Midwifery 30 (2014) 279–281
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
‘Unfinished business’? Reflections on Changing Childbirth 20 years on Tania McIntosh, MA, PhD, RM, PGCHE (Lecturer in Midwifery)a,n, Billie Hunter, PhD, PG Diploma in Midwifery, BNurs, RM, RN, HV, PGCE (RCM Professor of Midwifery)b a b
University of Nottingham, Academic Division of Midwifery, B Floor, East Block, Queens Medical Centre, Nottingham NG7 2UH, UK Cardiff University, UK
Introduction On 17 October 2013 a ‘witness’ seminar was held in London, UK, to celebrate the 20th anniversary of the publication of the English report Changing Childbirth Department of Health (1993).1 Most official reports have their day in the sun and then sink, superseded by the next initiative. Changing Childbirth was always a report with a difference however. Midwives who were in practice when it was originally produced still remember it; student midwives still debate its meaning and impact. Twenty years on the language developed by the authors of the report, which talked about choice, control and continuity of care for women, still resonates powerfully within the United Kingdom (UK) maternity services. The Changing Childbirth report was produced in 1993 by the Expert Maternity Group, convened by the Conservative Government and chaired by Baroness Cumberlege. It followed the publication in 1992 of the Winterton Report (DOH, 1992) and built on its recommendations. Changing Childbirth and the Winterton Report were widely heralded for enshrining the concept of woman-centred care and they led to the creation of many practice initiatives designed to support their core recommendations. They reversed official policy that hospital was always the safest place for birth, and highlighted the psychological as well as the physical impact of childbearing on women. The continued power of the report was demonstrated by the willingness of key players to attend the seminar and to discuss its development and legacy. The panel of discussants included Sir Nicholas Winterton who had chaired the Health Select Committee which examined the state of the maternity services in England in 1991, Baroness Julia Cumberlege who chaired the Expert Maternity Group, and diverse stakeholders including obstetricians, midwives, the National Childbirth Trust [NCT] and the Association for Improvements in Maternity Services [AIMs]. Professor Lesley Page, a panel
n
Corresponding author. E-mail address: [email protected] (T. McIntosh). 1 Witness seminars use an expert panel to discuss the chosen topic under a knowledgeable Chair with an invited audience also able to participate. The discussion is audio recorded and transcribed. The resulting document is then made available as archive data relating to the topic in question. The transcript from the Changing Childbirth seminar should be available in Spring 2014. All direct quotes in this commentary taken from the Changing Childbirth seminar transcript. 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.12.006
discussant who sat on the Expert Maternity Group, commented that involvement in Changing Childbirth was the proudest moment of her career. Sir Nicholas Winterton argued however that, ground-breaking though the Report was, it was ultimately ‘unfinished business’. This was partly because as with all other initiatives, Changing Childbirth did not exist in a vacuum and implementation was affected by economic and service pressures as much as by philosophical considerations. The report does however provide a rich and powerful example of the value of creating a common vision between policy makers, public and professionals. Changing Childbirth resonated deeply because it captured and expressed an impetus in the maternity services about the importance of humanised and responsive care. In this commentary we will draw on evidence from the meeting to reflect on how and why the report developed when it did, and the extent to which it was able to fulfil its stated aims. We conclude by considering the lessons still to be learned from the development and impact of Changing Childbirth and the ways in which these might be used to inform the future of maternity care.
