those figures were provided by the
Department of Health.
In addition, women who delivered at the birth centre had labours that were
on average 15 per cent. shorter than the labours of similar low-risk women
who delivered in local hospitals. Much less use was made of clinical
anaesthesia such as pethidine. Remarkably, 50 per cent. of babies born at
the centre during the evaluation period were born in water.
The cost of deliveries at the birth centre was significantly cheaper--by up
to 30 per cent.--than that for similar women delivering in hospitals.
The research and evaluation has some limitations--the comparatively small
sample, the difficulty of obtaining comprehensive and accurate financial
information, the lack of information about women who choose not to book at
the centre, and the fact that the research was done at the start of the
birth centre project.
Another practice that I am sure is well known to the Department and the
Minister is the Albany midwifery practice. The practice's costs are
£180,000 for the midwifery care of 2,316 women, of whom 47 per cent. are
Caucasian and 53 per cent. black African, Vietnamese or Asian. The home
birth rate is 37 per cent. The rate for non-pharmacological analgesia is 65
per cent. The rate for spontaneous vaginal delivery is very high, at 78.9
per cent. The rate for intact perineum is 63.5 per cent--that is very
important to women. At four weeks, 74 per cent. of women were
breastfeeding.
For those who do not know, I shall explain the history of the south-east
London midwifery group practice, which I shall call the Albany practice. It
was established in 1994 as a self-employed, self-managed group of midwives
and a practice manager. The aim of the group is to provide continuity of
midwifery care to local women--ante-natally, during the intra-partum period
and post-natally--with known midwives, with a policy of targeting certain
groups and promoting equity of access, thereby meeting the objectives of
"Changing Childbirth".
Dr. Peter Brand (Isle of Wight): I am very impressed by the Albany
statistics. Can the hon. Gentleman tell me
19 Apr 2000 : Column 214WH
whether the 26.5 per cent. of patients that did not have intact perineums
had episiotomies or perineal tears? Earlier, he said that the episiotomy
rate at the Edgware birth centre is extraordinarily low--much lower than
the rate for intact perineums that he quoted for Albany.
Mr. Winterton : I respect the hon. Gentleman for his professional
knowledge. I cannot immediately give him an answer, but I shall certainly
ascertain that statistic and come back to him. It is a relevant question,
and I am sorry that I am not currently in a position to respond to it.
The Albany practice secured direct funding from the health commission to
provide midwifery care for 130 women a year. The group also looked after a
further 20 women from the Greenwich area. The mode of care offered quickly
proved to be extremely popular with women, and the group's work soon became
nationally and internationally acclaimed as ground-breaking. It is still
valued as an important resource for all those who are interested in that
type of innovative midwifery practice.
Towards the end of 1996, despite its success, the Albany practice was under
serious threat. It became apparent that the health authority could not
readily make funds available for it to continue. Having always had positive
connections with King's college hospital--with especially strong support
from Cathy Warwick, the director of midwifery--the practice proposed a
sub-contract with King's health care trust.
Although that would inevitably mean losing some of its autonomy, the group
felt that it would be worth while in view of the potential of such
collaboration. I am pleased to report that the health authority was
supportive of such a solution and agreed to contribute to the funding
required for the new approach. In the light of the practice's excellent
outcomes and predicted cost-effectiveness and health gain among the local
population, both parties are hopeful about the effects of making the Albany
practice midwifery model part of what I would describe as midwifery
mainstream. The proposal would also relieve some of the pressure imposed by
long-term midwifery vacancies at King's college hospital.
The Minister will know that the Albany practice is one of eight midwifery
group practices at King's. The group comprises seven midwives and a
practice manager based at the Peckham Pulse and it is self-employed and
self-managed. A sub-contract has been negotiated between King's and the
Albany practice to provide maternity care for women in and around Peckham.
I am sure that that is of great interest to a friend of the Minister's, the
right hon. Member for Camberwell and Peckham (Ms Harman). The case load is
generated by four local general practitioners, some self-referrals and some
referrals from consultant obstetricians at King's.
The Albany midwifery practice offers women-centred care, as recommended by
the "Changing Childbirth" maternity group. The practice offers continuity
of midwifery care with two known midwives for each woman. It provides
ante-natal, post-natal and intra-partum care. I believe that the Albany
practice is unique in the United Kingdom, but I hope that that uniqueness
is quickly lost and that its example can spread throughout the country.
19 Apr 2000 : Column 215WH
The House and women owe a great deal to the Health Committee report and to
the subsequent work of Baroness Cumberlege. It is important that maternity
services in Britain are focused on the mother and the baby. Doctors have a
role to play, but care should not longer be organised around doctors,
obstetricians, gynaecologists and the medical profession. It should be a
service specifically for mothers and babies, in which midwives have a
pivotal role to play. I am delighted to be associated with them and I hope
that the Minister will respond positively to my concerns.
