From MIDWIFERY MATTERS, Issue No.113 - Summer 2007
There seems to have been one report after another on the maternity services, and this one follows hard on the heels of Dr Shribman's Making it Better for Mother and Baby. It's hard not to feel cynical, as the reports jostle for space in the headlines and seem to move ever further from the realities experienced by mothers and midwives - are the Government really hoping to improve things or do they just hope that if they keep telling what wonderful things they're going to do, we won't actually notice how bad they really are?
In Maternity Matters, there's lots of positive-sounding stuff - choice for women on the place of birth, midwives as the portal of entry into the maternity services, integration of services into the community, expansion of choices in accessing antenatal and postnatal care and outreach programmes for vulnerable and excluded groups - but there seems to be very little that will ensure that it will become reality. The major difficulty with virtually every Government pronouncement on this topic since Changing Childbirth is that not enough concrete targets are set and there is no ring-fenced funding - in other words, there is no incentive for PCTs or acute Trusts to deliver what is set out and no money for them to do it with either. Seeing as we're currently regularly hearing of home birth services being suspended for lack of staff, post-natal care limited to two or at the most three visits, and student midwives qualifying from their courses and finding there are no jobs for them to go to, not to mention midwifery led units under threat of closure, it is hard to see how all of this can be implemented by 2009.
There are also several areas where the promises don't reach far enough - for instance, the document specifies continuity of care for the antenatal and post-natal periods, but refrains from any mention of continuity of intra-partum care, where research has shown that it is likely to make the most difference - it even singles out for particular praise the Southampton Sure Start maternity team, where one of the key factors is that they offer 'continuity of care throughout pregnancy, birth and afterwards for up to six weeks' , but doesn't appear to notice the contradiction.
There are also passages that appear to contradict Making it Better for Mother and Baby which called for a cut in the number of obstetric units, whereas Maternity Matters calls for ensuring that 'all women have access to their midwife in their local community and, should it be required, can have immediate transfer to a fully equipped local hospital with obstetricians, anaesthetists and other specialists..'
Other statements that don't quite add up include the hope that commissioners use 'tariffs (to) support the effective commissioning of high quality and innovative services', when major concerns have been expressed that Payment by Results is leading to perverse incentives to intervene more in the birth process. The other massive gap is in staffing levels - the document is calling for increases in home births and midwife led units, choices in location of antenatal and postnatal visits (presumably home visits, antenatal clinics and 'shop-front' midwifery centres), while at the same time acknowledging that the changing profile of women getting pregnant is leading to more women being classified as high risk, so there is still a need for fully staffed obstetric units.
Although there is a lovely table showing the number of midwifery training places, there is barely any mention of the huge deficit in midwife hours. Even if there are 900 more WTE equivalents than in 1997, the birth rate then was 609,000 and is projected to be 701,000 this year, so those 900 extra midwives are going to have to work their socks off even to keep up with present demand, never mind providing lots more choice.
Despite the statements in favour of home birth, it's not clear how much they really want the home birth rate to go up - for instance, under 'choice of place of birth', the document states that providers offering 'high quality services' can increase capacity so that they can offer services to women from outside their area. 'High quality services' are therefore being equated with hospital care - there's no suggestion that high quality home birth teams can offer home births to women in neighbouring areas - how about that for an idea, roving home birth teams?!
This may seem a minor point, but the internal pedant was both appalled and astounded to see an errant apostrophe on page 20 - 'It's focus is on providing antenatal.' - perhaps the Government's prioritisation of 'education, education, education' should start with its own civil servants! Mind you, I wasn't much impressed either with the thought of a glorified employment agency having won the Social Enterprise Unit pathfinder funding, rather than the IMA's NHS Community Midwifery Model, so mere grammar isn't the worst part about that paragraph!
I would really like to be able to welcome this document and the statements it contains. However, the lack of specific targets and the absence of funding unfortunately means that this document will remain a 'soft' selection of aspirations that will probably remain as little implemented as Changing Childbirth. If one compares what it advocates and what one daily hears of happening in today's NHS, one has to wonder sadly what planet policy makers are living on.
Sarah Montagu
Maternity matters: choice, access and continuity of care in a safe service
Department of Health,
3 April 2007
You can download the Maternity Matters report from the DoH website.
This article was originally published in Midwifery Matters ISSUE 113, Summer 2007
AH updated 16 October 2008