§ 6 46 p.m.
§ Baroness Cumberlege rose to call attention to the quality of provision for maternity services in the United Kingdom; and to move for Papers.
§ The noble Baroness said: My Lords, I start by declaring an interest in that I am a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust—two very remarkable organisations. Together with the distinguished noble Lord, Lord Patel, I am a vice-chairman of the All-Party Parliamentary Maternity Group and the noble Earl, Lord Listowel, is our treasurer.
§ I suspect that the uninformed might think that in this House the subject of maternity services is a minority sport. They would be wrong. The list of distinguished speakers pays the lie to that. I thank all noble Lords who have chosen to take part this evening. I know that there is a wealth of wisdom and experience here and I very much look forward to what noble Lords have to say and to the Minister's response. I have given the Minister notice of four questions, for which I am sure he is ready with comprehensive answers.
The Minister will be aware that 10 years ago I wrote in the foreword to Changing Childbirth:
Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and taking on the long-term responsibility for caring and cherishing a new-born child. Generations of women have travelled the same route, but each journey is unique"—
and that is surely the point. Every woman is unique; every baby is unique; every birth experience is unique. That is why it is so important to give a woman and her
partner choice: choice of place of birth; choice of style of care; and choice of professional who is going to accompany them in this unique and very special journey.
§ In the 10 years since I wrote those words, much has changed: more young women are going to university or college; more women are entering the professions; more women in the population are from ethnic minorities; more women are the single parent and more women are the sole bread-winner.
§ The birth rate is declining and the teenage pregnancy rate increasing. Yet the words I wrote are as true today as they were a decade ago. They are as relevant to those who are less articulate, who struggle to make ends meet, as they are to those who have an easier and more comfortable life.
§ My concern is that with the closure of so many maternity units, with the crisis in recruitment and retention of midwives, not only is choice a luxury, but the very basic standards are not being met.
§ In a civilised country, the fourth richest in the world, is it not reasonable to expect that every mother giving birth should be accompanied by a midwife, a knowledgeable and skilled professional, to accompany her through what can be a traumatic and frightening experience?
§ All research shows that when a woman is well supported her labour is quicker, there is less use of analgesics and there are fewer medical interventions. We also know that one intervention leads to another and increases the likelihood of a caesarean section. One caesarean section tends to lead to another, especially if it is a first baby, so the rise is expediential.
§ The rate has increased by I per cent a year, almost doubling in the past 10 years and is now comparable with that in the USA. One in five women in England and Wales now gives birth by caesarean section. But the rate varies enormously from 12 per cent in Shrewsbury to nearly 29 per cent in Coventry. We have to ask, "What have we done to childbirth if women feel they need to have a major operation to avoid it?"
§ The Parliamentary Office of Science and Technology, (POST) describes the adverse health implications for the mother and the financial cost to the nation. Every 1 per cent adds £5 million to the cost of services. I know that the Government are prepared to invest in the NHS but this is not the type of investment we should need. There should be investment in obtaining more midwives.
§ POST now considers the high level of caesarean section rates so serious that it describes it as a public health issue. The World Health Organisation slates that there is no justification to have more than a 10 to 15 per cent rate. The Government should be worried—very worried. I know that next year the National Institute for Clinical Excellence (NICE) is due to produce some clinical guidelines on caesarean section. My fear is that yet again the emphasis will be on when to carry it out and the pamphlet for women will be about having a caesarean section.269
§ I think that that is foolhardy. We should change the approach. We need to promote normal birth. The assumption should be that births take place either in a birthing centre, a midwifery-led unit, or at home. The pamphlet should be entitled "How to avoid having a caesarean section", and should imply that an obstetric unit is an exceptional place in which to give birth, used only when absolutely necessary. So I would like to ask the Minister my first question. What action are the Government taking to reduce the numbers of caesarean sections? As a result of their actions when do they expect to see a decline in the rate?
§ However, there are pockets of hope. In Southampton, at a tertiary referral centre, they have bucked the trend. In part of a challenging Sure Start area, they have reduced the rate from 23 per cent to 14 per cent. They have achieved that through the introduction of case-load midwifery, a system where one midwife, working with a colleague to cover for sickness and holidays, looks after a woman during pregnancy, birth and the postnatal period. The midwife builds trust with the woman and her family and knows the circumstances. It is not surprising that when the time comes to give birth, both are confident in the ability of the other. Applications from midwives eager to work in the scheme were over subscribed and not a single one has left since the scheme was set up two-and-a-half years ago.
§ Reading the very interesting survey by the Royal College of Midwives, it is clear that the majority of midwives leave the profession because they are dissatisfied with the current midwifery organisation and practice. Shortages mean that they cannot practise in the way that they know to be right. The term "midwife" means "with woman" and too many midwives are compelled to be absent leaving the woman to labour alone.
§ Case-load midwifery and indeed birthing centres do not require rocket science. They require strong midwifery leadership, support from obstetricians, and a presumption that birth is a normal physiological event and not a medical activity. So my second question to the Minister is: what measures are the Government taking to promote normal birth?
§ Choice and user preferences depend on what is available. The National Childbirth Trust has recently carried out a survey of user representatives' views on the configuration of services. That work was commissioned in response to a policy vacuum and the rising panic at the closure of so many units. The Minister will be aware of Frank Dobson's initiative, when Secretary of State, to set up a multi-disciplinary working party to examine the pattern of maternity services. The report was completed and delivered but never published. The review was prompted by the fears that changes in doctors' working hours, and difficulties in recruiting and retaining midwives and neonatal nurses, would shortly impact adversely on services. Those fears have not lessened but increased, especially with the imminent introduction of the European Working Time Directive.270
§ Two years ago Yvette Cooper, Minister for Public Health, set up another group, the Maternity and Neonatal Workforce Group, whose report was due to be published last summer. I suspect that it was not published, like the earlier report, because it is unpalatable and the Government do not have the courage to face up to the contents. I certainly do not want a report that advocates closures, but at the moment we have a policy vacuum. Services are closing in a haphazard, idiosyncratic and unplanned way. That is no way to govern or manage a national service.
As an aside, I could not help but smile when I read the recent leak in the Financial Times, which stated that,
the health department needs to do more to convert its broad strategy for improving the NHS into concrete plans".
That came from the head of the Prime Minister's "delivery unit".
§ At this moment there are rumours that the future of both the midwife-led units in Malmesbury and Devizes is being questioned, despite excellent care being given by midwives whose morale is high. I ask the Minister whether closure is being considered. If so, what is the Government's view? What are the users' views?
§ At the other end of the spectrum—the highly specialised part of the service—we still await the long promised report on the development of neonatal services. I know that BLISS, the National Charity for the Newborn, is deeply concerned. A recent study published in the British Journal of Obstetrics & Gynaecology showed that in a three-month period 258 women with high risk pregnancies had to be moved to another hospital because the neonatal unit was full or had insufficient staff. Twelve per cent of the mothers were transferred on again to a third unit. Such treatment of very vulnerable women is totally unacceptable.
§ There is no sensible network for neonatal intensive care baby units or pregnant women at high risk. There is no clear political support for birthing centres, midwife-led units or home births. There is no commitment to audit health outcomes. As a result the strategy to retain more midwives and neonatal nurses is undermined. There is no national framework for responding to the European Working Time Directive which is cutting the number of doctor hours. The National Childbirth Trust survey indicates that users are not fully involved in proposed changes. Access to midwife-led and community-based care, including home-birth services, is evaporating.
§ So my last two questions are: when will the Government publish the report of the Maternity and Neonatal Workforce Group on reconfiguration of maternity services, and what measures are the Government taking to reduce the impact of the European Working Time Directive on the staffing in maternity units? I hope that I have not been too depressing. There are some good things happening, not least the formation of a new organisation: the Birth Centre Network. However, the overall picture is pretty bleak and in many places good initiatives are withering. I am sad to see, as a whole, this crucial service go backwards—a view expressed to me by a very distinguished director of midwifery.271
§ In Changing Childbirth we said that we wanted to see a service which did not jeopardise safety, yet was kinder, more welcoming and more supportive to women. Is that really too much to ask? My Lords, I beg to move for Papers.
§ 6.58 p.m.
§ Lord Chan
My Lords, I congratulate the noble Baroness, Lady Cumberlege, on securing this important debate on the quality of our maternity services, particularly in the NHS. I thank the noble Baroness for inviting me to speak on an issue that is of professional interest to me as a retired paediatrician who practised care of newborn babies in a Liverpool hospital.
Maternity services are crucial to the well-being of mothers and their babies during pregnancy and particularly in labour and childbirth. Failure to maintain high quality maternity care may result in catastrophe with severe life-threatening complications leading to the death of mother and baby.
The latest report of confidential inquiries into maternal deaths from 1997 to 1999 was published in December 2001. The report, entitled Why Mothers Die, showed a small reduction in deaths from obstetric causes. Suicide in the postnatal period was the leading cause of death. But vulnerable and socially excluded women had high death rates. They included women living in poverty, those suffering from domestic violence, very young girls and women from ethnic minority groups.
I wish to focus on issues of staffing of services, patients' choice, prevention of complications to newborn babies and the care of ethnic minority women. High-quality maternity services depend on a variety of staff, in particular midwives, as mentioned by the noble Baroness.