11.30 am
Mr. David Drew (Stroud): I pay tribute to the hon. Member for Macclesfield
(Mr. Winterton) for putting the case so fluently, in his own inimitable
way. It is good to see that the Minister for Public Health is present to
respond, as well as her shadow counterpart, the hon. Member for Meriden
(Mrs. Spelman).
I want to speak almost entirely about the midwife-led aspect of maternity
care. I was born through caesarean section, through no fault of my own, and
I know what an important aspect of care midwifery is. Stroud has a midwife
unit that is one of only two remaining units in the south-west. It was
under threat of closure some two or so years ago, which is why I have
spoken on these matters in a debate on national health service maternity
services that was led by my hon. Friend the Member for Braintree (Mr.
Hurst) in the House on 11 February 1998. I do not want to repeat the
arguments that were rehearsed in that pertinent debate.
The hon. Member for Macclesfield was Chairman of the Health Committee when
the seminal document "Changing Childbirth" was published in 1993. I make no
apology for repeating, rather than stealing or plagiarising, an important
part of that document, which was mentioned by my hon. Friend the Member for
Braintree in the debate in February 1998. The key element is choice. He
quoted a passage that I shall quote again now, because it is so important.
The Committee said:
We recommend that the policy of closing small rural maternity units on
presumptive grounds of safety be abandoned forthwith. We further
recommend that no decision be taken to close such a unit unless it can
be explicitly and incontrovertibly demonstrated that they are failing
to provide value for money and that the costs to the consumers are
carefully taken into account in making such calculations. We recommend
that in considering an appeal against the closure of such a unit, the
Secretary of State should make presumption against closure unless the
case is overwhelming, since we believe that there is a shift in
attitude towards maternity care which can only be met by maintaining
such units as a realistically available option.
Choice is the keynote of the debate, and that was borne out in the
"Changing Childbirth" report. The issue is one of disseminating best
practice and keeping maternity care as local as possible. The size of units
is also important. Within reason, women want smaller units for pre-natal
and intra-partum care, but also post-natally, including perhaps
transferring from a district general hospital when they want to be closer
to family and friends.
My contribution to the debate in 1998 was to argue strongly for midwife-led
services in Stroud to continue. The Stroud News and Journal led an
effective campaign, which I was happy to support. Our proposal involved
19 Apr 2000 : Column 216WH
saving £150,000 from a budget of £248 million, which puts the matter in
perspective. We wanted to show that women and families supported the
continued operation of the unit in Stroud. That was partly due to its being
part of a much larger operation in Stroud hospital, which has become a
centre of excellence. I thank the Government for the recent upgrading of
the accident and emergency department in Stroud. It seems important to have
the appropriate range of services across the age range. There is an
important development in elderly people's care on the hospital site, and it
is important to keep the maternity unit there. In 1993, when "Changing
Childbirth" was published, the unit was refurbished and was reopened by Dr.
Mark Porter--some hon. Members know him--a constituent of mine who is known
to me personally.
During the debate in February 1998, the then Under-Secretary, my right hon.
Friend the Member for Brent, South (Mr. Boateng), promised that proper
consultation would always take place on any proposal to close a unit, that
the presumption would be against closure and that the Government would
support best practice and new initiatives.
In discussing the two remaining threats I shall refer to a review document
that I have just obtained. The two threats seem to be the economic case for
further centralisation and medical opinion. The Government deserve praise
for the money that they made available to my area's health authority in the
Budget, and the commensurate changes made at the time, which have lifted
the pall that was over the authority. However, a value for money argument
can be made, and we cannot ignore it. Even so, very small sums are involved
in relation to the overall budget.
When we last discussed the Stroud midwife-led maternity unit, it was
decided to keep it open but to review it regularly. The latest 18-month
review has just been completed. We did not talk explicitly about the cost,
because that is a matter for the seven NHS trusts and the health authority.
A more difficult problem was that of medical opinion. The hon. Member for
Macclesfield made it clear that obstetricians and other specialists still
continue to argue in favour of babies being delivered in district general
hospital units.
I am not taking a dig at the GPs in my area, but they are generally
somewhat ambivalent towards a local midwife-led service. That does not
help, because most women will take their GP's advice when they receive the
happy news that they are pregnant. If GPs gave a more positive response, on
safety and the right to choose, we would have every reason to keep
midwife-led units open. The risk factor is slight, but in difficult cases,
Stroud is not a million miles away from consultant-led units in the
district general hospitals at Gloucester or Cheltenham. We can have the
best of both worlds. I hope that GPs and consultants will continue to
listen.
