~) Longman Group UK Ltd 1991
Midwifery
EDITORIAL
The provision of the maternity services in the UK I must again apologise to readers o f Midwifery who do not live in the UK for using a UK happening as the topic for this editorial. However, on 4 March 1992 an event which will have far-reaching effects on the future of the British maternity services and midwifery profession occurred in London and this news is worthy of being broadcast to all midwives throughout the world. I discuss the event here because in my opinion it could be of value to midwives in other countries in their struggle to provide satisfactory services to women having a baby. T h e event was the publication of Volume 1 of the Second Report o f the House of C o m m o n s Health Committee on the Maternity Services (HC, 1991-92). T h e Health Committee consists of 11 Members of Parliament drawn from all political parties. T h e committee is appointed to 'examine the expenditure, administration and policy of the Department of Health, associated public bodies and similar matters within the responsibilities of the Secretary of State for N o r t h e r n Ireland' (HC, 1991-92). T h e Health Committee has wide-ranging powers: it can require people to attend to give evidence or to explain matters of complexity; it has right of access to relevant reports and papers, and it can visit places of relevance to the Committee's remit. In investigating the provision of the maternity services this committee took oral evidence from organisations representing the users of the maternity services, organisations representing midwives, obstetricians, paediatricians, general practitioners, neonatal nurses and pathologists, as well as individuals. T h e committee also received oral evidence from the D e p a r t m e n t of Health, the D e p a r t m e n t of Social Security, the Office of Population Cencuses and Surveys and some Regional Health Authorities. T h e committee received written evidence from 446
organisations and individuals as well as making visits to areas in the UK and the Netherlands and Sweden. T h e result of the enquiry is the publication of a well written report which critically analyses the available research into the provision of maternity services in the UK. J o a n Walker (International News Editor) has summarised the conclusions and recommendations in the International News in this issue (p91). However, there are one or two points which are worthy of further mention. In the introduction the committee states that 'Becoming a m o t h e r is not an illness . . . It is a normal process which occurs during the lives of the majority of w o m e n and can indeed be seen as a manifestation o f health' (HC, 1991-92). Midwives have been making this point for a considerable period of time; at last we have an authoritative body to support us. In their investigations and throughout the report the committee have had in the forefront of their mind the needs of mothers and babies. It is a sad reflection on the maternity services that the committee, in more than one place in the report, states that this does not a p p e a r to be the most important point for those providing the services. In a previous editorial (Thomson, 1990) I questioned why one health authority in the UK was routinely sending women home 48 h after delivery because it was cheaper for the health authority, when the costs to the mother had not been investigated. T h e House of Commons Health Committee have stated that in planning services health authorities must consider the cost to the mother and her family, not just the health service. T h r o u g h o u t the report the authors constantly state that the consumers must be provided with choice on how and by whom their antenatal care 51
52
MIDWIFERY
is provided, the place of birth and how and where postnatal care is provided. T h e report's authors also state that wherever intrapartum care is provided there is a need to establish methods of giving less medicalised care in labour. On discussion with the recipients of care from the maternity services the committee were informed that what women want is continuity of care and continuity ofcarer. This continuity must go from antenatal care through labour and delivery and to the postnatal period. In the committee's view the most appropriate person to provide the continuity is the midwife. The committee recognised that it is not appropriate for an individual to provide this, but continuity of care should be provided by a small team of midwives who would become known to the woman during pregnancy. The Committee state that the provision of Team Midwifery will vary from area to area depending on local needs. In the report the committee recommend that the Department of Health supports research to assess the effectiveness and the costs of different styles of provision of care. In the past there have been some suggestions from some authorities that Team Midwifery costs more than the present fragmented style of care. However, the committee states that there is no evidence for this, particularly if the provision of care is considered in its totality, not just staffing levels. Staffing was an issue which was raised by obstetrician representatives. One consultant stated that the provision of consultant posts throughout the country varied greatly and was particularly bad in his area. The Royal College of Obstetricians guidelines state that there should be one consultant for every 500 deliveries was quoted to support the consultant's case that in this area where, there were only five consultants for 5260 deliveries, they were understaffed with consultants. In further support of his case the consultant quoted statistics from Scotland, where there was one consultant for every 544 deliveries, and Newcastle, New South Wales where there was one consultant tor every 163 deliveries. However, the committee urged caution in drawing conclusions from these statistics. The committee demonstrated that the cae-