‘Riding the wave’: why did Changing Childbirth happen? Changing Childbirth was the product of a set of particular circumstances and conditions. Reflecting on these Baroness Cumberlege suggested that ‘…if you ride the wave, you are going to be much more successful, and where you get passion and power colliding, then I think you get results.’ Contributors to the seminar highlighted these intersections, which linked both personal and institutional factors. Personalities mattered in instigating and developing the reports. Particular tribute was paid at the meeting to the role of Audrey Wise, a Labour Member of Parliament who was instrumental in the genesis of the Select Committee enquiry, partly because of her disgust at the Short Report of 1980 (Department of Health) which had focused entirely on the fetal risks of maternity at the expense of women0 s health and well-being. Individuals had an enabling role which tapped into a broader level of support, both political and professional. Kate Jackson, a midwife member of the Expert Maternity Group and leader of the Changing Childbirth implementation team, argued that ‘it was the right time, and to get the initiative coming from the Government,
280
T. McIntosh, B. Hunter / Midwifery 30 (2014) 279–281
which was really unusual, all-party support, not just the Government but all-party support.’ This sense of proactive communication and collaboration, if not necessarily always agreement, was seen also among professionals: I think one of the really impressive things has been the way the Royal Colleges of Obstetricians & Gynaecologists, the midwives, and the NCT have worked together. And for me as a Minister that was so important, because I could go to the Ministerial Team much later on and say, this is the three of them working together and this is what they0 re producing. And I didn0 t see that in any other part of the health service. (Julia Cumberlege) On a philosophical level, the momentum for change came very much from women as consumers but also as articulate and determined professionals. The sense that women0 s voices were heard was powerful and resonated through the meeting. The feminist concept of the personal being political was clearly true and influential in this context: Julia has talked today about her experience of having babies, and what I’ve noticed around the world when there are women politicians at a high level, they’ve actually been able to change things, and often their inspiration has been their own experience. So in Canada, New Zealand, here I’ve heard a number of very influential, very effective politicians, like Julia, tell the same story. (Lesley Page) In order to tell that story and create Changing Childbirth, the Expert Group drew on the developing body of maternity care evidence. The Short Report (Department of Health, 1980) seemed in retrospect to have represented the low-water mark of making policy based less on evidence and more on the beliefs of a particular professional group. In the succeeding 10 years evidence and research were increasingly being developed and seen, not just as ways of improving discrete elements of practice, but as tools for changing policy. The works of Campbell and Macfarlane (1987), the National Perinatal Epidemiology Unit, and Effective Care in Pregnancy & Childbirth (Chalmers et al., 1990) were particularly influential in supporting arguments about place of birth or philosophies of care. Consumer groups were quick to see the power of using evidence to drive debate and change, and groups such as NCT and AIMs both used and commissioned research. The existence of this research meant that Changing Childbirth was at heart not a ground-breaking document, but more of a road map representing good practice. As Jackson commented: I used to say, proudly, there is not an original idea in this report. That was true. It was all based on examples of good practice that were already happening but not everywhere. So the seeds were there, it wasn’t as if these reports were falling on bare earth. There were loads of people who wanted to bring about change. (Kate Jackson) It was helped by the power, and deceptive simplicity, of its message: I do remember having to go before television cameras thinking this is really a very comprehensive report, how am I going to put over in three minutes the essence of this report, and that is where the three Cs arose, because I had to boil it down in my head, and so it was about choice, continuity and control. (Julia Cumberlege)