The Department of Health is to be congratulated on its modernisation initiative of creating consultant midwives who undertake the supervision of midwife-led childbirth services. For the vast majority of women in childbirth, these services have been welcomed and are beneficial to mothers and their families.
But nine out of 10 maternity units in the NHS in England have unfilled posts for midwives, and the overall and long-term vacancy rates are the highest that the Royal College of Midwives has recorded, according to its latest survey conducted in July 2002. Long-term vacancies lasting for three months or more accounted for 59 per cent of vacancies in England.
London has critically high levels of midwife vacancies. On a personal note, my daughter resigned after three and a half years working as a community midwife in a central London maternity unit because of the excessively heavy workload resulting from the hospital's inability to recruit and retain community midwives.
The number of former midwives returning to practice still represents less than 1 per cent of midwives in post and less than 10 per cent of all joining the service. That represents a huge wastage in highly trained people the National Health Service needs 272 today. So I look forward to the Minister's response about the recruitment and retention of midwives and plans to improve the situation.
Maternity services have improved the choice of care for women in pregnancy and labour. As most pregnancies are normal, midwife-supervised antenatal care in the community is now common. Women with experience of normal pregnancies and births can opt to deliver at home if facilities are optimal and community midwives are available.
The improvement in patients' choice of maternity care depends on a normal pregnancy being regularly monitored by midwives and, where necessary, by obstetricians. It is also dependent on rapid transfer of the woman to hospital in the event of complications during labour.
In addition, patients who make informed choices about childbirth preferences should also be prepared to share responsibility when complications arise. In our increasingly litigious society, highly motivated doctors and midwives need to have the assurance that they will not be taken to court for every unforeseen complication associated with childbirth.
Enormous monetary settlements in court, in particular for severe brain injury to the baby associated with complications during labour and delivery, may take place many years later. These judgments have increased substantially in the last decade in England. I question the ethics of such inordinately large cash settlements when the affected individual will continue to receive expensive and long-term care free through the NHS and local social services.
The desired outcome of every pregnancy and labour is the birth of a healthy baby, looked after by a healthy mother. Antenatal care is designed to monitor the health of both pregnant mother and her unborn baby. Midwives and obstetricians are trained to identify the at-risk pregnancy and recommend transfer of the woman to a hospital where both mother and newborn baby can be cared for by specialists.
A small proportion of all births will require intensive care for babies born prematurely. The outcome of these births depends on the transfer to an appropriate hospital before labour begins. The transfer of sick and tiny babies after delivery tends to be complicated, with problems requiring intensive care of the newborn, and their outcome is compromised.
In that regard, health professionals involved in maternity care are waiting for the publication of the report on neonatal intensive care. That inquiry was completed a year ago. The report should give recommendations on the standards for the care of very sick babies born too early to survive without intensive life-saving support in hospital. I hope the Minister can tell us when the report will be published.
I want to draw your Lordships' attention to the plight of ethnic minority women in maternity care. Their numbers are increasing because of the younger age of ethnic minority groups. According to the confidential inquiries into maternal deaths in 1997–99, published in December 2001, Why Mothers Die, to 273 which I have referred, women from ethnic groups other than white and who speak little English are twice as likely to die than those in the white group.
Access to care is an issue for many of these women. One in five who died booked late for maternity care—that is after 24 weeks' gestation—or they had missed more than four routine antenatal visits.
In a large number of cases, professionals used family members to interpret for ethnic minority women. The report stated that there were several difficult cases where children were used inappropriately to interpret intimate personal or social details of the mother, and vital information was withheld.
I am appalled to read details of such poor quality practice in the NHS occurring today regarding interpreting for women who speak little English. For the past decade, recommendations have been sent out to all public services, including the NHS, about the need to arrange for a trained interpreter to assist people and patients who do not speak much English.
Many local reports throughout the NHS in GP practices and hospital clinics have demonstrated the importance of using interpreters who are trained to observe confidentiality and who are competent in the vocabulary of healthcare. In that connection, it is totally unsatisfactory for bilingual professional staff in hospitals to be called to interpret for patients outside their units. That practice disrupts the work of clinical units and leads to poor ratings for bilingual staff who are identified as not fully committed to the work they have been trained for and for which they are being paid.
Now that the Race Relations (Amendment) Act has made it compulsory for all NHS trusts to write race equality schemes, should we not ensure that the provision of trained interpreters is of the highest priority? The excuse of some managers that I have met is that interpreters are expensive and not required daily. Therefore, they are not considered essential. Will the Minister address that essential issue, which has caused the deaths of many women from ethnic minority groups using our maternity services?
Finally, The National Sentinel Caesarean Section Audit Report, published in October 2001, showed that in many regions in England one in three women have a caesarean birth. The highest rates are among ethnic minority women who speak little English. More research needs to take place to find out whether these surgical interventions are a consequence of poor antenatal clinic attendance with complications during labour. If that is the case, trained interpreters, bilingual midwives and doctors could run clinics in order to identify pregnancy problems early and avoid caesarean births.
Our maternity services are clearly of high quality, but we must address issues of staff shortages, the need for trained interpreters and guidelines on intensive neo-natal care and claims for medical negligence, to make those services even better and the best ever in the history of the NHS.
§ 7.10 p.m.
§ Baroness Greengross
My Lords, I congratulate the noble Baroness, Lady Cumberlege, on initiating this debate, which is terribly important. I am saddened that it must take place at all. We know very well what is best practice in this country. We can make childbirth an experience that women remember with awe and happiness. We know exactly how to do that because our best practice is magnificent.
Unfortunately, as my noble friend Lord Chan said, it is the most vulnerable young women who suffer the worst as a result of existing inequalities. We lack a strategy to ensure that those vulnerable women obtain access to best practice across the country.
We talk a lot about giving women choice, but we know that choice means having adequate knowledge, and it is obvious that many women, especially the most vulnerable ones, do not have that information to hand. We also know that women—especially young, first-time mothers—need someone who will listen to their fears with sympathy and understanding to make them feel that they are an important part of the journey that they are undertaking, which was so eloquently described by the noble Baroness, Lady Cumberlege. If people feel that their concerns are being taken seriously, they can then understand when they are not always met in the way in which they thought that they ought to be.
However, the ideal is a one-to-one service for all women. Where that is impossible, we should at least have community midwife teams, so that women know their names and know that one of them will be available to go with them to their scans, when they go to have the baby and afterwards, when they return home from hospital. We ought to be able to offer that to all women. However, we know that one-to-one services demand large numbers of trained midwives working long hours. Not everyone is willing to undertake such work. Staff concentration is expensive. I wish that our goal was to make that choice available to all women.
Everyone acknowledges that the shortage of midwives is a tragedy and must be addressed as a priority. Being a midwife can give people enormous job satisfaction, if we can get it right. We ought to set targets, and I hope that the Minister will tell us that he will. For example, we should aim to get the caesarian section rate at least down to the same level as that of the Netherlands and Scandinavia.
If a one-to-one or similar service was available throughout the country—it is not; in London, it is not even available from one part of a borough to another—we could inform women of the real implications of caesarean operation, future difficulties that they may experience as a result and why it is important to avoid them if one can. It would be ideal if we could develop dedicated birth centres, which the noble Baroness described, away from but near enough to an acute care centre so that, where necessary, women could be sent there. Normal birth would then be the norm for all our women.
275 I want there to be an on-going contact point for all women, from early pregnancy right through the experience of having a baby, delivery and early childhood and leading to contact with a health visitor, which takes them through until the child is five years old. Together with excellent initiatives such as HomeStart for the most vulnerable, that would begin to ensure a healthy, secure and supported start to life for all our children and a healthier and better adulthood, with genuine support for Britain's women —one not of isolation but of pleasure and happiness for them and their families.
§ 7.15 p.m.
§ Baroness Perry of Southwark
My Lords, I, too, thank my noble friend Lady Cumberlege for introducing this important topic, and for her elegant and knowledgeable speech. I also declare an interest as the chair of the research governance committee of Addenbrooke's NHS Trust and Cambridge University Clinical School, and as a former non-executive director of Addenbrooke's NHS Trust.
Like so much of the NHS, maternity services are under severe stress—some might even call the stress in some areas intolerable. Despite the excellent work undertaken by consultants, midwives and technical and support staff, staff shortages mean that services are having to be cut back and wards are closing, decreasing the service available to women and their babies and causing mothers a great deal of anxiety and distress.
In the modern age, young mothers have high expectations—far higher than when most of us underwent our pregnancies. For the modern woman, scans, screening, blood tests and management of all kinds of abnormalities are available. Excellent though it is that those services are now available—many mothers and babies are healthy because of them—they all require a huge increase in specialised time, which is increasingly difficult to find. As my noble friend Lady Cumberlege said, the biggest issue is the shortage of midwives. The Rosie Maternity Hospital in Cambridge, part of the Addenbrooke's NHS Trust, is 20 per cent below its funded numbers—that is, it receives funding for 20 per cent more midwives than it can possibly find. That is a terrible waste of government funding.