The three keynote terms in the 1993 report and today's are the need for a
service that is comprehensive, flexible and based on choice. The current
review is now completed. The target was 350 births a year. That is
difficult to reach; although the number of births has increased, it must be
set against an overall decline. We are trying to go against the tide.
19 Apr 2000 : Column 217WH
If complications arise, cases will inevitably be transferred to the
district general hospital, which will reduce the number of women using the
local midwife-led unit. Indeed, there is always pressure to go for the safe
solution. I did not go for that option: two of my children, Laurence and
Christopher, were born in Stroud maternity hospital. Esther was born at
home with the help of the midwife service run from Stroud. I have personal
experience of the quality of care and the personal service offered by the
midwife service.
I do not wish to mix statistics with the hon. Member for Macclesfield--he
left me for dead with his--but I have no reason to doubt their importance.
The number of births each month can vary. For instance, in December 1998
there were only 13; last month, there were 27. That is obviously going in
the right direction, but variations can occur. Transfers back to the
midwife-led unit for ante-natal and post-natal care are somewhat
unpredictable. However, such variations are inevitable because childbirth
has yet to be completely sanitised. Long may that continue.
Some significant improvements have taken place. We now have the support of
paediatricians at Gloucester Royal hospital. That has led to the drawing up
of a protocol which shows that there is a belief that the service in Stroud
is safe, that it has a high quality threshold and that it is popular. Much
has been done to publicise the service and to show women in the area that
it is open for business. The service wants to make itself known to as many
people as possible. The fact remains, however, that GPs are not always as
helpful as they might be. Anything that I can do to persuade them otherwise
is important.
There is good support from the National Childbirth Trust, the league of
friends of the hospital and the ladies circle that works with the league of
friends. We are not yet at the threshold of 350 births a year. I hope that
that will not be used as an opportunity to revisit the usual
response--difficult meetings with officials--with many people being angry
that their wonderful and well-loved service was threatened.
Much is happening. There are many initiatives. One of our midwives--Helen
Conway--is well known to me. She is in China learning about different ways
of delivering and the use of acupuncture. Anyone who knows Stroud will be
aware that we are very alternative there. I probably have more
acupuncturists than general practitioners in my constituency. Acupuncture
provision will fit centrally into what women seem to want.
I want from my hon. Friend the Minister a clear statement that there is a
future for midwife-led units, that they are safe and that they should be
there to respond to the choice that women wish to exercise. I want her to
pass on my message to the local trust that we do not want to revisit the
possible closure of the unit. Such threats lead to great public aggravation
and take us no further forward. I want to hear that the costings, which are
not as important as the medical opinion, can be put in place to show that
the staff have a future. The staff may then breathe a sigh of relief and
the women and families of the area may then be given the services
19 Apr 2000 : Column 218WH
that they so clearly want, not only in the local midwife-led unit but at
the district general hospital. The choice must always be there for people.
11. 46 am
Dr. Peter Brand (Isle of Wight): I hesitate to contribute to the debate, as
a man and, worse, a doctor with a qualification from the Royal College of
Obstetricians and Gynaecologists. The college appears to be the baddie of
the debate.
"Changing Childbirth" was a seminal document. It was important because it
recognised that childbirth had changed over the years. When I first saw the
title I thought that it was ridiculous. Women have always had babies and,
other than Pallas Athene, who was delivered through an especially unusual
route, they have had them vaginally or by caesarean section.
We have moved too far towards technical intervention in childbirth.
However, I would like to remind the hon. Member for Macclesfield (Mr.
Winterton), who spoke with great depth of feeling about the benefits of
natural childbirth, that natural childbirth can also result in a high rate
of dead or handicapped babies. It can result in significant mutilation of
mothers with subsequent obstetric disasters and perhaps, even more sadly
for them, incontinence, which is extremely difficult to treat. One need
only consider what happens in the third world, where nature is all that
people can fall back on, to understand that natural childbirth does not
deliver an especially good service. Whatever we discuss with regard to
maternity care, we must not deny that nature needs professional and
high-quality help.
I am as one with the hon. Member for Macclesfield in saying that the
approach should be woman-centred. I was pleased that he acknowledged later
in his contribution the importance of the baby. He was right to say that we
need a personal service for women. Childbirth can be the most wonderful
experience, not only for the woman having the baby and the family concerned
but for the other people involved in the birth. The experience can also be
hairy and frightening when things unexpectedly go wrong and get slightly
messy. Whatever model we adopt, we must ensure the flexibility to which the
hon. Member for Stroud (Mr. Drew) referred.