sarean section and induction of labour rates were highest in the areas where there was a greater proportion of consultants and the perinatal mortality rate was lowest in the area where the proportion of consultants was lowest. Does this mean that obstetricians actually cause more interference and the perinatal mortality rate goes up? Tew & Damstra-Wijmenga (1991) would support that line of argument. Or does it mean that the less-interventionist style of midwives who will be carrying out the care in the areas where there are fewer obstetricians is more beneficial to the health of women and babies. This point is worthy of further investigation and the committee recommend that research should be carried out into the staffing levels appropriate for safe provision of maternity services. There is much more in this report that I would wish to bring to your attention but I am in danger of reproducing the whole report. However, there is one further point that I wish to make. In the report the committee quote the words of Dr Iain Chalmers when the committee visited the National Perinatal Epidemiology Unit (NPEU) in Oxford. Dr Chalmers has been a long-time supporter o f midwives and it is good to read that he raised the issue of funding for midwifery research with the committee. Dr Chalmers reported that midwives have difficulties in obtaining funding for research because the questions that midwives ask are different from the questions asked by those undertaking medical research. As a result of their discussions with Dr Chalmers the committee have recommended that in order to expand research by midwives a midwifery research funding body should be set up and it should be attached to the NPEU. As I have already stated, the report critically analyses the available research into the provision of maternity services in the UK. The committee states that there is a need for more research. However, the committee has demonstrated that much could be done with the existing research to provide a service which meets the needs of the consumers. I recommend that midwives throughout the world read this report, not because I wish to see a British style of maternity service throughout the world, but, because the
MIDWIFERY 53 r e p o r t ' s a u t h o r s constantly m e n t i o n t h e n e e d to p r o v i d e services suitable to local n e e d s , t h e r e is m u c h which c o u l d be a d a p t e d f o r use in various parts o f the world. H o w e v e r , at t h e time o f writing the r e p o r t is o u t o f print! T h e r e p o r t is so p o p u l a r that the first p r i n t r u n has a l r e a d y b e e n sold, so s o m e of" you may h a v e to wait a little b e f o r e the r e p o r t is available. ANN THOMSON
References House of Commons 1991-92 Health committee second report, maternity services. HMSO, London Tew M, Damstra-Wijmenga 1991 Safest birth attendants: recent Dutch evidence. Midwifery 7:(2) 55-65 Thomson A 1990 Choices in childbirth. Midwifery 6(1): 1-2
Midwifery
EDITORIAL
The provision of the maternity services in the UK I must again apologise to readers o f Midwifery who do not live in the UK for using a UK happening as the topic for this editorial. However, on 4 March 1992 an event which will have far-reaching effects on the future of the British maternity services and midwifery profession occurred in London and this news is worthy of being broadcast to all midwives throughout the world. I discuss the event here because in my opinion it could be of value to midwives in other countries in their struggle to provide satisfactory services to women having a baby. T h e event was the publication of Volume 1 of the Second Report o f the House of C o m m o n s Health Committee on the Maternity Services (HC, 1991-92). T h e Health Committee consists of 11 Members of Parliament drawn from all political parties. T h e committee is appointed to 'examine the expenditure, administration and policy of the Department of Health, associated public bodies and similar matters within the responsibilities of the Secretary of State for N o r t h e r n Ireland' (HC, 1991-92). T h e Health Committee has wide-ranging powers: it can require people to attend to give evidence or to explain matters of complexity; it has right of access to relevant reports and papers, and it can visit places of relevance to the Committee's remit. In investigating the provision of the maternity services this committee took oral evidence from organisations representing the users of the maternity services, organisations representing midwives, obstetricians, paediatricians, general practitioners, neonatal nurses and pathologists, as well as individuals. T h e committee also received oral evidence from the D e p a r t m e n t of Health, the D e p a r t m e n t of Social Security, the Office of Population Cencuses and Surveys and some Regional Health Authorities. T h e committee received written evidence from 446
organisations and individuals as well as making visits to areas in the UK and the Netherlands and Sweden. T h e result of the enquiry is the publication of a well written report which critically analyses the available research into the provision of maternity services in the UK. J o a n Walker (International News Editor) has summarised the conclusions and recommendations in the International News in this issue (p91). However, there are one or two points which are worthy of further mention. In the introduction the committee states that 'Becoming a m o t h e r is not an illness . . . It is a normal process which occurs during the lives of the majority of w o m e n and can indeed be seen as a manifestation o f health' (HC, 1991-92). Midwives have been making this point for a considerable period of time; at last we have an authoritative body to support us. In their investigations and throughout the report the committee have had in the forefront of their mind the needs of mothers and babies. It is a sad reflection on the maternity services that the committee, in more than one place in the report, states that this does not a p p e a r to be the most important point for those providing the services. In a previous editorial (Thomson, 1990) I questioned why one health authority in the UK was routinely sending women home 48 h after delivery because it was cheaper for the health authority, when the costs to the mother had not been investigated. T h e House of Commons Health Committee have stated that in planning services health authorities must consider the cost to the mother and her family, not just the health service. T h r o u g h o u t the report the authors constantly state that the consumers must be provided with choice on how and by whom their antenatal care 51
