This report reviews the key trends in midwifery and obstetric staffing over the last 30 years and examines how these and national policies have affected the ability of NHS maternity services to respond to choice while at the same time providing a low risk and pleasant environment for mothers, fathers and their babies.
In 1993 the Changing Childbirth report by the House of Commons expert maternity panel recommended more involvement of midwives, development of their roles, and greater patient choice over place of delivery and the professional providing care. Twelve years on, and despite a considerable expansion of obstetrician (but not midwife) numbers, progress has been at best modest.
What was rightly envisaged was a plurality of provision of midwifery and obstetric antenatal and delivery services, from low risk midwifery-led birthing units to high risk obstetrician-run maternity units. Instead there has been considerable centralisation of services. In England, the number of practising units has fallen from 527 in 1973 to 341 units in 1996 and 282 in 2004.
The fall has occurred predominantly among units conducting less than 2,000 deliveries annually. As a result a much greater proportion of births take place in larger units. The largest English unit is Liverpool Maternity with 8,084 deliveries in 2003. In contrast, the largest maternity unit in France has 4,000 births per year and the largest unit in Germany has 3,000.
Risk assessment at pregnancy booking is rudimentary. “Low risk” midwifery-led birthing units do exist, with high levels of patient satisfaction, but low risk women are seen too frequently in large, “high risk” units. High risk women find it difficult to get appointments for consultations and investigations as a result.
The justification for this centralisation has been to save money and improve patient safety but it is far from clear that this has been achieved:
- The Kennedy commission reviewed three hospitals in which concerns had been raised over a two year period (Northwick Park in London, New Cross in Wolverhampton, and Ashford St Peters in Chertsey). In all three, serious deficiencies were identified including poor reporting of adverse incidents. It is implausible that similar findings would not have been made in many other hospitals had they been subject to similar detailed review.
- Only 18 units achieved Level 2 of the clinical negligence scheme for trusts (CNST) in 2004.
- In 2003 the Euronatal Working Group found that the NHS appeared to have the highest rate of suboptimal care.
In terms of staffing, the service gives every appearance of being under strain:
- The current numbers of midwives are below recommended levels and insufficient to provide one to one care. Midwife numbers (expressed as whole time equivalents per delivery) have fallen slightly over the last 30 years in the NHS, despite a considerable expansion in the midwives’ role. Total midwife hours worked have fallen by 14 per cent between 1994 and 2004.
- In addition, departments now have to deal with audit, risk management, implementation of NICE guidelines and the plethora of directives that are now a feature of daily clinical life. Such work is important but it takes staff away from giving patient care and dealing with real obstetric emergencies.
- Although the number of obstetricians has risen by 50 per cent over the last thirty years, and rapidly in the last five years, even the larger maternity units do not enjoy 24 hour ‘on site’ consultant cover.
- Few maternity units are operating at below capacity, and in none is there an ability to respond to upturns in activity. Most units have midwifery staffing below the optimum levels and a significant number are under-staffed in relation to their funded establishment. It is the same with obstetricians and sonographers. A sudden increase in booking numbers of even 5 per cent to any unit is likely to place severe strain on both staffing, resources and space, with no mechanism for these units to respond to choice being exercised.
- Mothers are to some extent able to choose their birthing unit but the funding systems that underpin such choice have led to dangerous consequences. The better units have tended to find themselves overrun by demand and unable to cope. This can lead to a drop in the quality of services and in the worst cases lead to greatly increased clinical risk. The recent tragedies at Northwick Park can be partly explained by this.
- Even under the payment by results system there is a real risk that a unit that takes on an increase in demand will not see the extra money that their increased activity merits. Instead increased funds simply go to the Trust that the unit is part of rather than directly to the unit. This is an acute problem in a time when NHS funding is becoming distinctly more restricted.
Maternity services are likely to come under greater pressure in the future. Policy makers must be realistic about how lifestyle change with much older mothers and more early births are raising the amount and quality of care required; not only obstetric and midwifery, but also neonatal.
Reforms to patient choice and funding would enable the development of more midwifery led units and more home births with close links to centres which can offer emergency care and rapid transfer when difficulties do arise. The health reform principles apply just as much to maternity services as to elective services. A modern framework for maternity services should meet certain conditions:
- Choice from a variety of providers, whether NHS, charitable or private, for antenatal care and delivery. Historically the NHS in England has commissioned a very limited number of independent maternity providers. Independent provision can however emerge and play a very useful role. The lack of such provision and competition is undoubtedly part of the reason for poorer performing services.
- Funding that directly and transparently follows the mother to the maternity unit that carries out the delivery, associated medical treatments and ante-natal facilities. There must be a link between a unit’s activity and income.
- Integrated systems of care involving cooperation and networks between high and low risk providers. Competition should occur between integrated units or networks, offering all levels of care, rather than between high and low risk units.
- An end to the drive towards larger, more centralised delivery units across the UK. Although such mergers are currently often driven by the problems of staffing small neonatal intensive care units, other European countries use improved neonatal transport networks to achieve excellent outcomes without the need for an equivalent centralisation of maternity care.
- All maternity units must have the financial autonomy in order to be able to respond to increased demand, including the ability to hire new staff and purchase new facilities.
- Increased presence of senior doctors on labour wards. Competing maternity hospitals marketing themselves on the level of consultant availability in labour, and women voting with their feet, is a strong driver keeping senior doctors on labour wards in the rest of Europe. It will have a similar effect here.
- Expansion in both midwifery and obstetric training numbers combined with an increased focus on the quality of training. There is anecdotal evidence to suggest that some NHS strategic health authorities will, in the current harsh financial climate, actually make training cut-backs. This is unacceptable.
- Greater provision of scans, screening and tests by the independent sector. New networks can involve independent diagnostic providers, ameliorating the current very difficult issues surrounding the provision and access to screening.