Mr. Winterton : I am listening carefully to the hon. Gentleman and,
although it is early in his speech, he has not so far mentioned midwives.
The midwife is a qualified professional, and if there is continuity of
care, the mother to be can be provided with the confidence and expertise to
have a normal birth. Midwives are professionals, and if it becomes
necessary to involve a consultant, they will immediately pass over the
case. However, the midwife can provide the continuity that is so essential
to the woman in giving birth.
Dr. Brand : I am grateful for that intervention. The hon. Gentleman
anticipated my next point. Professional help is required, and the lead
professionals in this area are midwives. The expertise and time of midwives
can make an enormous contribution to a normal delivery. I have no doubt
that women who are well looked after, who feel relaxed and are confident of
the support of someone they know, have much better births and the
19 Apr 2000 : Column 219WH
process is much more positive. I agree with the hon. Member for
Macclesfield that there is evidence that women who are relaxed and
confident need less anaesthesia, but I do not agree that it is necessarily
a bad thing for a woman to choose to have analgesia. At times during his
speech, I thought that we were listening to the critics of Queen Victoria,
who indulged in artificial anaesthetics during some of her many deliveries.
The essence of my remarks is that giving birth is the province of midwives.
The setting for giving birth should be the personal choice of the woman who
is having the baby, but in promoting home deliveries, which are the most
satisfying part of one's career, it is important to remember that they can
be carried out only if there are experienced midwives in sufficient number.
Otherwise, one might find that no one is available, except a midwife 30
miles away whom the mother has never met, which destroys the whole idea of
continuity of care.
It is also essential that a second pair of hands is available at the time
of birth in case there are problems with the baby. It is essential that
someone at the birth can intubate the baby if required. It is also
essential that the home circumstances can be enhanced if necessary. One of
the reasons why the Dutch have much better statistics than we do is that
they provide social support in the later stages of pregnancy, which makes
an enormous contribution. It is also vital that there should be ready
access to a flying squad. I am one of the wicked GPs who dissuaded people
from having their babies at home because it took about one hour for a
flying squad to arrive. That is a complete waste of time, and a flying
squad should include someone with obstetric experience as well as an
anaesthetist.
We heard some good stories from the hon. Member for Stroud (Mr. Drew). I
had the privilege of witnessing the birth of both of my sons, but they were
born in hospital. One of them would not have survived at home, and my wife
would not have survived if she had been at home when she gave birth to the
other. We must put this in perspective. Home deliveries require an adequate
standard of professionalism at the home and back-up by the hospital unit.
There should also be the option of the midwife transferring the mother to a
midwife unit within the hospital or to an obstetric unit run by a
consultant. We have made progress on that. The Cumberlege report was a
bombshell for most obstetricians who withdrew into a professional laager
saying, "The world will now stop." They realised that they had
underestimated the professional capacity and capability of midwives and had
overestimated their own importance in women's minds. Patients are sensible
and pick who suits them best.
If we are to continue to extend the role of midwives, which is a positive
approach, we need to do something about their training, as the hon. Member
for Macclesfield said. We must also allow them to have a decent career
structure. It is unacceptable for a qualified midwife to be employed at a D
or E grade. That is what drives them out of the national health service.
When we consider different patterns of deliveries--I was impressed by the
statistics for the Edgware birth centre and the Albany unit--we must ensure
that we compare like with like. Innovative units attract a different
section of the population than a district general hospital, which is used
by a more average part of the population. A pre-selected group might
produce different outcomes.
19 Apr 2000 : Column 220WH
The Health Committee last year, or possibly the year before, considered
caesarean section rates published by the NHS executive. I asked how many
home deliveries had occurred in the district for which the rates were being
given, but that figure was not known. If 30 per cent. of normal babies are
being born at home rather than in a hospital unit, it is obvious that
caesareans are being performed on a different section of the population. We
need to be clever with statistics because they can be used in different
ways.
The hon. Member for Macclesfield mentioned the role of independent
midwives. I have no problem with independent midwives, but they need to
function within a framework that provides the full back-up that is
available to other midwives. They must also accept clinical governance. I
am afraid that independent midwives are sometimes reluctant to have their
figures queried. It is not good enough to rely on high-profile press
reports when something goes disastrously wrong. They should be licensed and
have their competence evaluated, which should also happen to general
practitioners. I hope that that will be part of the accreditation system.