No doubt, at the end of our debate the Minister will tell us about the large sums of money that have been invested in the NHS, but I hope that he will also acknowledge that there can be no adequate return of money supplied for services where the goods and services for which it is given are simply not available. Money for non-existent nurses or doctors and the beds that they make possible is a recipe for inflation and bad management and produces no improvement for patients.
According to the Government's research measurements for workforce planning, Addenbrooke's needs another 60 per cent more midwives than it has currently. At present, it has only 105 midwives; using the Government's workforce planning measure, it needs 169. 276 That is a serious situation, but there is little hope that it will be solved, because the number of midwives entering training is also thinning to a small number.
The traditional route was 18 months of post-registration training. Those places are now not being taken up as people who have become nurses consider the stresses of the midwife's job. The shortage of other midwives, long hours and inadequate pay, especially for those who work in high cost areas such as London and Cambridge, are not an inducement, even though the 18-month route has the advantage of paying a full salary while in training.
In response to the low take-up of the 18-month post-registration route, the Government set up an alternative route of three-year direct entry training. That was a good idea, but unfortunately there is no funding for students on that course. That is a real difficulty, especially for the kind of person that the course was intended to attract: the more mature woman, who thinks carefully before undertaking three years of training that will be a heavy burden on her pocket and, perhaps, that of her family.
I am told by senior midwives that the profession aspires to the status of an all-graduate profession, but the lack of student support and the introduction of fees in higher education makes that a very distant prospect. What is more, there is developing a severe shortage of trainers of midwives. Midwives now have three alternative routes to promotion and to higher status. They can become teachers, as midwifery trainers; they can become managers; and, under a new government initiative, they can now become consultant midwives.
Of course, the consultant midwifery initiative was introduced with the best of intentions. It is a good idea to offer a promotional route to enable staff to stay in the clinical environment. Unfortunately—or perhaps one might even say fortunately—that has proved to be a very attractive route to midwives because most like to remain in the clinical area. However, because so many midwives are choosing the consultancy, route, the teaching and management routes are experiencing severe difficulties in recruitment. Therefore, the number of teachers available—even if it were possible to recruit candidates for training—is becoming a major problem.
As other noble Lords have said, there is the related problem of the shortage of neonatal cots and neonatal nurses. Noble Lords mentioned the long wait for a government response to the report on neonatal services. Because of the delay and shortage of neonatal cots and neonatal nurses, women in labour find themselves being piled into ambulances—quite often at a late stage in their labour—to be taken to a hospital where provision is available for their baby. In one recent case, a new mother was even told to get on a train so that she could catch up with her baby who had been taken to a neonatal unit. That must be a terrible experience for a woman a few hours after childbirth.
The position on consultants also gives little cause for optimism. Recent changes in training conditions, and the results of the European Working Time Directive, mean that there are now fewer available hours of 277 consultant time. Already the European Working Time Directive means that all time "on-call" is counted as working hours, which will be reduced to 48 hours by 2009. Working hours are being reduced with the best of intentions, but that reduces the number of hours of consultants being available to help in the most difficult cases.
For reasons best known to themselves, the Government reduced the number of consultants in obstetrics' training in 1998–99. There appears to have been no account taken in the 1998–99 report—which resulted in the reduction of training places—of the effects of the European Working Time Directive and the changes in training conditions. Therefore, the number of consultants in obstetrics training was cut back and the Royal College of Obstetricians and Gynaecologists in its 2000 report, Blueprint for the Future, predicted a major shortfall by 2003 as a result of that reduction in training places. That is already becoming apparent in key areas.
I ask Her Majesty's Government to act and act very quickly to remedy this situation. I hope that the Minister will give us some reassurances. Incidentally, by action, I do not mean throwing more money at the NHS; I mean a hard look at what is needed to solve some of the problems.
In spite of the problems, there is good news to report. With the leave of the House, I should like to pay tribute to the hospital that I know best—the Rosie Maternity Hospital—for the initiatives that it has managed to introduce and its achievements in recent years. In the past two years two new consultant posts—one, a professor in the university clinical school—have been established. That means that women who have difficulties with their pregnancy and birth are now being referred to the hospital from the whole region. At the same time, that has driven up the quality of provision for all women, including those with normal births.
A high dependency unit is being established for women with difficulties. The training is already in place; the unit will move into action soon. Plans are also moving ahead for a multi-disciplinary perinatal service, bringing together neonatology, neonatal-surgery, genetics and radiology. That means that a splendid service will be provided not only for women in difficulties but for all women in the region.
For the healthy—one might say—normal birth, a midwifery-led unit has been established which includes a birthing pool—a thought which I find terrifying, but which seems extremely popular with young mothers. A newly appointed consultant midwife is leading that service. There is closer collaboration with neighbouring hospitals enabling women to be cared for in the way which is most appropriate for them. As my noble friend said, every woman and every baby is individual and deserves individual, carefully tailored care.
278 With those initiatives the hospital and the trust are able to provide a service tailored to individual needs. All they ask is for less government direction and interference. They believe that the maternity services can deliver and should be left to do so.
§ 7.26 p.m.
My Lords, I, too, should like to thank the noble Baroness, Lady Cumberlege, for initiating this debate. There can be little doubt about her commitment to improving maternity services. Her report, Changing Childbirth, familiarly known as the Cumberlege report, may not have been universally well received, but it certainly raised the profile of maternity services and changed the thinking from looking at maternity services from the profession's point of view to putting mothers and babies centre stage.
Irrespective of any changes in the services introduced now or in the future, we should not go backwards. We run the risk of doing so with some of the recent reconfiguration of services. Frankly, our maternity services are in a mess. However, there is still time to stop the situation worsening if there is recognition from the centre that something needs to be done.
Much of today's debate is about the reconfiguration of maternity services that is going on ad hoc—for example, as a response to the pressure of reduction in junior doctors' hours, shortage of staff, lack of resources, cost saving initiatives, falling birth rate, smaller units, and so forth.
In an attempt to cope with the pressures, managers and clinicians embrace changes that do not serve the needs of mothers and their babies. Amalgamation of maternity units into bigger units, without capacity building in the number of staff and facilities, leads to further reduction in the quality of care delivered, and standards fall. Evidence gathered from midwives, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists demonstrates that.
Every time there is a crisis of confidence in maternity services an inquiry is held. It happened with the Peel report and again in 1992 when the House of Commons Health Select Committee conducted an inquiry into maternity services—to which I was one of the advisers. That led to the then government report, Changing Childbirth.
It was announced yesterday that the Maternity Services Sub-committee of the House of Commons Health Select Committee is to start an inquiry focusing on variation in maternity services, data collection, staffing structures, caesarean section rates, and so forth. There are also other initiatives. We heard about the initiative from the National Institute for Clinical Excellence, which has commissioned guidelines on caesarean section following a national audit. I hope that the guidelines will define standards of care that women undergoing caesarean sections should expect, including who makes, and has the responsibility for, the decision to carry out a caesarean section.
279 I understand that in future there will be guidelines for antenatal care and screening in pregnancy. Other initiatives have already been mentioned—the workforce group on children's and maternity services, a department initiative report on criteria to be met when reconfiguring maternity services. The Secretary-General of the Royal College of Midwives and I, with the former Secretary of State, Frank Dobson, asked for that initiative report to be carried out. Neither of these reports is in the public domain. I wonder what the recommendations were that cannot be made public.
Another initiative set up by the Department of Health is the National Service Framework for Children's Services, but it will include a section for maternity services. Will the Minister say whether this section defines the framework for maternity services?
It all seems to be rather haphazard planning. What we need is a co-ordinated strategy, initiated by the Department of Health, together with maternity services, in the same league as our near-neighbours in Europe, or better.
We have a serious shortage of staff. All of the previous speakers have referred to this. We have a huge shortfall in the number of midwives, a profession that is key to delivering high-quality care to all mothers and their babies during both pregnancy and the post-partum period. We have a shortage of obstetricians, particularly of those who are able and willing to deliver hands-on care at all times of the day whenever women need their help.
The noble Baroness, Lady Perry of Southwark, eloquently described the problems and how they occurred, and I will not dwell on them again, but I am grateful to her for highlighting them. Apart from obstetrics being a more demanding specialty, obstetricians and gynaecologists may see the choice of taking one of the ever-expanding, sometimes esoteric, gynaecological sub-specialties as a better option. If so, there may be a need to look at the training and remuneration for obstetrics as distinct from gynaecology. The training of doctors and all health professionals should reflect the health needs of society. I hope that a new postgraduate medical education and training board, when established, will have the responsibility and authority to make sure that all training programmes reflect this.
I am pleased to see the current president and vice-president of the Royal College of Obstetricians and Gynaecologists, Professor Dunlop and Miss Mellows, attending this debate. I am sure that they and the college will look at ways to improve recruitment to obstetrics, for it is important that women who need care from obstetricians receive it from fully trained and competent doctors. Managers, also, should recognise the need to recruit more obstetricians.
My noble friend Lord Chan has already alluded to the problems with paediatrics and ethnic minorities. I simply concur.
Staffing is not the only issue. We have a lack of appropriate facilities. This leads to an early discharge of mothers and babies from maternity units. It could 280 affect rates of breast feeding and confidence building, particularly in first-time mothers. We have examples of women in labour, sometimes with problems identified in the antenatal period, being asked to stay at home until a bed is found somewhere, risking both themselves and their babies.