The legacy of Changing Childbirth The primary success of Changing Childbirth appears to have been as a call to action that re-cast the terms of the debate: So we were determined it wasn0 t just going to be a philosophical document, it was actually going to have action plans, targets and we wanted a grip to try and get things to happen… (Julia Cumberlege) The power of the ‘three Cs’ struck a chord with professionals, consumers and policy makers, leading to a sense that the service could be humanised. In turn this approach came to inform other health service initiatives and reports. Gavin Young, a general practitioner (GP) and Expert Group member, suggested that: However limited the impact was, there was a huge change, and Julia [Cumberlege] hasn’t used it today but she kept using the word ‘kindness’ in the meeting and saying, actually what women want is kindness, and you don’t see that in many medical documents, it doesn’t figure very highly. That really was a huge change to actually start asking women what they wanted, and then try to give them it and humanise it and, as you say, I think it has had an impact on other parts of the Health Service that now attempt to listen to what patients say and humanise that service. (Gavin Young) So it seems that Changing Childbirth provoked a sea change in the way that professionals approached maternity care, and it is for this that it is remembered rather than for producing lasting measurable policy change. In subsequent commentaries Changing Childbirth has sometimes been cast as a middle-class document, reflecting the wishes and expectations of a small group of educated and articulate women, and so their needs became the template for the entire maternity service (for example: Porter 2004:190). The Expert Maternity Group, following the lead of the Winterton Report, saw their role as far more inclusive than this, encompassing women with complex obstetric and social needs, although as Kate Jackson noted this went far beyond the report’s original remit. Changing Childbirth drew attention to ‘…the homeless, HIV and AIDS, drug addicts, refugees and also a lot about women with disabilities; we took a lot of evidence on that…’ (Julia Cumberlege). However the Report was perhaps the victim of its over clear message around the three Cs. It seemed to be all about home birth and continuity of carer, both areas where it did not succeed in making a lasting impact, but both issues which overshadowed the power of its other messages. Although Changing Childbirth was greeted with hope and excitement in many quarters, there was also an element of fear which impacted on its implementation. Lesley Page described the Report as embodying common sense but that common sense could be radical. It could also be terrifying; ‘the feeling that I got from a lot of midwives was, this is an opportunity but my god it’s frightening, and how are we actually going to do all this’ (Julia Cumberlege). It required new ways of thinking and working by professionals and policy makers, together with strong and responsive leadership in order to drive and embed change. An implementation group was developed by the Expert Maternity Group in order to support change, but even this floundered in the face of psychological barriers including fear, and institutional ones such as lack of funding. As Kate Jackson commented ‘that’s what’s really hard about maternity in particular, you can’t stop the service while you bring about change.’ Some of the brakes on the impact of Changing Childbirth came from external pressures, and from unanticipated issues. These included a rising birth rate, rising maternal age, and the growing
T. McIntosh, B. Hunter / Midwifery 30 (2014) 279–281
obstetric and medical complexity of pregnancy. Changing Childbirth struggled to make an impact on the medicalisation of the service: Changing Childbirth talked primarily about the choice, control and continuity of carer, and that was a very big agenda. Despite what people think, it didn’t particularly address the rising medicalization of care. That is really important, as what we’ve been up against over the last 20 years is a rising tide of medicalization. Despite some moves towards women having more choice, more control and very occasionally a little bit of continuity (and it is very occasional and on the margins), it’s been against this rising tide of medicalization. So, yes, women have more choice but within an increasingly medicalised model, so it’s really lip service to choice. I think that’s a very important thing for us to realise. (Mary Newburn) There were also other ideological and practical pressures in the health service including the development of an internal market in the NHS, which changed how local services were commissioned and financed, and a drive to centralise and standardise care (National Health Service and Community Care Act, 1990). Perhaps most importantly the five year target which the Changing Childbirth Report set to achieve radical practical and philosophical changes in the maternity services was certainly a positive call to action, but also a millstone because it was a very short term challenging target, and any failure would be, and was, clear and observable. ‘Unfinished business’? As well as considering the development and impact of Changing Childbirth, the Witness Seminar panel and audience discussed the present and future direction of the maternity services through the lens of the sense of hope and change engendered by the report. Two of the