It is unacceptable for GPs to be on an intra-partum obstetric list if they
are not involved in intra-partum care. It is unfair--and silly--to call out
a practitioner who has not delivered a baby for two years to deal with a
complication that is being handled by a professional who probably manages
100 deliveries a year. We need an ante-partum list and, with the right
education, post-natal care will look after itself.
I am glad that we have had this debate. Not only is the way in which
childbirth is being managed changing all the time, but so is the population
that is giving birth. We must remember that women are now much older when
they have their first baby. Again, I have some problem with the promotion
of natural childbirth at all costs. We must consider the mother's age. It
is rather rude to talk about elderly primates. The age used to be over 35;
I think that it has now been raised to 40. There is no doubt that women
have babies much more easily in their early 20s or late teens than in their
late 30s or early 40s. It would be foolish to encourage people to take a
completely natural route if any complications were envisaged.
Mr. Winterton : Does the hon. Gentleman agree that the mother to be should
make that choice--I accept with the best advice? To date the clinician has
too often left no choice. Those who support the views that I have expressed
want the mother to be to make that choice, but from a position of
knowledge, if there are complications.
Dr. Brand : Of course the woman should make the choice, but it should be an
informed choice and one that takes into account the outcome of the
process--the baby. I do not accept that it is necessarily bad practice to
have a high rate of epidurals, to offer analgesia or to have foetal
monitoring, whether in the home or in hospital. If we are to screen out
higher-risk procedures and anticipate events, the safest way to shift a
baby to a place of safety is in the mother's womb, and not attached to
something else.
Technology should help natural childbirth; we should not look to it as an
alternative.
19 Apr 2000 : Column 221WH
12.1 pm
Mrs. Caroline Spelman (Meriden): I congratulate the hon. Member for
Macclesfield (Mr. Winterton) on securing this important debate and drawing
attention to the Health Committee's work on this issue. I found it
particularly interesting to hear all the information about the Edgware
birth centre. When that is on the record, many more people will be aware of
its interesting statistics.
I know that the Minister for Public Health gives midwifery a high priority,
because in her new year message she said that maternity services were at
the heart of Government. She perhaps knew at the time just how important
that would be to those in government. Indeed, we wish the Prime Minister
and his wife all the best in their imminent happy event.
For all the fine words, there is a gathering crisis in midwifery when a
third of all trusts cannot provide one-to-one care for a woman. There is
nothing more terrifying for a woman who is in labour, perhaps for the first
time, than when the midwife leaves the room. Although I have no information
to support my theory, I suspect that such non-attendance occurs more often
in an institutional setting than at home, when, by definition, the midwife
has to be there. At such times, prospective parents feel very vulnerable if
they are left alone with the incessant bleeping of the foetal monitor. It
is just the sort of thing that "Changing Childbirth" was designed to avoid.
I am pleased that hon. Members on all sides have paid tribute to the work
of Baroness Cumberlege in producing that document, which is a seminal work.
All of us are united in wanting to see it implemented.
It is essential to quantify the extent of the crisis. The Royal College of
Midwives survey shows that three out of four midwifery units carry
vacancies and that the number of long-term vacancies has risen to 55 per
cent. of all vacant posts. That translates into a shortfall in absolute
terms of 1,000 full-time midwives. There is no doubting the strong sense of
vocation that midwives feel, but their morale is not good at present. That
is not hearsay; the facts speak for themselves. Only 36 per cent. of
registered midwives are practising today and the number of students
entering midwifery education is falling. Several hon. Members have
suggested reasons for that.
I echo the view that there should be a review of the salary structure in
midwifery. Nurses' pay has increased, especially at the upper end, but
midwives often find that their wage levels reach a plateau, despite years
of experience in midwifery that should be recognised. Midwives, by
definition, travel a great deal as part of their work and a further
aggravation is that their mileage allowance remains very low. In order not
to sound hypocritical, I should point out that it is less than half that of
a Member of Parliament.
The recruitment and retention problems are not only due to pay levels. The
number of vacancies has a bearing on working conditions. When vacancies are
not filled, those who remain must carry a greater load. The average
shortage of midwives is 2 per cent., but that disguises big regional
variations, especially in the London catchment area where competing
salaries make retention even more difficult. In the North Thames area,
19 Apr 2000 : Column 222WH
the vacancy rate is 5.9 per cent., and in South Thames it is 6.1 per cent.
Those figures are significantly above the national average.
Some of the low morale is related to the erosion of the status of the
profession. Midwives feel that the integrity of their profession has been
compromised by the fact that they are now trained jointly with nurses for
much of their preparation for practice. Respect for that practice is
undermined by forcing midwives to join nurses in studying courses that are
not relevant to midwifery--for example, courses designed to train nurses in
the early detection of the signs of dementia. That is unlikely to be
relevant to women of childbearing age. They may become demented during
labour but it is not a permanent condition.