In terms of outputs we do not feature in the top league. While our perinatal mortality is not the worst in the developed world, it is well down the league table. We have not seen a reduction in the unexplained antenatal still birth rate for more than a decade. We have the second-highest rate of low-birth weight babies in the developed world, second only to the United States of America.
We have a high a premature birth rate. Now I know that social deprivation is an important factor for poor outcomes for mother and baby. Therefore, it is even more important that our services can deliver care to these at-risk mothers. Our data collection system is inadequate and we are not able to compare outcomes related to different models of care in the whole population.
We have a rising caesarean section rate. The noble Baroness, Lady Cumberlege, referred to this. It will keep on rising until we have a service that provides one-to-one support to all women in labour by midwives and care by trained and competent obstetricians for those women who are at risk of requiring caesarean section. Both midwife and obstetric support is essential if we are to reduce caesarean section rates.
We also have one of the highest rates of litigation: 50 per cent of all medical litigation is related to pregnancy and child birth. It is estimated that the cost of settlements of currently pending cases may well be in the region of £2 billion to the NHS. I understand that the department has on-going initiatives through risk management and clinical governance to reduce the level of litigation in obstetrics.
I return to my theme of haphazard, uncoordinated stabs at tackling the problems. Does the Minister not agree that it would be better now to produce a Department of Health- sponsored maternity services framework, with clear targets for implementation and monitoring, which the future commission for health auditing inspectorate could monitor? Both Scotland and Northern Ireland have done so and I would commend to the Minister the Scottish framework and implementation documents.
I agree that the current configuration of maternity services is not sustainable for all the reasons mentioned earlier. We need to develop services which recognise this, but which also recognise that the potential of all professionals involved in caring for mother and baby needs to be harnessed in a co-ordinated way, working across boundaries, while at the same time they retain their own professionalism.
This has implications for common, continuing education programmes. For this to happen, there needs to be committed and strong leadership from the centre and all health professions, with the focus on the needs of women and their babies.
281 It is not too late. Here is an opportunity for the Minister to give a lead and bring our maternity services into the 21st century, for a model service that we can all be proud of. He could start by establishing a framework for maternity services.
Finally, I did not declare an interest at the beginning. My credentials are all too clear. I feel passionately about the care of women in pregnancy and labour. For most of my life I have been an obstetrician.
§ Baroness McFarlane of Llandaff
My Lords, it is an honour to follow my noble friend Lord Patel, and I wish to add my name to those who want to thank the noble Baroness, Lady Cumberlege, for raising this debate and for the customary skill with which she introduced it and faced us with the facts and issues.
If I have an interest to declare in this debate, it is that last year was the 50th year since I completed my midwifery training. I hasten to assure the House that I am no longer registered to practise as a midwife, but I have a deep interest in midwifery and the welfare of women in childbirth. I view my midwifery experience now with nostalgia and through rose-coloured spectacles. Most of my deliveries, some hundreds of them, were home deliveries in a rural area of Herefordshire and it was idyllic—both the country and the experience.
Perhaps I may describe one of my last deliveries. I trudged across a ploughed field with my little black bag to get to an isolated farmhouse where the mother was in labour. Once arrived there, I found there was no running water. Unfortunately, my midwifery training had not taught me how to extract water from a pump. Unfortunately for the father, I had to rouse him from a deep sleep by the fire because he was overcome with the thought of impending fatherhood. He managed to draw water out of the pump successfully.
Later on, the feather bed on which the mother was lying burst. After that, she had a post-partum haemorrhage. We had to call out the Flying Squad, which we then used, to deal with that. However, in some ways, the case finished with every satisfaction for the family and certainly for me, the midwife.
In my state of ignorance about present-day midwifery, I have been so grateful to receive briefing papers that have brought me slightly more up to date than I would otherwise have been in this debate—papers from the National Childbirth Trust; the Royal College of Midwives; the Royal College of Nursing; the Schools of Nursing and Midwifery at the Universities of Manchester and Sheffield; from individuals and various reports of meetings of the All-Party Parliamentary Group on Maternity. These have given us a wealth of information about the present situation in midwifery.
Unfortunately, from these papers I get a very strong view that all is not well in the state of our midwifery services. Certainly the experience of some mothers is 282 not now positive, and there is obviously great dissatisfaction among midwives. I therefore wish to talk briefly about the reconfiguration of the service and the kind of structure that there should be in the future; the increasing medicalisation of care, of which we have heard today; the increasing rate of caesarean section; the shortage of midwives; and patient satisfaction, if I get that far.
The reconfiguration of the service is extremely important. What shape should the service take in our present state of health service provision? As I read the papers, there seems to be a stark difference of view between those who favour home births and smaller, midwife-led community units, where care is much more easily accessible to the consumer and the midwife can give much more personal supervision throughout the period of labour. The Secretary of State has described this continued care of the mother by one midwife as the gold standard for our midwifery services.
Set against this position is the view that larger units can effect economies of scale. That is important in the present state of our health service. More importantly, a unit within an acute hospital has obstetricians and paediatricians much more readily available. It is important that this kind of medical help is readily available. I recall one obstetrician with whom I worked frequently stating, "No birth is normal except with hindsight". There may be something in that statement.
We have heard that there is an increasing medicalisation of childbirth, certainly since 50 years ago when I was practising. The increased rate of caesarean section has already been mentioned and is a cause for concern. The "Postnote" that I have received dated October 2002 states that in the 1950s 3 per cent of births in England were by caesarean section; by the early 1990s this had risen to 10 per cent; and to 21 per cent in 2001. But the national figures mask tremendous local variations of between 10 and 30 per cent.
The differential cost to the National Health Service of caesarean section versus vaginal delivery is considerable. The Audit Commission has calculated that every 1 per cent rise in the caesarean section rate costs the National Health Service an extra £5 million a year.
The parliamentary "Postnote" is valuable in regard to the caesarean section rate. It reviews the medical factors that have contributed to the increase, and the non-medical factors such as culture, organisation and maternal choice, which I believe is often influenced by the line taken by the media.
Clearly these are considerations that call for us to think deeply about reconfiguration of the service. I appreciate the paper from the National Childbirth Trust, which looks at the questions that need to be answered before we tackle reconfiguration of the service and contains a suggested reconfiguration.
283 As regards the increased rate of caesarean section, I look forward to receiving the promised guidelines from the National Institute for Clinical Excellence. Although it is an extremely difficult issue on which to give guidelines, they will be a valuable help to us.
I am extremely concerned, as are many other noble Lords, about the shortage of midwives and the lack of job satisfaction. This situation has been researched by Mavis Kirkham, Professor of Midwifery at the University of Sheffield. The work was sponsored by the Royal College of Midwives and the Department of Trade and Industry Partnership Fund. Professor Kirkham followed up 2,325 midwives who notified their intention to practice in 1999 but did not do so the following year in 2000. That is quite a significant loss of midwives in one year.
Making the decision to leave midwifery was often a protracted and painful business. The professor said that the research painted a depressing picture of a group of committed professional women struggling over a protracted period of time within an environment of increasing confrontation and stress. The largest group of those who left—30 per cent—were dissatisfied with midwifery. There were other causes, but the midwives had a predominant feeling that they could not practise as they were taught to practise under the conditions now existing in the health service.
Midwives are now educated in a way that gives them specialised knowledge and problem-solving skills which enable them to base their practice on evidence derived from research. Their expectation is that they will be able to practise autonomously, but what they meet in practice is very different and bears little resemblance to what is implied in the midwives' code of practice. There are matters which militate against their practising as they would wish. They are made to rotate through all the shifts and around all the areas of clinical practice and feel that they have insufficient control over their working lives. These frequent dislocations of the place in which they practice make it difficult to maintain confidence and relationships with both clients and colleagues. It is essential that we do something about the recruitment and retention of midwives.
As a final point I was going to talk about mothers—the consumers—and patient satisfaction. I shall not do so because my time is up. I wanted to recount to your Lordships the experiences that some of the younger members of my family have had in childbirth. It is not a pretty story.
§ 7.48 p.m.
§ The Earl of Listowel
My Lords, I, too, am most grateful to the noble Baroness, Lady Cumberlege, for securing the debate today. Perhaps I may also say how useful I have found the meetings of the All-Party Parliamentary Group for Maternity, which the noble Baroness and Julia Drown, MP, founded some two years ago.
Indeed, at the launch of the all-party parliamentary group I was very much struck by the contribution from Cathy Warwick, a clinician at King's College 284 Hospital. The midwifery unit she described that cares for mothers in south London—mothers sometimes living in bed-and-breakfast accommodation, often from ethnic minorities and often on low incomes—appeared remarkable. Its practice is an example of the case-load midwifery that the noble Baroness, Lady Cumberlege, and several other noble Lords have referred to.
According to the evaluation report published in March last year, the Albany midwifery practice was enabling such mothers to achieve breast-feeding rates of 93 per cent at birth, as against a norm for the area of 75 per cent. Breast-feeding remained high at 28 days, at 70 per cent of mothers. Health visitors reported continuing high breast-feeding rates.
Compared with the other midwifery group practices, the Albany practice had a lower induction rate, a higher vaginal delivery rate, a lower elective caesarean section rate, a higher intact perineum rate, a lower episiotomy rate, a greater use of the birthing pool and a lower use of pethidine and epidurals.