positive drivers for continued change sprang from ideas embodied by Changing Childbirth, that of the centrality of multiprofessional working and the use of research evidence to drive and support debate. Discussion of guidelines such as those developed by NICE centred around their potential for supporting good evidence based care, and the tightrope to be walked between that and, as Mavis Kirkham described it, the ‘fossilis[ation]’ of guidelines into ‘rules and laws’. Riding a future wave of change also depends on the education and professional confidence and competence of midwives, obstetricians and general practitioners. The move of midwifery education into universities has been a vital one, allowing midwives to engage in research and debate on the same terms as doctors and policy makers. It was suggested that this should be balanced, however, with a greater focus on normality in obstetric training and education which would give doctors a broader sense of maternity care. It was also suggested that new organisational and managerial structures in the NHS in England, such as Clinical Care Commissioning Groups (CCGs), could be utilised to support a woman-centred midwifery agenda. Speakers agreed that the way forward might be to use these new structures at both local and national level to develop midwifery units, and continuity of care schemes. One of the issues lost in Changing Childbirth, and in subsequent reports and debates, was the potential value and power of locally based primary care. Although change after Changing Childbirth was implemented on a local, piecemeal level, it nevertheless followed a policy-driven top-down change agenda. One of the reasons that the ideas of Changing Childbirth struggled to remain embedded once the waves of initial funding ceased, was that change was only skin-deep and not responding to local needs and expectations. One of the hidden stories of the maternity services in the last 20 years has been the extent to which GPs have been marginalised in
281
service provision, which has been driven by the demands and beliefs of the acute sector. It may be that engagement with new management structures at a local level will allow services to be developed which are driven by and responsive to the needs and expectations of particular communities. Changing Childbirth was intended to be a short sharp report with immediate demonstrable indicators of success. By this measure it largely failed. However, its enduring visibility suggests that it had more subtle, sustainable successes: finding a new vocabulary for maternity care which gave women, midwives and doctors new ways of discussing and developing care. The rhetoric of the Report and the concepts which it enshrined have echoed through subsequent national policy documents including Maternity Matters (Department of Health, 2007), Midwifery 2020 (Department of Health, 2010), and the development of structures such as National Service Framework designed very much to put the patient as consumer at the heart of care-planning and decisionmaking across a spectrum of conditions. The difficulty of translating rhetoric into action as experienced by Changing Childbirth has, however, continued to be a feature of maternity care. The National Audit Office Report Maternity Services in England (2013) highlighted the continued gap between ideals and reality in service provision, suggesting that like Changing Childbirth before it, Maternity Matters failed to realise its potential for change due a failure to consider both financial and practical implications of its ambitions. The challenge for policy makers and practitioners alike remains to make this leap. The ideas that the Winterton Report and Changing Childbirth developed around collegiate working and the use of evidence continue to resonate and remain relevant. With the NHS in a state of flux and a sense that everything is up for grabs, a new generation of practitioners, policy makers and service users could draw on the example of the success and failures of Changing Childbirth to inform new developments in the maternity services. The Witness Seminar provided a valuable opportunity to explore the genesis and development of a significant English maternity policy and illuminate its legacy. Note: The opinions expressed are those of the authors.
