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Country Report – United Kingdom

In the last report that I did, in 2004, I said that maternity care in the UK was very confused. It still is. While we are making progress there are times when we wonder if it will take another 50 years to achieve the changes we want. Progress is slow, but there is progress.

Our Government has finally realised that community based midwifery care produces healthier and fitter mothers and babies with fewer interventions and fewer caesarean sections, and costs less. Unfortunately, it does not have the courage to insist that the local Trusts implement their proposals and it has provided no money to do so. So we have childbirth groups campaigning like mad and challenging as many local initiatives as possible because the local Trusts, while pretending to do what the consumers want, are busy closing down small midwifery units and centralising hospital care. We have had success in many areas, but the Trusts wait a couple of years and then try again, one midwife commented that she has fought over 30 campaigns to keep her local unit open and she is getting tired of doing so.

The Government's ambition for maternity is set out in the maternity standard of the National Service Framework (NSF) for Children, Young People and Maternity Services. The standard sets out their vision for maternity services for the next ten years. Their basic principle is this: they wish to ensure that women will have flexible and individualised services.

Under the maternity standard, NHS maternity care providers and PCTs are required to ensure that the range of ante-natal, birth and post-birth care services available locally constitutes real choice for women (including home births) and that local options for midwife-led care will include midwife-led units in the community or on a hospital site.

The NSF proposals are as follows:

  • Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies.
  • Woman-centred services are required to meet the needs of each mother and her baby, and ensure that parents are involved in the planning and evaluation of services. Women make informed choices and plan their care in partnership with professionals. They have easy access to information and support throughout their pregnancy and post-birth, including support for women suffering from domestic violence and the opportunity to disclose it.
  • Care pathways and managed care networks link maternity and neonatal services with a range of services and professionals to ensure all women and their babies have equal access to high quality care.
  • Improved pre-conception care includes local health promotion highlighting the importance of the health of women and their partners before conception. In pre-birth care, women are able to access a midwife as their first point of contact and all women are supported by a known midwife throughout their pregnancy. High quality ante-natal and newborn screening is offered to all women.
  • Health care professionals are competent in identifying and addressing mental health problems for women during or after pregnancy and local perinatal psychiatric services are available for women who need them.
  • Women are able to choose the most appropriate place to give birth from a range of local options including home birth and delivery in midwife-led units, with the facility for women delivering in the community to be transferred to hospital rapidly if complications arise. A consultant obstetrician is involved in any decision to offer a caesarean section which will also depend on there being evidence of clinical benefit to either mother or baby.
  • A professional skilled in neonatal resuscitation is present at every delivery, and newborn infants receive a physical examination soon after birth. Mothers receive post-birth care based on a structured assessment provided by a multidisciplinary team. This recommendation has resulted in more midwives taking resuscitation courses and paediatricians insisting that they have to be available at every birth – i.e. hospital deliveries.
  • Up-to-date information on breastfeeding and breastfeeding support for mothers is provided in line with the government's commitment to improving the health of the population. Not a lot of hospitals fulfill this requirement.

The Department of Health has required that the maternity standards should be achieved by 2009 so that all women will have choice over where and how they have their baby and what pain relief to use. The government wants every woman to be supported by the same midwife throughout her pregnancy but they have provided no money or facilities to increase the numbers of midwives. In 3 April 2007, the Department published Maternity Matters: Choice, access and continuity of care in a safe service which is the framework to support local implementation of the Government's maternity commitments. Accompanying Maternity Matters is a self assessment tool for commissioners in CD format to help the Trusts and their partners ensure local maternity services meet population requirements and address health inequalities.

In November 2004 the Confidential Enquiry into Maternal and Child Health published their report ‘Why mothers Die' 2000-2002. This report, for the first time, identified suicide as the leading cause of maternal death over the whole year following delivery. AIMS had lobbied for some years for the Confidential Enquiry to investigate maternal death instead of categorizing death by method and this is one of our successful initiatives, but we have more to do because the Enquiry only looked at deaths up to one year – we want them to look at deaths up to five years because so many women struggle on but eventually give in and they commit suicide.

All this change is taking place at a time of serious staff shortages, the fuss is, invariably, made about the problems that doctors have, but this pales into insignificance when one examines the serious shortage of midwives and a rising birth rate. The Trusts see midwifery as a soft option and invariably try and cut the services even further.

A survey of 58 Heads of Midwifery revealed that:

  • three quarters (76%) said they had seen an increase in the birth rate this year and
  • just over half (53%) said the births had become more complex;
  • eight out of ten (81%) said they did not have enough staff available and
  • fewer than one in five (18%) said their staffing levels were about right;
  • more than one in 10 (12%) reported a cut in the number of staff they had - by an average of 1.5%. The respondents also said fewer newly qualified midwives had been taken on this year.
  • a third of senior midwives said they had seen reductions in budgets, with the average level of cuts running at 2%.

Training budgets for ongoing professional development have also been cut.

On the positive side, more women are having home births and births in small midwifery units, but it is a constant battle to maintain and increase that trend.

Beverley A Lawrence Beech – 6th June 2007

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