There were also benefits from the midwife's point of view. I invite your Lordships to consider what a pleasure it might be for a midwife to follow one mother from registration to birth and from birth to four weeks.
I invite your Lordships to consider how attractive it might be for a midwife to work in the community in a centre which has a safe play area for children, a swimming-pool, a well-equipped gymnasium, right next to the shopping centre in Peckham.
Please consider how satisfying it might be for a midwife to be the mistress of her employment. The Albany practice operates on a contractual basis unique in the UK. The noble Baroness, Lady McFarlane, eloquently set out the concerns that midwives feel about not being in control of their working environment and the stress that that places them under. In the Albany practice, they, the midwives, decide on salary and pay, on sickness and holiday leave. They have a practice manager to relieve them of the administrative burden of such responsibility. This control of their working conditions may be helpful in reducing the stress that is inseparable from their work.
The Albany midwives are dedicated to offering continuity of care to their patients. A full-time midwife is on 24-hour call to 36 mothers for nine months of each year.
Thirty-six weeks prior to birth, the primary midwife and secondary midwife will talk the mother and the mother's birth partner through all the options for her care. The primary midwife, the mother's key worker, will explain that she can be reached at any time, day or night, by calling her on her pager.
In practice, mothers almost invariably call during the night only in an emergency, because of the special personal relationship that they develop with their primary midwife and the respect and consideration that that engenders.
The germ of this practice lay in the ambition of three pairs of independent midwives in the early 1990s—one of whom is present in the Public Gallery. They wanted 285 to see the well-evidenced positive outcomes for their paying clients provided for free, on the NHS, to the women who most needed continuity of care. Fostered by a favourable political climate which the noble Baroness, Lady Cumberlege, did so much to engender, their goal has been achieved.
I should say that the past success of the model of caseload midwifery that I have described has been qualified. A great deal of support is necessary for midwives prepared to offer a 24-hour personal service to their clients. Such work would not suit the circumstances of some midwives.
But the outcomes for mothers, for mothers who are particularly vulnerable, are encouraging. The introduction of three months' annual leave, the careful setting of caseload and the increase in professional autonomy, supported by a practice manager, may be attractive to many midwives. The satisfaction of seeing one's patient through the pregnancy and beyond might be an incitement for midwives to continue to work in the profession, and to return to the profession, and for young people to train as midwives.
When I visited the Albany practice yesterday afternoon, I heard how satisfied the midwives felt in their work. I heard of the pleasure they had in not only seeing the infant through the first four weeks, but in also having mothers call by, so that they, the midwives, could see how well the mother's six year-old was doing, a child delivered in the clinic. So the midwives are very much part of their community and can see the children for whom they have cared in the past growing up.
I should like to ask the Minister whether he has studied the Albany model and what lessons he considers can be learnt from it. Is he undertaking research into why this particular model has given rise to high home birth rates and breast-feeding rates in an area of such high deprivation? Will the relationship between the continuity of care given, the provision of ante-natal education and the positive birth outcomes in this model be explored in further research?
I apologise for not giving the Minister notice of these detailed questions. I hope that he may be good enough to write to me if he has no response ready.
Yesterday, I also met with a manager of a children's home with more than 30 years' experience. The home had recently received a troubled 15 year-old girl who was pregnant. The manager was of the view that the model of continuity of care offered by the Albany practice would be exactly that which would be of most benefit to her new resident.
I am advised that it is easy to overlook the vulnerability of mothers during their pregnancy. Because childbirth is common, it can be thought to be unproblematic.
I believe that we still have the highest rate of teenage pregnancies in western Europe. A report by the National Children's Bureau in the 1990s found that nearly half of girls leaving care were mothers within 18 to 24 months. So, there are many groups of mothers who particularly need continuity of care during their maternity.
286 YoungMinds, a charity dedicated to promoting the emotional well-being of children, advises me of the importance of relationships with midwives characterised by continuity, reliability and familiarity. It is vital that mothers should feel ready and welcoming of their baby, vital for the sound and secure attachment to the baby. It is this attachment which so much research underlines as being the sure foundation for an individual life. My noble friend Lord Northbourne may have more to say on this point.
I have no doubt that, if we can develop first-rate services to mothers during their maternity, answering their physical and emotional needs, we shall go some way to ensuring that fewer children go to prison, that fewer children are taken into care and that the cycle of failure from generation to generation is somewhat ameliorated. Hand in hand with improvements in housing, education, other health services, social services and a sound economy, we could see many more children fulfilling more of their potential.
§ 7.58 p.m.
§ Lord Northbourne
My Lords, I had already apologised to the noble Baroness for the fact that I might be late this evening. I was, and I apologise to the House.
I want briefly to refer to one specific aspect which may in future become an important part of the role of the maternity services. Over the past 100 years or so, the maternity services have evolved mainly with a concern for the physical welfare of the mother and child. More recently, the emotional welfare of the mother has been of increasing concern.
However, modern research based on powerful new scanners indicates that the period in the womb and the first 33 months of a child's life are critical in the development of that child's brain.
A significant number of children today are born into, and grow up in, severely disadvantaged family circumstances—often multiple disadvantages—and sometimes with parents who have little or no experience of caring for children. In that context, maternity services and staff can be the gatekeepers who identify imminent problems. Some believe that the maternity services can play that very important role. They hold the patient's confidence. Their role should be primarily diagnostic, although some believe that they should also be trained to deliver advice and support services to parents without a clue about how to bring up their child. They could put the advice in simple, common language.
In my view, there is little argument about whether there is a role for the maternity services in identifying problems. The question is whether their role should be purely diagnostic; whether it should be signposting; or whether staff should be trained to deliver support services relating to the mother's emotional condition and the child's cognitive and emotional development needs.
The maternity services should be trained in three aspects: to recognise potential problems; to gain parents' confidence—which they do anyway; and 287 successfully to transfer that confidence to other services. For that, they must be trained, and the other services must be available. I shall explain what I mean by "transfer that confidence". Consider a health visitor who, at the end of the six-week visiting period, tells a mother, "I am sorry, Molly, I am not coming anymore, but I will refer you to Social Services". Contrast that approach with the health visitor who says, "Molly, I am terribly sorry; I shan't be able to help you anymore because I am not allowed to. Butt my friend Susan is really nice and I think you'll like her. Would you like me to give her your name so that she could call and you could see if you like her?". The difference is between acceptance and rejection in the case of many vulnerable people.
I regret to have to say that Social Services are not the people to do this job. Unfortunately, and through no fault of their own, Social Services have become the enemy to many deprived and disadvantaged families. They are thought of as the people who take your child away and are perceived by many as policemen rather than support services.
There is a role for the extended family, but often relatives need support, co-ordination, help and resources. There is a potential role for neighbours, the community and the voluntary sector. These services, wherever they come from, will probably need to be coordinated. possibly for training or accreditation. Who should be in charge of accreditation, training and coordination—the Department of Health, the Department of Education or local authorities? I do not know. But I know that the criterion ought to be: which will be the most effective? I ask the Minister to take into account what I have said.
§ 8.4 p.m.
§ Baroness Thomas of Walliswood
My Lords, like others, I welcome this debate. The noble Baroness, Lady Cumberlege, does us all a service by reminding us regularly of the enormous importance of the birth process. I apologise for the absence of my noble friend Lord Clement-Jones, who has an unbreakable arrangement abroad. It is a pity because I am sure that he knows much more about these matters than I.
Birth is a process we have all undergone. It is natural and normal and in most cases it has a healthy outcome. The death of mother or child is now a rare result, although no less dreadful when it occurs. Eighty per cent of women have babies, and 90 per cent of those babies are healthy. Of the others, very few require more than a little help with breathing in the first few hours, treatment for jaundice or suchlike. A tiny minority need the highest level of care—on the whole, then, a success story for Mother Nature and the advances in healthcare working together. However, we should heed the words of the noble Lord, Lord Patel, on our place in the league table.
Yet, in preparing for this debate, I was struck by the chaos that seems to hang over the service and policy discussions about it. I was also struck by a lack of relevant statistics. What is the best sort of service for mother and baby? Are midwife-led, low-tech 288 procedures in special birth units more appropriate than obstetrician-led procedures in hospitals, with all the high-tech support available? What are the cost benefits of each? Why is the rate of caesarean sections rising so inexorably? Why do rates of so-called "normal" births vary so much between places? Do those two variations not suggest a lack of consensus among practitioners on what constitutes good practice? What is the right level of home births? Why is the percentage rate in single figures in this country while it is around 30 per cent in Holland, to take but one example? Where should we provide care for the most fragile or sick babies? How can we secure the very best service from paediatricians? Why are the statistics so incomplete?
Inevitably, the question arises of why the Government have not given a steer? There have been no responses yet to the National Childbirth Trust Report and no action taken on their own report on neo-natal services. When will the framework document on children's services be published, and what aspects of maternity and neo-natal services will be covered? It appears that NHS trusts require guidance from the Government to assist them with the difficulties in prioritising and judging between the main options for maternity treatment. There can be no doubt about what women want, once someone gives them a chance to talk. They value good advice given in a way that they can understand. They want to be in contact with the same professionals, preferably midwives, during pregnancy, through the confinement and on into aftercare. They prefer the homely surroundings of a local birth unit or community hospital to a more impersonal district hospital.