Acknowledgements The authors would like sincerely to thank the Wellcome Trust for a Small Grants Award to fund the Seminar, and to Professor Mavis Kirkham, the panel members and audience for their involvement. They would also like to thank the University of Nottingham, Cardiff University and the University of the West of Scotland for supporting the event. References Chalmers, I., Enkin, M.W., Keirse, MJNC (Eds.), 1990. Effective Care in Pregnancy and Childbirth, 1 and 2. Oxford University Press, Oxford. Campbell, R., Macfarlane, A., 1987. Where to be Born? The Debate and the Evidence. National Perinatal Epidemiology Unit, Oxford. Department of Health, 1980. Perinatal and Neonatal Mortality. Second Report from the Social Services Committee 1979–80 (Short Report). HMSO, London. Department of Health, 1992. Health Committee Second Report: Maternity Services (Winterton Report). HMSO, London. Department of Health, 1993. Report of the Expert Maternity Group: Changing Childbirth (Cumberlege Report). HMSO, London. Department of Health, 2007. Maternity Matters. HMSO, London. Department of Health, 2010. Midwifery. HMSO, London p. 2020. National Audit Office, 2013. Maternity Services in England, 〈https://www.nao.org. uk/report/maternity-services-england/〉 (accessed 11 December 2013). Porter, M., 2004. Changing Childbirth? The British midwife0 s role in research and innovation’. In: Van Teijlingen, E.R., Lowis, G.W., McCaffery, P., Porter, M. (Eds.), Midwifery and the Medicalization of Childbirth: Comparative Perspectives. Nova, New York, pp. 183–190.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
‘Unfinished business’? Reflections on Changing Childbirth 20 years on Tania McIntosh, MA, PhD, RM, PGCHE (Lecturer in Midwifery)a,n, Billie Hunter, PhD, PG Diploma in Midwifery, BNurs, RM, RN, HV, PGCE (RCM Professor of Midwifery)b a b
University of Nottingham, Academic Division of Midwifery, B Floor, East Block, Queens Medical Centre, Nottingham NG7 2UH, UK Cardiff University, UK
Introduction On 17 October 2013 a ‘witness’ seminar was held in London, UK, to celebrate the 20th anniversary of the publication of the English report Changing Childbirth Department of Health (1993).1 Most official reports have their day in the sun and then sink, superseded by the next initiative. Changing Childbirth was always a report with a difference however. Midwives who were in practice when it was originally produced still remember it; student midwives still debate its meaning and impact. Twenty years on the language developed by the authors of the report, which talked about choice, control and continuity of care for women, still resonates powerfully within the United Kingdom (UK) maternity services. The Changing Childbirth report was produced in 1993 by the Expert Maternity Group, convened by the Conservative Government and chaired by Baroness Cumberlege. It followed the publication in 1992 of the Winterton Report (DOH, 1992) and built on its recommendations. Changing Childbirth and the Winterton Report were widely heralded for enshrining the concept of woman-centred care and they led to the creation of many practice initiatives designed to support their core recommendations. They reversed official policy that hospital was always the safest place for birth, and highlighted the psychological as well as the physical impact of childbearing on women. The continued power of the report was demonstrated by the willingness of key players to attend the seminar and to discuss its development and legacy. The panel of discussants included Sir Nicholas Winterton who had chaired the Health Select Committee which examined the state of the maternity services in England in 1991, Baroness Julia Cumberlege who chaired the Expert Maternity Group, and diverse stakeholders including obstetricians, midwives, the National Childbirth Trust [NCT] and the Association for Improvements in Maternity Services [AIMs]. Professor Lesley Page, a panel
n
Corresponding author. E-mail address: [email protected] (T. McIntosh). 1 Witness seminars use an expert panel to discuss the chosen topic under a knowledgeable Chair with an invited audience also able to participate. The discussion is audio recorded and transcribed. The resulting document is then made available as archive data relating to the topic in question. The transcript from the Changing Childbirth seminar should be available in Spring 2014. All direct quotes in this commentary taken from the Changing Childbirth seminar transcript. 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.12.006
discussant who sat on the Expert Maternity Group, commented that involvement in Changing Childbirth was the proudest moment of her career. Sir Nicholas Winterton argued however that, ground-breaking though the Report was, it was ultimately ‘unfinished business’. This was partly because as with all other initiatives, Changing Childbirth did not exist in a vacuum and implementation was affected by economic and service pressures as much as by philosophical considerations. The report does however provide a rich and powerful example of the value of creating a common vision between policy makers, public and professionals. Changing Childbirth resonated deeply because it captured and expressed an impetus in the maternity services about the importance of humanised and responsive care. In this commentary we will draw on evidence from the meeting to reflect on how and why the report developed when it did, and the extent to which it was able to fulfil its stated aims. We conclude by considering the lessons still to be learned from the development and impact of Changing Childbirth and the ways in which these might be used to inform the future of maternity care.
