Delivering better maternity care

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Despite countless inquiries, initiatives and ministerial pledges ... maternity care remains one of the NHS's problem areas ...

In recent weeks there have been two significant pieces of evidence published that will help shape practice affecting the UK's 800,000 births a year. The National Institute for Health and Clinical Excellence (NICE) produced new guidelines for the NHS in England and Wales on the circumstances in which mothers-to-be should be able to have a Caesarean-section delivery.

Meanwhile the landmark Birthplace study ... sought to clarify the relative risks of having a baby at home, in hospital or in a birth centre run by midwives; the study found all settings carried a low level of risk. Both documents aim to advise maternity teams on how to give mothers and their babies the best possible experience.

... It is no wonder maternity services are under pressure ... England has had a 22% increase in births over the past decade ...

But the maternity workforce is not just short of midwives, the roundtable heard. Of those 800,000 annual births, 94% of them take place in hospitals where doctors are present along with midwives; the others, at home (2%) and in birth centres (4%), have midwives solely in charge. But the Royal College of Obstetricians and Gynaecologists (RCOG) believes the 2,186 senior doctors working as consultants in that area of medicine is too few. It wants the NHS to boost numbers to 3,000-3,300.

Mothers-to-be would benefit because every hospital maternity unit would have a consultant on hand 24/7 and less experienced doctors would no longer be in charge overnight and at weekends ...

... "the current system of maternity care is unsustainable. You have to reconfigure". The participant meant that some maternity units should be closed – merged, in effect – so fewer, larger childbirth centres could offer mothers a better service, partly thanks to more specialist staff handling a greater number of deliveries concentrated in the same place.

It makes little sense for large urban areas to have separate maternity units just a few miles apart, a view confirmed for the speaker by seeing that sort of setup on a recent visit to Leeds and nearby towns.

Many health professionals support the concept of reorganisation. And the reconfiguration of neonatal care services in 2003, which led to fewer units dealing with sick babies but offering enhanced care, is a potential model to follow, another participant added. But there is a major obstacle to overcome first: ... To close your core maternity service is a death trap as an MP. So that will not happen," ...

... simply creating fewer, but larger, hospital units is not the answer and there needs to be more midwife-led birth centres, either standalone units or situated beside hospitals, in case a mother needs urgent medical attention ...

There was also a strong consensus that the huge proportion of births occurring in hospitals, 94%, is too high. While there was support for moving towards an equal split – 33% at home, 33% in birth centres and 33% in hospital – there was also a recognition that politics, entrenched attitudes and the tightest NHS budget in a generation means that will probably remain just an aspiration for the foreseeable future.

... In 2007, Maternity Matters promised women in England a choice of birth place, but the reality is that many still do not get that. One participant working on the NHS frontline said pressure on maternity services was so great in some places that midwives who usually help women to have home births are having to work, instead, on labour wards, thus depriving those seeking a home birth of that supposedly guaranteed right.

Similarly, surveys by the Healthcare Commission and its successor as the NHS regulator for England, the Care Quality Commission, have shown the promise to women of one-to-one care from a midwife during their labour is also not honoured for as many as a quarter of mothers-to-be, who are left alone and find it stressful ...

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