A recent baby boom in the UK has highlighted the problems faced by understaffed and overstretched NHS maternity units. Denis Campbell reports on a roundtable debate about the future direction of obstetric care

-Team@CMHF

• Despite countless inquiries, initiatives and ministerial pledges, going back two decades, maternity care remains one of the NHS’s problem areas. Concern about it means it is rarely far from the headlines.
• In recent weeks there have been two significant pieces of evidence published that will help shape practice affecting the UK’s 800,000 births a year. The National Institute for Health and Clinical Excellence (NICE) produced new guidelines for the NHS in England and Wales on the circumstances in which mothers-to-be should be able to have a Caesarean-section delivery.
• Meanwhile the landmark Birthplace study, published last month, for which Oxford University researchers examined 64,500 births by low-risk women in England, sought to clarify the relative risks of having a baby at home, in hospital or in a birth centre run by midwives; the study found all settings carried a low level of risk. Both documents aim to advise maternity teams on how to give mothers and their babies the best possible experience.
• That was also the motive of the Guardian’s recent roundtable debate about the quality, safety and future of maternity care. The debate, which was sponsored by Danone Baby Nutrition, was held under the Chatham House rule, which means comments can be reported without attribution to encourage a free exchange of views.
• The starting point was the Royal College of Midwives’ (RCM’s) first annual State of Maternity Services report, published last month, which provides a detailed account of the situation in each of the four home nations. While some of its findings were familiar, such as the difficulties caused by the UK-wide baby boom over the past decade, others were more surprising.
• For example, while England is seeing a failure to adequately address the chronic shortage of midwives, Scotland and Northern Ireland have enough midwives. As one roundtable participant said: That shows a shortage of midwives isn’t inevitable. However, the fact the midwifery workforce is ageing – a related but less well-appreciated problem – is a key issue across the UK, apart from in Wales.

Under pressure

• It is no wonder maternity services are under pressure. As the RCM’s report states, England has had a 22% increase in births over the past decade, while it has been 17% in Wales, 15% in Northern Ireland and 12% in Scotland. England and Wales have been “overwhelmed” by this baby rush, the RCM says.
• But the maternity workforce is not just short of midwives, the roundtable heard. Of those 800,000 annual births, 94% of them take place in hospitals where doctors are present along with midwives; the others, at home (2%) and in birth centres (4%), have midwives solely in charge.
• But the Royal College of Obstetricians and Gynaecologists (RCOG) believes the 2,186 senior doctors working as consultants in that area of medicine is too few. It wants the NHS to boost numbers to 3,000-3,300.
• Mothers-to-be would benefit because every hospital maternity unit would have a consultant on hand 24/7 and less experienced doctors would no longer be in charge overnight and at weekends, says the RCOG.
• Those present agreed with the strong view expressed at the outset by one expert that the current system of maternity care is unsustainable. You have to reconfigure. The participant meant that some maternity units should be closed – merged, in effect – so fewer, larger childbirth centres could offer mothers a better service, partly thanks to more specialist staff handling a greater number of deliveries concentrated in the same place.
• Many health professionals support the concept of reorganization. And the reconfiguration of neonatal care services in 2003, which led to fewer units dealing with sick babies but offering enhanced care, is a potential model to follow, another participant added. But there is a major obstacle to overcome first: the controversy such proposals arouse.
• Why hasn’t reconfiguration happened? It’s politics. To close your core maternity service is a death trap as an MP. So that will not happen, said the proponent of centralising maternity services.
• Maternity services have recently been reorganised in Greater Manchester and, while painful, the process has resulted in a new system that should now be offering better care, added a contributor.
• We need political will to [help] build a very different system and to be brave about reconfiguration, and brave about telling the public what a high-quality maternity service looks like. We really do need help from the government on this and it’s not there, lamented another pro-reconfigurationist.
• If reorganization did occur, what sort of services should emerge? Everyone present agreed that simply creating fewer, but larger, hospital units is not the answer and there needs to be more midwife-led birth centres, either standalone units or situated beside hospitals, in case a mother needs urgent medical attention. The RCOG favours adjacent midwifery units.
• There was also a strong consensus that the huge proportion of births occurring in hospitals, 94%, is too high. While there was support for moving towards an equal split – 33% at home, 33% in birth centres and 33% in hospital – there was also recognition that politics, entrenched attitudes and the tightest NHS budget in a generation means that will probably remain just an aspiration for the foreseeable future.

The role of government

• Picking up the theme of political involvement in maternity care, several participants noted that suggestions for changes in maternity services, supported by most people in the field, have been around since the early 1990s.
• Unfortunately, many suggestions for change have been accompanied by frustratingly limited progress. As one contributor put it: Solutions put forward over the last 20 years have stayed the same, but they have not been enacted. Maternity Matters [the last government’s maternity guidance document] came out in 2007, but it contained some of the same things that were in the government’s big maternity policy document in 1992. Why don’t things change? Why don’t things get implemented?
• In 2007, Maternity Matters promised women in England a choice of birth place, but the reality is that many still do not get that. One participant working on the NHS frontline said pressure on maternity services was so great in some places that midwives who usually help women to have home births are having to work, instead, on labour wards, thus depriving those seeking a home birth of that supposedly guaranteed right.
• Similarly, surveys by the Healthcare Commission and its successor as the NHS regulator for England, the Care Quality Commission, have shown the promise to women of one-to-one care from a midwife during their labour is also not honoured for as many as a quarter of mothers-to-be, who are left alone and find it stressful.
• Other problems were discussed too: women’s feelings of isolation; postnatal care; worryingly, a concern that midwives’ and maternity doctors’ competence is, in some cases, not what it was; a recent rise in maternal mortality in London; and the need for staff to communicate much better with pregnant women during what can be a very stressful and confusing time.
• The roundtable also involved more upbeat contributions, such as the one about the hospital that, at the suggestion of its head of midwifery, began letting partners sleep on pull down beds beside their loved one and newborn child.
• The midwives were initially nervous, but soon appreciated an innovation that led to the partners being able to support their wives and girlfriends. So not all progress needs to be the result of a new Whitehall policy.
• A telephone number for expectant women or their partners to call if they are confused or scared might also help. All these things were cited as potential ways of reducing what one speaker memorably described as a culture of acceptance that when you go into hospital, things won’t be right.
• There will be compromises and frustrations in getting the care you want. But there are other solutions. We need to start making small changes immediately, said that participant. Another summed up the determination shared by all present to finally move this agenda forward, irrespective of what central government decides. This isn’t about needing more evidence. It’s about getting the support to do things, to achieve things. Everyone around the table sincerely hoped ministers and NHS policy-makers heed that call.

For further reading log on to
http://www.guardian.co.uk/healthcare-network/2011/dec/14/delivering-better-maternity-care?newsfeed=true