Another factor that has a bearing on the crisis in midwifery is the
shortage of consultant posts in obstetrics. That is a piece of NHS
mismanagement of the first order. In response to the shortage, an
accelerated training programme--the Calman programme--was set up five years
ago. It was agreed that the number of new grade, specialist registrars
should increase at a rate of 6 per cent. a year. That was designed to
achieve a target of 2,000 consultant posts over 15 years. However, the
number of consultant posts has not kept pace with the target, and trained
obstetricians cannot now find jobs. Indeed, they are leaving the NHS
altogether.
Last year, the Royal College of Obstetricians and Gynaecologists and the
Royal College of Midwives jointly published a document called "Towards
Safer Childbirth". One of its recommendations was that a consultant should
be present in the labour ward for 40 hours a week. Speaking as a lay woman
in this matter, I cannot help observing that babies are no respecters of
the 40-hour week and have a tendency to arrive at night. As I know to my
cost, things can go wrong very suddenly during childbirth. It is important
to have specialised help on hand if, for example, a woman suffers a
haemorrhage.
As the hon. Member for Isle of Wight (Dr. Brand) pointed out, the
increasing age of women at childbirth is an important factor when
considering the ratio of midwives and obstetricians to the number of women
giving birth. For the first time, the average age of women at first birth
is now over 30. There are more complications in childbirth as the age of
the mother increases. The advancing age at first birth may also partially
explain the rise in the caesarean section rate, although I agree with the
main thrust of the argument advanced by my hon. Friend the Member for
Macclesfield that there is a strong tendency towards technical births
rather than natural ones. However, it is important to note that the
advancing age of women at first birth is likely to give rise to an increase
in the caesarean section rate.
In another place, Earl Howe drew attention to the unacceptable level of
preventable accidents in labour. He said:
In 1995, 453 babies died as a result of asphyxia or trauma suffered
during labour or delivery.--[Official Report, House of Lords, 12
January 2000; Vol. 608, c. 738.]
That represents half the total number of infant deaths in childbirth. The
shortage of midwives must be a contributory factor to the state of morale
in the obstetric profession.
19 Apr 2000 : Column 223WH
Another important point that was brought out in the debate was that this
country has one of the highest percentages of low birth weight babies,
higher than even Albania and Latvia. That is a disgrace, and I would like
to hear from the Minister what steps the Government are taking to tackle
it. Low birth weight is, of course, associated with other health
difficulties in later life. I suspect that it is not unrelated to the
problem of childbirth to very young mothers and their level of knowledge
about care of themselves and their babies during pregnancy. I want to hear
from the Minister on that point.
Given the facts, it is surely time for the Government to restore the rate
of growth in consultant posts, so that we are back on target for the full
complement by 2010, as originally envisaged, and so that the considerable
amount of public money that has gone into training doctors in obstetrics is
not wasted because there are no posts to which they can be appointed. Then,
we will see that training translated into helping women and midwives to
ensure that we can improve on the number of safe deliveries. That must be
our main goal, in implementing good practice in maternity services.
12.11 pm
The Parliamentary Under-Secretary of State for Health (Yvette Cooper ): I
congratulate the hon. Member for Macclesfield (Mr. Winterton) on securing
the debate. It is an important issue and is close to my heart, because of
recent personal experience. I am aware of his long-standing interest in the
subject. The report by the Select Committee that he chaired in the early
1990s prompted real and lasting change in the provision of maternity care.
I pay tribute to that report and to the "Changing Childbirth" report and
the work done by Baroness Cumberlege on the issues in the mid-1990s.
Huge advances have been made in the past few years in changing the
experience of women during pregnancy and childbirth. There has been real
progress towards the provision of a safer, more personal, woman-centred
maternity service that offers women greater choice, continuity of care and
control. It is now safer to give birth than ever. The figures for maternal
and perinatal mortality are at their lowest ever level, and it is the
overriding expectation of pregnant women, their partners, their families
and those who care for them that the pregnancy and delivery will be safe
and healthy for mother and baby.
Childbirth is about more than safety. Maternity services exist to support
women throughout their pregnancy, to help them to experience pregnancy and
childbirth as a positive and life-enhancing experience and to give their
babies the best possible start in family life. On the whole, satisfaction
rates for NHS maternity services are high. The Audit Commission report on
maternity services, published in March 1997, found that 90 per cent. of the
women surveyed were very pleased or pleased with how they were treated
during pregnancy and childbirth. That is a high satisfaction rate, and it
is a credit to the dedication and skills of all the professionals who are
involved in maternity care.