‘Riding the wave’: why did Changing Childbirth happen? Changing Childbirth was the product of a set of particular circumstances and conditions. Reflecting on these Baroness Cumberlege suggested that ‘…if you ride the wave, you are going to be much more successful, and where you get passion and power colliding, then I think you get results.’ Contributors to the seminar highlighted these intersections, which linked both personal and institutional factors. Personalities mattered in instigating and developing the reports. Particular tribute was paid at the meeting to the role of Audrey Wise, a Labour Member of Parliament who was instrumental in the genesis of the Select Committee enquiry, partly because of her disgust at the Short Report of 1980 (Department of Health) which had focused entirely on the fetal risks of maternity at the expense of women0 s health and well-being. Individuals had an enabling role which tapped into a broader level of support, both political and professional. Kate Jackson, a midwife member of the Expert Maternity Group and leader of the Changing Childbirth implementation team, argued that ‘it was the right time, and to get the initiative coming from the Government,
280
T. McIntosh, B. Hunter / Midwifery 30 (2014) 279–281
which was really unusual, all-party support, not just the Government but all-party support.’ This sense of proactive communication and collaboration, if not necessarily always agreement, was seen also among professionals: I think one of the really impressive things has been the way the Royal Colleges of Obstetricians & Gynaecologists, the midwives, and the NCT have worked together. And for me as a Minister that was so important, because I could go to the Ministerial Team much later on and say, this is the three of them working together and this is what they0 re producing. And I didn0 t see that in any other part of the health service. (Julia Cumberlege) On a philosophical level, the momentum for change came very much from women as consumers but also as articulate and determined professionals. The sense that women0 s voices were heard was powerful and resonated through the meeting. The feminist concept of the personal being political was clearly true and influential in this context: Julia has talked today about her experience of having babies, and what I’ve noticed around the world when there are women politicians at a high level, they’ve actually been able to change things, and often their inspiration has been their own experience. So in Canada, New Zealand, here I’ve heard a number of very influential, very effective politicians, like Julia, tell the same story. (Lesley Page) In order to tell that story and create Changing Childbirth, the Expert Group drew on the developing body of maternity care evidence. The Short Report (Department of Health, 1980) seemed in retrospect to have represented the low-water mark of making policy based less on evidence and more on the beliefs of a particular professional group. In the succeeding 10 years evidence and research were increasingly being developed and seen, not just as ways of improving discrete elements of practice, but as tools for changing policy. The works of Campbell and Macfarlane (1987), the National Perinatal Epidemiology Unit, and Effective Care in Pregnancy & Childbirth (Chalmers et al., 1990) were particularly influential in supporting arguments about place of birth or philosophies of care. Consumer groups were quick to see the power of using evidence to drive debate and change, and groups such as NCT and AIMs both used and commissioned research. The existence of this research meant that Changing Childbirth was at heart not a ground-breaking document, but more of a road map representing good practice. As Jackson commented: I used to say, proudly, there is not an original idea in this report. That was true. It was all based on examples of good practice that were already happening but not everywhere. So the seeds were there, it wasn’t as if these reports were falling on bare earth. There were loads of people who wanted to bring about change. (Kate Jackson) It was helped by the power, and deceptive simplicity, of its message: I do remember having to go before television cameras thinking this is really a very comprehensive report, how am I going to put over in three minutes the essence of this report, and that is where the three Cs arose, because I had to boil it down in my head, and so it was about choice, continuity and control. (Julia Cumberlege)
