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