There is, however, no room for complacency. "Changing Childbirth" set out a
vision of maternity services with which few could disagree. The report's
central principles--appropriateness, effectiveness and
19 Apr 2000 : Column 224WH
accessibility in maternity care--are largely embedded in current mainstream
practice. We are not, and cannot be, content to stand still. The Government
must continue to examine maternity services to see what can be done to
secure further improvements, particularly in the quality of care and in
tackling inequalities of care.
I want to cover some of the issues raised during the debate. The hon.
Member for Macclesfield referred to unacceptable variations in caesarean
section rates. The Department is concerned about those variations
throughout the country and we need to deal with the lack of clarity about
appropriate standards and best practice. We are aware of concern about the
widespread variation, so we have put in place a chain of work to deal with
that. First, we have taken steps to strengthen local audit processes and to
publish figures on caesarean section rates by individual trusts for the
first time. Secondly, we have commissioned a national audit study on
caesarean section rates from the Royal College of Obstetricians and
Gynaecologists to set standards where they are badly needed. That move has
been widely welcomed by professional groups, consumers and women. We shall
look carefully to see what lessons can be learnt from the thorough audit
and to ensure that the results are used to develop best practice in future.
Thirdly, we have funded the development of clinical guidance in problem
areas such as induction of labour and electronic foetal monitoring.
Fourthly, we have worked closely with consumer organisations to improve
information on caesarean section, because the information that is provided
to pregnant women varies dramatically throughout the country.
The reconfiguration of maternity services was also raised. A report will be
published shortly by the Royal College of Obstetricians and Gynaecologists
and I am sorry that it was not published before our debate, because it
could have been used to inform that debate. I apologise for the fact that
it is not yet in the public domain and that I am commenting on it when
other hon. Members have not been able to see it. The report was
commissioned by the Department of Health to examine the changes in the way
in which maternity care is provided. Women's expectation of services has
changed. Hospital stays are shorter and care is provided, as much as
possible, in accessible community settings and is delivered by midwives.
That report does not recommend the closure of many small maternity units,
as has been rumoured in the press. It provides reference criteria to be
taken into consideration when changes in maternity services are planned and
will be widely welcomed by those involved in maternity services. For
example, it makes it clear that issues such as access, transport,
availability and choice must be taken into account in local
decision-making.
In reply to my hon. Friend the Member for Stroud (Mr. Drew), there must be
a future for midwife-led units and they will continue to be a matter for
local decision making. We believe strongly in a future for midwife-led care
as part of reconfiguration.
As part of our response to the report, we shall examine obstetric risk
assessment. Safety is always paramount for women and health professionals,
but it must not be used as an excuse to return to the traditional medical
model of childbirth. Pregnancy is not an illness and maternity services
exist to provide care for a predominantly healthy population during a
normal life
19 Apr 2000 : Column 225WH
event. The vast majority of pregnancies and births are uncomplicated and
best cared for in a predominantly midwife-led service.
For the minority of pregnancies and births that prove complicated, there
must be access to expert medical advice. One issue covered in the report is
the need for national standards for obstetric risk assessment, so that
low-risk pregnancies can be consistently distinguished from high-risk
pregnancies and managed accordingly in appropriate settings.
Mr. Winterton : I am encouraged by much of what the Minister has said.
Before she finishes, will she comment on the exceptional success of the
Edgware centre and on the Albany midwifery practice, which again sets a
standard that could be repeated all over the country and provides the real
choice and the midwifery-led service that so many of us believe in?
Yvette Cooper : I was indeed planning to comment on some of the best
practice issues that hon. Members have identified. I was lucky enough to
benefit from team midwifery care in Pontefract, where a small team of
midwives, whom women are able to get to know, provide support in the
community before the birth, during labour and after the birth. I was very
impressed with the service and the support that I was given and gained huge
benefits from it.
A wide variety of models is in place across the country, but continuity of
care is crucial. There is a huge gap in our knowledge about how successful
and effective the different models are and what the benefits are for the
women who experience them. The hon. Member for Macclesfield highlighted the
successful results at the Edgware birth centre and mentioned other examples
as well.
We need to obtain comprehensive information about the different models that
are in place. That is why we have commissioned detailed research into this
issue and will report over the next year on the nature of the models of
midwife care around the country, the way in which they are organised,
funded and arranged and the difference that they can make to the women
concerned.
Mrs. Spelman : Could I encourage the Minister to consider, as part of that
research, whether midwives are being replaced by less well qualified
personnel for after-care visits? I am sure that, like me, she benefited
from the midwife calling after the birth. I understand that there is a
tendency for the midwife to be replaced after delivery by somebody who is
less qualified.