The legacy of Changing Childbirth The primary success of Changing Childbirth appears to have been as a call to action that re-cast the terms of the debate: So we were determined it wasn0 t just going to be a philosophical document, it was actually going to have action plans, targets and we wanted a grip to try and get things to happen… (Julia Cumberlege) The power of the ‘three Cs’ struck a chord with professionals, consumers and policy makers, leading to a sense that the service could be humanised. In turn this approach came to inform other health service initiatives and reports. Gavin Young, a general practitioner (GP) and Expert Group member, suggested that: However limited the impact was, there was a huge change, and Julia [Cumberlege] hasn’t used it today but she kept using the word ‘kindness’ in the meeting and saying, actually what women want is kindness, and you don’t see that in many medical documents, it doesn’t figure very highly. That really was a huge change to actually start asking women what they wanted, and then try to give them it and humanise it and, as you say, I think it has had an impact on other parts of the Health Service that now attempt to listen to what patients say and humanise that service. (Gavin Young) So it seems that Changing Childbirth provoked a sea change in the way that professionals approached maternity care, and it is for this that it is remembered rather than for producing lasting measurable policy change. In subsequent commentaries Changing Childbirth has sometimes been cast as a middle-class document, reflecting the wishes and expectations of a small group of educated and articulate women, and so their needs became the template for the entire maternity service (for example: Porter 2004:190). The Expert Maternity Group, following the lead of the Winterton Report, saw their role as far more inclusive than this, encompassing women with complex obstetric and social needs, although as Kate Jackson noted this went far beyond the report’s original remit. Changing Childbirth drew attention to ‘…the homeless, HIV and AIDS, drug addicts, refugees and also a lot about women with disabilities; we took a lot of evidence on that…’ (Julia Cumberlege). However the Report was perhaps the victim of its over clear message around the three Cs. It seemed to be all about home birth and continuity of carer, both areas where it did not succeed in making a lasting impact, but both issues which overshadowed the power of its other messages. Although Changing Childbirth was greeted with hope and excitement in many quarters, there was also an element of fear which impacted on its implementation. Lesley Page described the Report as embodying common sense but that common sense could be radical. It could also be terrifying; ‘the feeling that I got from a lot of midwives was, this is an opportunity but my god it’s frightening, and how are we actually going to do all this’ (Julia Cumberlege). It required new ways of thinking and working by professionals and policy makers, together with strong and responsive leadership in order to drive and embed change. An implementation group was developed by the Expert Maternity Group in order to support change, but even this floundered in the face of psychological barriers including fear, and institutional ones such as lack of funding. As Kate Jackson commented ‘that’s what’s really hard about maternity in particular, you can’t stop the service while you bring about change.’ Some of the brakes on the impact of Changing Childbirth came from external pressures, and from unanticipated issues. These included a rising birth rate, rising maternal age, and the growing
T. McIntosh, B. Hunter / Midwifery 30 (2014) 279–281
obstetric and medical complexity of pregnancy. Changing Childbirth struggled to make an impact on the medicalisation of the service: Changing Childbirth talked primarily about the choice, control and continuity of carer, and that was a very big agenda. Despite what people think, it didn’t particularly address the rising medicalization of care. That is really important, as what we’ve been up against over the last 20 years is a rising tide of medicalization. Despite some moves towards women having more choice, more control and very occasionally a little bit of continuity (and it is very occasional and on the margins), it’s been against this rising tide of medicalization. So, yes, women have more choice but within an increasingly medicalised model, so it’s really lip service to choice. I think that’s a very important thing for us to realise. (Mary Newburn) There were also other ideological and practical pressures in the health service including the development of an internal market in the NHS, which changed how local services were commissioned and financed, and a drive to centralise and standardise care (National Health Service and Community Care Act, 1990). Perhaps most importantly the five year target which the Changing Childbirth Report set to achieve radical practical and philosophical changes in the maternity services was certainly a positive call to action, but also a millstone because it was a very short term challenging target, and any failure would be, and was, clear and observable. ‘Unfinished business’? As well as considering the development and impact of Changing Childbirth, the Witness Seminar panel and audience discussed the present and future direction of the maternity services through the lens of the sense of hope and change engendered by the report. Two of the positive drivers for continued change sprang from ideas embodied by Changing Childbirth, that of the centrality of multiprofessional working and the use of research evidence to drive and support debate. Discussion of guidelines such as those developed by NICE centred around their potential for supporting good evidence based care, and the tightrope to be walked between that and, as Mavis Kirkham described it, the ‘fossilis[ation]’ of guidelines into ‘rules and laws’. Riding a future wave of change also depends on the education and professional confidence and competence