I hope that the Minister will take on board suggestions from the noble Lord, Lord Chan, and others that more effort needs to be made to take the message of how to access maternity care to the most underprivileged and vulnerable members of our society. It was a very important point which has been echoed by other speakers.
It is very important what mothers think and feel. An experience of childbirth which leaves a mother with postnatal depression can, untreated, result in a four year-old with behavioural problems who turns into a problem teenager. Mothers who are taught to breastfeed will have healthier babies. It is amazing what good midwives can achieve. One practice in a deprived area of south London has achieved a 40 per cent rate of home births with no adverse consequences. With the percentage of home births so low nationwide, it is easy to see what a good and cost-effective achievement that is.
The variation in "treatment"—I put it in inverted commas on purpose—seems extreme judged by the standards of other specialties. Indeed, the very word "treatment" seems wrong. In the majority of cases the mothers do not need "treatment". They are not ill. They just need professional help and support.
I entirely agree with the noble Baroness, Lady Cumberlege, on the subject of caesarean section and the need to promote normal birth. As she said, last 289 year Shrewsbury had the lowest rate in England of caesarean section, at 10.4 per cent, and the highest rate of normal birth, at 67.7 per cent. Yet, in Worcester, women have no choice but to go into the infirmary, where the rate of caesarean section is 25 per cent. The mothers seem to have little choice. As others have pointed out, the cost of this high rate of caesarean section is great: each costs £1,000 more than an ordinary delivery. Saving 30 unnecessary caesarean sections buys one midwife. So the opportunity costs are clear. The costs to the child also can be considerable, especially when the procedure is carried out before term.
The reasons for the apparently inexorable increase in caesarean section are not clear. One idea often put about by the press is that it results from the personal choice of smart or busy mums. It could be the result of concentrating births in district hospitals. Again, better statistics would help. Whatever it is, caesarean section must be the only major surgical intervention which seems to be available if asked for, even when it is not necessary.
One thing seems clear—namely, that mothers who have had a caesarean section are almost invariably advised to have another, although I know from experience in my own family that that is not necessarily required. So the most important thing is to try to ensure that the first caesarean never takes place unless strictly required for the health of mother or child.
The problem of a shortage of midwives has been mentioned by many, but particularly by the noble Baroness, Lady McFarlane. There seems to be a vicious circle at work here. For example, a hospital loses its baby acute care beds and closes the maternity beds as a safety measure, or midwives are transferred to an even larger general hospital where they lose their status, cannot keep in touch with their patients, feel they are not giving the service they want to give, and leave. Something similar can happen when local birth units are closed, as has been happening in recent times, despite the evidence that they can deal with the majority of normal births at least as satisfactorily as any hospital. Any policy which the Government propose will have to recognise the very special role that midwives play in the care of mothers and babies. They will also have to attract back into the NHS those who have left.
This evening a wide measure of agreement has emerged as to what would make a good maternity service. First, proper prenatal care is essential to assess correctly which mothers, or their babies, are likely to need the medical attention that only a hospital can provide—although not even hospitals and senior medical professionals are entirely foolproof. I know of a horrible case, reported to me by one of my colleagues, in which a young woman being examined two months after an ectopic pregnancy was told that a small shadow on the x-ray was nothing to worry about. Two and a half months later, she nearly died after a severe loss of blood from a second ectopic 290 pregnancy. The Ectopic Pregnancy Trust says that such cases of misdiagnosis are common even where there is a history of ectopic pregnancy.
Returning to more cheerful subjects, however, the healthy woman should have a choice of where to give birth: at home, in a reasonably local birth unit or in hospital. In the first two at least, she will be able to have continuous care from the professionals who have looked after her during her pregnancy. If a large number of women chose the first two options and good practice secured the same levels of success that have been mentioned in particular instances, a considerable saving in beds would accrue to district hospitals. I am sure that those beds could be used for things other than housing perfectly healthy women. Post-natal care could be given in the same unit and then in the home.
A real effort should be made to establish breast-feeding, which is cheaper for the mother and better for the baby. Differential rates of breast-feeding are really surprising, with the lowest rate for the least number of weeks among women from more deprived backgrounds—just where the additional protection against illness and obesity given by breast-feeding would be most valuable.
A back-up service would be required should complications arise during the birth, just as for any other medical emergency. Very sick or fragile babies should be treated in specialty centres, if that is the only or best way in which to get the constant presence of a paediatrician and the quality of nursing care that such children need.
I look forward to hearing the Minister's response to the many questions that have been raised, and his idea of what maternity services should be like.
§ Lord Winston
My Lords, before the noble Baroness finishes, will she clarify her remark that mistakes are common? Professional mistakes are not at all common in midwifery, but there is a perception—often in the courts, quite unjustifiably—that they are because of monitoring that gives imprecise information. It is unwise to say that mistakes are common. As a practising doctor in this field, I believe that it is untrue.
§ Baroness Thomas of Walliswood
My Lords, I bow to the noble Lord's superior knowledge. I was referring to a type of mistake made in a particular case and quoting a letter sent to me by a pressure group. I am sorry if I gave a mistaken impression: I am certainly not suggesting that mistakes are common in obstetric care in general or trying to justify the large claims made by lawyers on behalf of their clients.
§ 8.16 p.m.
§ Baroness Noakes
My Lords, I add my congratulations to my noble friend Lady Cumberlege for initiating this important debate and for drawing in so many expert speakers. It has been an excellent debate.
We know that the topic is important, as it touches the lives of almost 600,000 women who give birth each year, and the lives of their families. As other noble 291 Lords have said, it is also apt that the debate should be led by my noble friend, who has been closely associated with the development of maternity services over the past decade. The report entitled Changing Childbirth is much better known as the Cumberlege report. That report was revolutionary in proposing women-centred care.
Simple principles underpinned that, including choice for women, continuity of care and control of women over their care. When the Audit Commission examined maternity services in 1997, its report, entitled First Class Delivery, found that the policies of the Cumberlege report were not being achieved. It said,there is a wide variation in the sort of service offered that cannot be attributed to women's own choices".A key issue is what the Government have achieved since 1997. It is far from clear that we can confidently say that in 2003 maternity services live out those principles of choice, continuity in care and control. The Minister has said, on more than one occasion in your Lordships' House, that the principles of Changing Childbirth—the Cumberlege report—are now embedded in maternity services. That is a complacent view and not one that is shared by professionals or users. Indeed, the noble Lord, Lord Patel, said earlier that maternity services are in a mess.
I start with home births. They are not desired by all women, but a substantial number want home delivery—we do not know how many. The statistics for home births are at around 2 per cent, but that does not tell anything like the full story. The Association for Improvements in Maternity Services has repotted many instances of women being pushed into hospital delivery, usually at a very late stage in pregnancy, because they are told that no midwife will be available to support a home delivery. Those women have been denied real choice and have lost control of their birth arrangements. Some parts of the country achieve home birth rates of 12 per cent, or occasionally even more. One can deduce from that that unmet demand is at least 10 per cent. It is clear that in home births, choice and control for women is simply not happening.
We have heard from many people this evening that pregnancy and childbirth are not illnesses: they are part of normal human life. Yet maternity services have developed around a different concept. I mean no disrespect to the medical profession, and in particular to obstetricians, when I say that the medicalisation of pregnancy and childbirth is part of today's problems.
Of course we are proud of the low level of our maternal, neonatal and perinatal mortality rates, which are so much lower than when many of your Lordships were children. However, as an article in the British Medical Journal last April pointed out, these improvements are attributable to many causes. The article said:it cannot be assumed that access to obstetric care … has invariably had beneficial effects".We have to be concerned about increased medicalisation and consequent decreases in normal births, by which I mean straightforward vaginal births without intervention.
292 Several noble Lords have already referred to caesarean rates, which are frighteningly high and still rising. They are well above the WHO's bench-mark level. The variations around the country that 'we have also heard about are even more worrying. Every unnecessary caesarean carries with it a raft of potential problems for both mother and child. My noble friend Lady Cumberlege and the noble Baroness, Lady McFarlane, both referred to the Audit Commission's estimate back in 1997 that for every 1 per cent of unnecessary caesareans, there is a cost to the NHS of around £5 million. Rolling that forward to today's prices, it is probably nearer £7 million. I have heard no recognition from the Government that this is a serious problem for which practical and urgent solutions are necessary.
Caesarean sections are not the only issue. There are other aspects of increased medicalisation, including instrumental deliveries and rates of anaesthesia and of episiotomies. As my noble friend Lady Cumberlege pointed out, some interventions tend to lead to more interventions, which makes the problem worse. It is clear that the rate of normal births is declining. That is not what women want or deserve.
What problems lie behind these features of modern maternity services? The Royal College of Obstetricians and Gynaecologists will say that there are not enough senior obstetricians available and that this will get worse as the Working Time Directive takes hold. We have heard from my noble friend Lady Perry of the related problems for obstetricians.