Yvette Cooper : I shall look into that. It is not an issue that I am aware
of. High-quality care in the weeks and months after the birth is important,
partly to prevent post-natal depression, which can have repercussions on
the beginning of family life and can affect children's chances for many
years to come. The research is being done by the national perinatal
epidemiology unit to inform our development and our ability to spread best
practice across the country and ensure that it is evidence-based.
Hon. Members also asked about midwife staffing. Maintaining and developing
excellent midwifery services is at the heart of our agenda. The national
19 Apr 2000 : Column 226WH
recruitment, retention and vacancy survey, which we published in September
last year, showed that only 2 per cent. of midwifery posts--some 370--have
been vacant for three months or more, although there are variations across
the country. We shall work closely with the trusts that are under pressure
to address the difficulties, but we are making progress.
The hon. Member for Meriden (Mrs. Spelman) referred to midwifery training.
I find her remarks slightly surprising. The 28 per cent. cut in the number
of nursing and midwifery training places between 1992 and 1995 was felt
throughout the NHS. I am pleased to report that the Government-funded
expansion in training places during the past two years--some £50 million
was involved by the end of last year--has meant that applications for
midwifery training have risen by 50 per cent.
As a result of our national recruitment exercise, last year more than 550
midwives contacted NHS employers about returning to work. Since this year's
campaign was launched on 28 February, more than 6,000 calls have been
received from people who are interested in midwifery, including more than
120 calls from qualified midwives who are interested in returning to the
NHS. We need to continue with that important effort and to resolve the
concerns that hon. Members raised this morning about career progression.
"Making a Difference" sets out the Government's strategic vision for
nursing, midwifery and health visiting. That strategy will ensure that
midwives benefit from better support and that modern, flexible,
family-friendly employment practices are promoted. Many midwives have
family responsibilities, and introducing family-friendly employment
practices into the NHS will make a difference to recruitment and retention.
Dr. Brand : Will the Minister explain what the minimum grade for a
qualified midwife should be in the present system?
Yvette Cooper : Hon. Members asked important questions about the
progression of midwives' careers. We are currently appointing the first
midwifery consultants--the most experienced and expert practitioners are
being appointed to those important midwifery positions. The establishment
of those posts will extend the clinical career structure, which will
encourage practitioners who might otherwise have gone into management to
remain in practice and to do what they came into midwifery and nursing to
do.
"Changing Childbirth" was mentioned earlier. In the few minutes that
remain, I want to discuss the way in which we have extended that approach.
"Changing Childbirth" changed the scene dramatically, but we cannot stand
still. One of the most important ways in which we can extend its values is
to tackle inequalities across the country. In the United Kingdom, the
poorer one is, the less healthy one is likely to be. Life expectancy at
birth for a baby boy is about five years less in social classes 4 and 5
than it is for baby boys with professional parents. We are determined to
tackle such differences, which can have an effect at the start of a child's
life or in the womb.
Our debate has progressed, and we now need to build on "Changing
Childbirth" and to take steps to deal with inequalities in maternity care.
Drug misuse in pregnancy
19 Apr 2000 : Column 227WH
needs to be tackled. The number of women who misuse drugs increased
considerably during the past 30 years, and many of those women are in their
childbearing years. Pregnancy can act as a catalyst for change, and it is
vital for the mother and the baby that pregnant drug misusers have proper
access to support from appropriate services. Earlier this month, the
Department of Health published guidelines on clinical management, which
include best practice for managing pregnant drug misusers.
Some innovative services have been established, including a project in
Sheffield for pregnant mothers who are addicted to heroin. The project has
established a co-ordinated approach that includes GPs and a central clinic
that offers quick access to the usual primary care services and to
specialist drug services.
Women who smoke and who are pregnant constitute another priority area. Each
year, more than 400 babies are stillborn or die soon after birth because
the mother smoked. Smoking during pregnancy is associated with health
inequalities.
The hon. Member for Meriden asked about low birth weight. That is part of
our concern about health inequalities because low birth weight is linked to
low income and to deprivation. The sure start programmes will examine the
matter across the country. Those programmes will provide £450 million over
three years across England to give support to the children and families who
are most in need. That must involve support for maternity services,
including better support during the weeks and months immediately following
the birth of the baby--as the hon. Member for Meriden said--and examination
of issues surrounding post-natal nutrition and support for the mother and
baby.
There is much excellent practice across the country; we need to build on
that and to tackle variations in maternity care. Like hon. Members who have
spoken, I believe that midwife care must lie at the centre of that.
Mr. Deputy Speaker (John McWilliam): Order. Time is up.
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