of midwives, obstetricians and general practitioners. The move of midwifery education into universities has been a vital one, allowing midwives to engage in research and debate on the same terms as doctors and policy makers. It was suggested that this should be balanced, however, with a greater focus on normality in obstetric training and education which would give doctors a broader sense of maternity care. It was also suggested that new organisational and managerial structures in the NHS in England, such as Clinical Care Commissioning Groups (CCGs), could be utilised to support a woman-centred midwifery agenda. Speakers agreed that the way forward might be to use these new structures at both local and national level to develop midwifery units, and continuity of care schemes. One of the issues lost in Changing Childbirth, and in subsequent reports and debates, was the potential value and power of locally based primary care. Although change after Changing Childbirth was implemented on a local, piecemeal level, it nevertheless followed a policy-driven top-down change agenda. One of the reasons that the ideas of Changing Childbirth struggled to remain embedded once the waves of initial funding ceased, was that change was only skin-deep and not responding to local needs and expectations. One of the hidden stories of the maternity services in the last 20 years has been the extent to which GPs have been marginalised in
281
service provision, which has been driven by the demands and beliefs of the acute sector. It may be that engagement with new management structures at a local level will allow services to be developed which are driven by and responsive to the needs and expectations of particular communities. Changing Childbirth was intended to be a short sharp report with immediate demonstrable indicators of success. By this measure it largely failed. However, its enduring visibility suggests that it had more subtle, sustainable successes: finding a new vocabulary for maternity care which gave women, midwives and doctors new ways of discussing and developing care. The rhetoric of the Report and the concepts which it enshrined have echoed through subsequent national policy documents including Maternity Matters (Department of Health, 2007), Midwifery 2020 (Department of Health, 2010), and the development of structures such as National Service Framework designed very much to put the patient as consumer at the heart of care-planning and decisionmaking across a spectrum of conditions. The difficulty of translating rhetoric into action as experienced by Changing Childbirth has, however, continued to be a feature of maternity care. The National Audit Office Report Maternity Services in England (2013) highlighted the continued gap between ideals and reality in service provision, suggesting that like Changing Childbirth before it, Maternity Matters failed to realise its potential for change due a failure to consider both financial and practical implications of its ambitions. The challenge for policy makers and practitioners alike remains to make this leap. The ideas that the Winterton Report and Changing Childbirth developed around collegiate working and the use of evidence continue to resonate and remain relevant. With the NHS in a state of flux and a sense that everything is up for grabs, a new generation of practitioners, policy makers and service users could draw on the example of the success and failures of Changing Childbirth to inform new developments in the maternity services. The Witness Seminar provided a valuable opportunity to explore the genesis and development of a significant English maternity policy and illuminate its legacy. Note: The opinions expressed are those of the authors.
Acknowledgements The authors would like sincerely to thank the Wellcome Trust for a Small Grants Award to fund the Seminar, and to Professor Mavis Kirkham, the panel members and audience for their involvement. They would also like to thank the University of Nottingham, Cardiff University and the University of the West of Scotland for supporting the event. References Chalmers, I., Enkin, M.W., Keirse, MJNC (Eds.), 1990. Effective Care in Pregnancy and Childbirth, 1 and 2. Oxford University Press, Oxford. Campbell, R., Macfarlane, A., 1987. Where to be Born? The Debate and the Evidence. National Perinatal Epidemiology Unit, Oxford. Department of Health, 1980. Perinatal and Neonatal Mortality. Second Report from the Social Services Committee 1979–80 (Short Report). HMSO, London. Department of Health, 1992. Health Committee Second Report: Maternity Services (Winterton Report). HMSO, London. Department of Health, 1993. Report of the Expert Maternity Group: Changing Childbirth (Cumberlege Report). HMSO, London. Department of Health, 2007. Maternity Matters. HMSO, London. Department of Health, 2010. Midwifery. HMSO, London p. 2020. National Audit Office, 2013. Maternity Services in England, 〈https://www.nao.org. uk/report/maternity-services-england/〉 (accessed 11 December 2013). Porter, M., 2004. Changing Childbirth? The British midwife0 s role in research and innovation’. In: Van Teijlingen, E.R., Lowis, G.W., McCaffery, P., Porter, M. (Eds.), Midwifery and the Medicalization of Childbirth: Comparative Perspectives. Nova, New York, pp. 183–190.