That may well be part of the problem, but a much more serious problem is that from the perspective of the Royal College of Midwives. Many noble Lords have referred to the severe shortage of midwives. The noble Lord, Lord Chan, referred to the 2002 survey by the Royal College of Midwives, which shows the highest vacancy rate against funded establishment that the college has recorded since it started its surveys. It also shows great disparities around the country. We know that some areas of London operate at near crisis level. Perhaps more importantly, in the survey, 70 per cent reported that their funded establishments were too low to meet the demands of today's maternity services.
The midwifery shortages identified by so many noble Lords are very important because they reduce the prospects for continuity of care, which many noble Lords have explained is a crucial part of achieving normal births and high levels of patient satisfaction. We need more midwives if we are to improve the prospect of real choices being available to women—choices such as home births, but also births in other settings.
The shortages in midwifery are imposing massive burdens on remaining midwifery staff. That leads to the inevitable loss of staff morale and causes further midwives to choose to leave the profession. We cannot afford that. We will need more midwives if there are to be more community-based maternity services and more midwife-led maternity units. It is through those routes, backed up by appropriate acute services and 293 service delivery protocols, that maternity services will be able to start to deliver the policy aims of women-centred services.
The Minister will be aware that community-based and midwife-led maternity services are "win-win" services. Studies have shown their popularity with women. More than that, studies show that they cost less and have outcomes at least no worse than acute-based services. Will he say what proportion of maternity services are currently midwife-led in England and, similarly, what proportion are community-based? Does he agree that those aspects of maternity care should be given priority in funding service delivery? Is he satisfied that primary care trusts give adequate priority to them in drawing up their commissioning plans? Is he satisfied that PCTs adequately consult users of maternity services when they draw up their plans? I hope that he will not be complacent on the matter, and will be able to set out what proactive steps the Government will take.
Many of the problems keep coming back to the shortage of midwives. The Minister will say that the Government have the target of a further 2,000 midwives by 2005. Early last year, a Health Minister in another place said that there would be an extra 500 in place by the end of 2002. Will the noble Lord say how many midwives there are currently and how many there were in 1997 —not just in terms of head count, but in terms of whole-time equivalents? What matters is not the number of midwives, but the amount of time cumulatively that they can contribute to maternity services. In particular, the problem with targeting returners is that they often come back into part-time work, so simply adding heads will not solve the problems. The figure that I have for whole-time equivalents is 18,050 at the end of 1997, and again in 2001. Will the Minister confirm those figures? Will he say whether there is any increase at all in that in 2002?
In May 2001, the Secretary of State for Health promised a national service framework for children and maternity services including, to use his phrase, "a gold standard" of a dedicated midwife 100 per cent of the time in labour, and choices for all women including home birth. That framework was promised by the end of 2002, but has not yet seen the light of day. As we have heard, Scotland and Northern Ireland are already ahead of us. Will the Minister say when the framework will appear? Will he confirm that it will include the two matters that I have just mentioned, which were 100 per cent dedicated midwife cover, and more choice including home birth? Will that framework promote normality in childbirth in the hope of offsetting the trends that have happened in our maternity services recently? I look forward to the Minister's reply.
§ 8.28 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)
My Lords, I congratulate the noble Baroness, Lady Cumberlege, on securing the debate. It is some time since we had one on maternity services, and the debate 294 has been helpful and has raised a number of very important matters on which we need to make progress. As other noble Lords have mentioned, she played the key role in Changing Childbirth. She knows that, when the report was published, I gave it warm and wholehearted support. The Government, of course, remain committed to the principle of establishing a high-quality woman-centred maternity service.
I was looking for some optimistic signs in the speech of the noble Baroness, Lady Cumberlege, but she was rather bleak about some of the outcomes that she thought had been achieved since her report was published. One can identify considerable signs of progress, although they are not as consistent throughout the NHS as she and I would have wished. However, that is progress none the less. I thought that the noble Baroness, Lady Perry, was very cheery in that respect.
There are examples of fundamental changes. Information and communication to women have improved considerably over the past decade; there is more discussion with women about aspects of their pregnancy care; there is more emphasis on women seeing a smaller number of midwives; and many women carry their own notes. I am not in the least complacent; we need to confront some difficult issues. However, we should not underestimate some of the progress that has been achieved.
On strategic leadership—the fundamental issue of what strategy we have and how we are going to take it forward—the key decision has been mentioned by various noble Lords; that is, the announcement of the children's national service framework in February 2001, including maternity services. In the new architecture of the NHS the setting of national standards through the national service frameworks is just about the most effective way of ensuring consistency of service provision and quality in what is, as the noble Baroness, Lady Perry, suggested, a devolved healthcare system.
We have debated the balance between devolution and central direction. It is interesting that the Audit Commission report, which was mentioned by the noble Baroness, Lady Noakes, found in 1997 that, despite the impetus that the noble Baroness, Lady Cumberlege, gave to the Changing Childbirth report, there was very patchy implementation. I am convinced that if we wish to achieve the right balance between wishing to have national standards, which is absolutely right, and giving room for the service to breathe at local level, the development of the NSF is undoubtedly the way forward. The aim is to set national standards of care and to look at how maternity services can be more flexible, accessible and appropriate. It will also pick up the issue of the commissioning of maternity services and the points raised by the noble Lord, Lord Chan, about establishing the network of maternity services, whether that involves primary, secondary or tertiary care. He rightly pointed to the need for an integrated approach.
295 We have formed a maternity external working group to advise on the development of the NSF. Appropriately, it is co-chaired by Heather Mellows, the junior vice-president of the Royal College of Obstetricians and Gynaecologists, and by Meryl Thomas, who is vice-president of the Royal College of Midwives. The work of that advisory group is being taken forward through five sub-groups. In a sense, the pathway of those sub-groups covers the point made by the noble Baroness, Lady Thomas, about what she wished to be covered, starting with pre-birth and involving birth.
I accept the points about home births. My understanding is that the figures have risen from 1 per cent in the 1980s to about 3 per cent, according to the latest data for 2000–01. I recognise that many more women would have wanted a home birth but that circumstances made that difficult. Undoubtedly, the NSF will need to look at that. It will need to consider post-birth and baby support.
The points raised about inequalities will also be covered in the national service framework. The noble Earl, Lord Listowel, was right about breast-feeding. The statistics are overwhelming in indicating a huge variation between the different social and ethnic groups in this country. That matter has to be addressed. I shall come later to the issue of caesarean rates, but, as the noble Lord, Lord Chan, suggested, those rates also indicate that some of the same issues arise.
The NSF will also look at the question of user involvement, which I recognise as extremely important. Indeed, as part of the work of preparing and developing the NSF, today my department held a discussion with midwives and users about the experience and relevance of the maternity services liaison committee. I was able to visit the committee for about an hour and to listen to some feedback. Some very interesting ideas were put forward with regard to good practice and the effectiveness of some maternity services liaison committees. Reports of committees feeling that they did not have sufficient support to make an impact were also mentioned.
There is no doubt that the ability of the national service framework to allow us to set national standards and frameworks for the future will be critically important. We shall want them to explore some of the areas to which the noble Lord, Lord Northbourne, referred. The noble Lord made some interesting remarks about how one dealt with particularly vulnerable parents—often young parents. I believe that the initiatives that we have taken in Sure Start plus show some of the ways forward, but we shall need to pick up the points raised by the noble Lord.
We want to explore all the areas which we know are important to women: a safe birth which is as normal as possible; a choice of place of birth, with home birth as a realistic option; appropriate support for women in labour and the feasibility of one-to-one care; improving the support and advice that women need when they are making decisions about how they are going to feed their babies—I very much accept the 296 need to ensure that the benefits of breast milk are widely known—and the provision of appropriate information, presented in a variety of formats, to assist women and their families to make those decisions.
The noble Baroness, Lady Noakes, is always asking me when we are going to publish reports. The first module of the national service framework covering children in hospital will be published shortly. The other modules will follow. I cannot give a precise date for the maternity service module, but obviously I hope that it will be as soon as possible. However, clearly it will take time to ensure that it is as thorough as we would all like it to be.
A number of noble Lords, including the noble Lord, Lord Patel, asked about one-to-one care by midwives. We have already said that that is our aim. The gold standard should be that every woman has access to one-to-one care. It is intended that the children's national service framework will set out how best we can achieve that gold standard and that it will give a timetable for doing so.
The evidence that we have from the midwifery practice audit report for 2000–01 of the English National Board for Nursing, Midwifery and Health Visiting is that the percentage of units not able to provide one-to-one midwifery care to each woman in labour reduced from 28 per cent in 1999 to 22 per cent in 2000; in other words, 78 per cent provide one-to-one care to all women in labour. However, we shall look for further guidance on that from the national service framework.
The national service framework will consider the examples of good practice mentioned in tonight's debate. The noble Earl, Lord Listowel, asked about the Albany practice. Of course, we shall be very interested to know of the experience of that practice and of other examples of good practice.
Before I deal with a number of specific issues which have been raised, I say to the noble Lords, Lord Chan and Lord Patel, that I recognise very clearly the issue of litigation. It goes somewhat wider than the maternity services module of the children's national service framework. But anyone looking at experience in the NHS at the moment has to be concerned about the cost of litigation, and, even more so, whether it leads to defensive medical practice. We are looking seriously at what we need to do to ensure that we move away from some of the current difficulties.