52
MIDWIFERY
is provided, the place of birth and how and where postnatal care is provided. T h e report's authors also state that wherever intrapartum care is provided there is a need to establish methods of giving less medicalised care in labour. On discussion with the recipients of care from the maternity services the committee were informed that what women want is continuity of care and continuity ofcarer. This continuity must go from antenatal care through labour and delivery and to the postnatal period. In the committee's view the most appropriate person to provide the continuity is the midwife. The committee recognised that it is not appropriate for an individual to provide this, but continuity of care should be provided by a small team of midwives who would become known to the woman during pregnancy. The Committee state that the provision of Team Midwifery will vary from area to area depending on local needs. In the report the committee recommend that the Department of Health supports research to assess the effectiveness and the costs of different styles of provision of care. In the past there have been some suggestions from some authorities that Team Midwifery costs more than the present fragmented style of care. However, the committee states that there is no evidence for this, particularly if the provision of care is considered in its totality, not just staffing levels. Staffing was an issue which was raised by obstetrician representatives. One consultant stated that the provision of consultant posts throughout the country varied greatly and was particularly bad in his area. The Royal College of Obstetricians guidelines state that there should be one consultant for every 500 deliveries was quoted to support the consultant's case that in this area where, there were only five consultants for 5260 deliveries, they were understaffed with consultants. In further support of his case the consultant quoted statistics from Scotland, where there was one consultant for every 544 deliveries, and Newcastle, New South Wales where there was one consultant tor every 163 deliveries. However, the committee urged caution in drawing conclusions from these statistics. The committee demonstrated that the cae-
sarean section and induction of labour rates were highest in the areas where there was a greater proportion of consultants and the perinatal mortality rate was lowest in the area where the proportion of consultants was lowest. Does this mean that obstetricians actually cause more interference and the perinatal mortality rate goes up? Tew & Damstra-Wijmenga (1991) would support that line of argument. Or does it mean that the less-interventionist style of midwives who will be carrying out the care in the areas where there are fewer obstetricians is more beneficial to the health of women and babies. This point is worthy of further investigation and the committee recommend that research should be carried out into the staffing levels appropriate for safe provision of maternity services. There is much more in this report that I would wish to bring to your attention but I am in danger of reproducing the whole report. However, there is one further point that I wish to make. In the report the committee quote the words of Dr Iain Chalmers when the committee visited the National Perinatal Epidemiology Unit (NPEU) in Oxford. Dr Chalmers has been a long-time supporter o f midwives and it is good to read that he raised the issue of funding for midwifery research with the committee. Dr Chalmers reported that midwives have difficulties in obtaining funding for research because the questions that midwives ask are different from the questions asked by those undertaking medical research. As a result of their discussions with Dr Chalmers the committee have recommended that in order to expand research by midwives a midwifery research funding body should be set up and it should be attached to the NPEU. As I have already stated, the report critically analyses the available research into the provision of maternity services in the UK. The committee states that there is a need for more research. However, the committee has demonstrated that much could be done with the existing research to provide a service which meets the needs of the consumers. I recommend that midwives throughout the world read this report, not because I wish to see a British style of maternity service throughout the world, but, because the
MIDWIFERY 53 r e p o r t ' s a u t h o r s constantly m e n t i o n t h e n e e d to p r o v i d e services suitable to local n e e d s , t h e r e is m u c h which c o u l d be a d a p t e d f o r use in various parts o f the world. H o w e v e r , at t h e time o f writing the r e p o r t is o u t o f print! T h e r e p o r t is so p o p u l a r that the first p r i n t r u n has a l r e a d y b e e n sold, so s o m e of" you may h a v e to wait a little b e f o r e the r e p o r t is available. ANN THOMSON
References House of Commons 1991-92 Health committee second report, maternity services. HMSO, London Tew M, Damstra-Wijmenga 1991 Safest birth attendants: recent Dutch evidence. Midwifery 7:(2) 55-65 Thomson A 1990 Choices in childbirth. Midwifery 6(1): 1-2