Despite a litany of gloom tonight there are encouraging signs of improvement. I am surprised that no noble Lord mentioned the £100 million capital allocation we have made to over 200 maternity units to modernise the environment. The money that has gone to the service has ranged from large to small sums, but it has all helped to improve the environment.
Good as that is, there is no question that unless we have enough midwives we are not going to get very far. All noble Lords have raised this question. There is no doubt that a great deal of work has to be done to get recruitment and retention up to the standard that we wish to see. We are offering more places for students to train as midwives. I say to the noble Baroness, Lady 297 Perry, that compared with 1997 there are 226 more training places available. As regards the number of midwives, there has been an increase since 1997 of about 700, although the figures quoted by the noble Baroness, Lady Noakes, are also correct. That shows that we have to increase the effort in co-ordinating a recruitment, retention and return to practice strategy.
As regards the question raised by the noble Baroness, Lady Noakes, that funding establishments are too few, we are supporting the use of what is described as birthrate plus, which is an excellent workforce planning tool. Many trusts are now using it. I hope that that will lead them to a more realistic assessment of the number of midwives required.
But if we recruit and train enough of them, we have to retain them. The noble Baroness, Lady Cumberlege, and the noble Baroness, Lady McFarlane, discussed why it is that midwives leave the profession. I say clearly that we do not want midwives to feel that they are either de-skilled or unable to provide the care that they wish in all settings. I echo the wishes of noble Lords for midwives to have professional autonomy, to feel confident in their skills and to be in a position to promote normal birth. I am sure that that is the key to answering the question posed by the noble Baroness, Lady Cumberlege, as to how we should promote normal births. I am convinced that the key is in the autonomy and support that midwives are given, supported by appropriate midwifery leadership in management and with the continued appointment of consultant midwives with responsibility for giving clinical support.
I agree that the more women receive care from a midwife they know the better the care. The issue of one-to-one midwifery is tied up with the recruitment of more midwives into the National Health Service.
The noble Baroness, Lady Perry, applauded the appointment of consultant midwives and then regretted that that meant they were diverted from management and teaching tasks. We have 32 consultant midwives and they are doing excellent work. I believe that our ability to reward high calibre people to stay in practice is excellent. We need more than 32 consultant midwives. As regards teaching, I am very exercised about that, not for midwifery but for clinicians and nurses. It is an issue that we continue to discuss. Between the Department of Health and the Department for Education and Skills a number of new strategies have been launched. But in light of what the noble Baroness has said, I shall ensure that the midwifery teaching issue is picked up.
On management, I could not agree more with the need to ensure that we have strong midwifery management. We know that we have to do more to help heads of midwifery make as big an impact as they can within their local organisations. The Leadership Centre is exercised in ensuring that we do that. In relation to addressing the group of people that I met today within the national service framework, I have said to my officials that we need to think clearly about 298 how we can help heads of midwifery make more impact when it comes to the trusts' boards making the right decisions for the development of services.
That issue is a common one between two governments. I do not believe that we have yet found a way of carrying that out as effectively as possible. I am absolutely sure that having good, strong head-midwifery leadership within each NHS trust is absolutely critical to achieving the right qualities at the local level.
I turn to medical workforce issues. I know that there are concerns in that area. The number of consultant obstetricians and gynaecologists in post has increased by 21 per cent over the past five years, but currently with the college we are exploring expanding the number of consultants.
The European working time directive has been mentioned by the noble Baroness, Lady Cumberlege, and other noble Lords. It is a major challenge. There is no question about that. We produced a circular on implementing the directive only eight or nine days ago. We have a programme of pilot projects in NHS trusts to develop and to test innovative solutions. There is no doubt that that will pose significant challenges on the National Health Service.
That brings us to the issue of configuration. We know that a combination of service and workforce development is having a major impact on the configuration of maternity services. Pressures such as the drive for improved safety, more efficient use of resources, better medical training and the directive have often tended towards greater concentration of services on to a smaller number of sites. But those pressures have to be balanced against local access to services and—particularly in maternity—promotion of normal pregnancies and births without unnecessary intervention.
I have no doubt whatever that we have to achieve the correct balance. I say that as someone who a year or so ago had to deal with the issue of the Hemel Hempstead maternity service, where we were faced with agonising decisions. There is no doubt that we must achieve effective configuration to gain the correct balance. We cannot allow a headway drive into centralisation to undermine so many of the units that are currently in place.
I was asked about the Maternity and Neonatal Workforce Group and when the report will be published. It will be published shortly and it will be taken forward. In the department we are also developing a configuring hospitals project which is picking up those issues, not just in relation to maternity services but in relation to the broader issue of configuration. It will also look at the particular focus of the challenges facing smaller hospitals and at creative options to ensure that the headlong rush into centralisation is not always inevitable.
Of course, I recognise the value of birthing centres and the value of midwifery-led units. I hope that the national service framework will enable us to explore those options and to encourage them further in the future.
299 On Malmesbury and Devizes, I am assured by the PCT that it aims to modernise services and that no decisions will be made without public consultation. I shall keep an eye on that matter in the light of the comments that have been raised today.
I cannot finish without turning to the issue of medical intervention and caesarean section rates. I accept that the noble Baroness, Lady Noakes, is right to say that the medical interventions taking place do not just cover caesarean sections. The reasons for their increase are complex. Over the past 20 years, technical advances have enabled obstetricians and midwives to identify complications at a much earlier stage, so that appropriate interventions that improve clinical outcomes can take place.
If noble Lords are asking me to say whether I am concerned about the current rates, I am and always have been concerned about them. I have made no secret of that. None of us can say that all caesarean sections are unnecessary. Sometimes they are very necessary. I am also aware of the variations between different parts of the country. However, the absolute evidence needed to draw hard conclusions is not available. That is why we have commissioned the Royal College of Obstetricians & Gynaecologists to undertake the largest ever national sentinel audit.
The initial result of that audit has provided valuable data. The noble Baroness, Lady Thomas, raised the question of choice. That audit showed that 7 per cent of caesarean sections are performed at the request of women. This is a very difficult issue. I do not pretend to have any easy answers to it.
The issue of choice has been raised. It is important, but decisions have to be made by well-informed women with the appropriate unbiased information and in the light of the best clinical evidence available. All interventions must be based on sound evidence. I agree with the points made by the noble Baroness, Lady Greengross, on the matter. That is why we have asked the National Institute for Clinical Excellence to develop guidelines for some of the most used interventions, including caesarean sections.
The noble Baroness, Lady Cumberlege, invited me to set targets for reductions in caesarean rates. She usually tells me that I set too many targets for the health service. I understand why she should want me to do this.
§ Baroness Cumberlege
My Lords, I did not use the word "targets" in my speech. I asked what action the Government are taking to reduce the numbers of sections and, as a result of their actions, when they expect to see a decline in the rate.
§ Lord Hunt of Kings Heath
My Lords, I apologise to the noble Baroness. I think that another noble Lord picked up her point and suggested targets. I understand why some noble Lords think that targets would be appropriate. I do not think that I can respond directly to that issue until we have the results of the NICE clinical guidelines. At that point one would then think about the strategies needed to reduce 300 caesarean sections, if, in the light of the work undertaken by NICE, that is considered appropriate. But if noble Lords are asking me whether I have concerns about the current situation, I do have concerns about it.
The noble Baroness raised the point about the World Health Organisation. We have all used the figures of 5 per cent to 15 per cent. My understanding is that the World Health Organisation is now looking again at those issues. That will be helpful and it is to be hoped that, if done quickly, it will inform the work that we also need to take forward.
In the time available I have not answered every point, but I hope that I have convinced noble Lords that I, together with the Government, am not at all complacent about the big issues that face maternity services in this country. I believe that great progress has been made during the past few years. I again commend the noble Baroness, Lady Cumberlege, for her outstanding work.
I believe that recruitment and retention strategies for midwives, the issue of leadership, the work of the national service framework and the work that we are doing with users will combine together to give us the national cohesive strategy that we all agree needs to be developed. It will be very much informed by the comments made and the points raised in this debate. I assure your Lordships that I will ensure that they are conveyed to those who are leading the national service framework.
§ 8.55 p.m.
§ Baroness Cumberlege
My Lords, I should like to conclude this debate by thanking all noble Lords who have taken part. It has been a wise and interesting debate that has highlighted the great strengths of this House. In particular, I thank the Minister for his full response to the vast majority of our questions. There is no doubt about his personal commitment to the matter, and I thank him for that.
I welcome the introduction of maternity into the national service framework for children. That is an excellent move. I advocate speed on that, because the situation in the country is changing fast. Your Lordships have been enormously generous to me in this debate, and I thank you for that, but I want the Government to produce a maternity policy all its own. I want to see the son and daughter of Changing Childbirth, because it is when the Government embrace their own policies that we shall experience a real difference. People have been so generous and nice—not only in this Chamber but throughout the country—about the work that I did. But that was 10 years ago. Life has moved on and it is time that the Government put some strong political will behind the issue and improved the lot of women and children in this country. My Lords, I beg leave to withdraw the Motion for Papers.
§ Motion for Papers, by leave, withdrawn.
§ House adjourned at three minutes to nine o'clock.