Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by The Royal College of Midwives (PH 30)


  The Royal College of Midwives is the professional organisation and trade union representing 95 per cent of practising midwives in the UK. Midwives play a key role in public health, as the lead carer for women during pregnancy, childbirth and the postnatal period. As part of this role, they:

    —  work to a holistic philosophy of care which emphasises the interdependence of women's physical, psychological and social well-being, and which locates maternal health within its family and social context;

    —  provide integrated care across hospital and community settings, and in women's own homes;

    —  provide advice and information on nutrition, exercise, smoking, alcohol, home safety and general health;

    —  offer a range of antenatal screening and testing services;

    —  support women in initiating and sustaining breastfeeding, with its significant health benefits for both mother and child;

    —  provide information and appropriate referral for medical, social, financial and relationship difficulties;

    —  monitor psychological well-being and detect postnatal depression;

    —  support women and their families through the transition to successful and confident parenthood; and

    —  provide advice and support in the postnatal period; reducing long-term morbidities and enhancing infant well-being.

  Midwives are key public health practitioners. Their contribution to public health is currently under-utilised, however. This paper:

    —  argues that maternal and infant health should be given higher priority in national and local policies and practice;

    —  identifies key obstacles to improving the public health of mothers and babies; and

    —  provides recommendations on how the maternity services could fulfil their potential contribution to the nation's health.

Why prioritise maternal and infant health?

  Recent analyses of determinants of population health, and of inequalities in health, show the likely importance of early life influences on health and the lifetime cumulative effect of experiences and exposures. Focusing on families with children will not only help with immediate problems of maternal and child health but may help reduce the longer-term risks of adult chronic illnesses such as bronchitis and coronary heart disease[5].

  In 1998 the Independent Inquiry into Inequalities in Health recommended that, "a high priority is given to policies aimed at improving health and reducing inequalities in women of childbearing age, expectant mothers and young children"[6].

  It noted that the babies of women in disadvantaged groups are more likely to have reduced growth rates in utero, and that this is associated with coronary heart disease, diabetes and hypertension in later life. In addition, babies born to disadvantaged mothers are less likely to be breastfed, which decreases the incidence and severity of many infections of infancy and later health problems, and which may also protect maternal health. Smoking in pregnancy is markedly higher among women from poorer social groups, and this increases the risk of low birth weight and sudden infant death syndrome.

  Women who are socially excluded—perhaps as refugees, or homeless, or drug using, or because do not speak English—may have particular problems accessing the advice and support they need during pregnancy and after birth, and this will have a damaging impact on their ability to care for themselves and their child during the first weeks and months of life. Poor care during this time does not just undermine health gain; it also contributes to social problems such as poor parenting, marital tension and family breakdown.

  While the RCM has welcomed Government initiatives to address maternal and infant health, such as SureStart and the national childcare strategy, it does not believe that the recommendation of the Acheson Report has been met in a coherent or co-ordinated way. If we are to make a real impact on public health, we must start at the start of life; and in order to do that we need a national strategy for maternal and infant health.

What are the obstacles?

  Maternity services have been largely neglected in recent public health policy and initiatives. This is partly due to lack of understanding of the role of the midwife, who is often seen as someone who delivers babies in hospital settings. While intrapartum care is a core component of midwifery practice, it takes up a relatively small amount of the midwife's time. Most midwifery work is antenatal or postnatal care, and much of that takes place in community settings or in women's own homes. Nevertheless, because midwives are usually (though not always) employed by and managed from acute sector settings, and because the acute sector is not at the forefront of public health activity, midwives are often excluded from the development of health improvement programmes, or SureStart initiatives, or other developments with a public health focus.

  The fact that midwives provide an integrated service across the acute and primary sectors should not disqualify them from participation in the public health agenda; indeed, such integration should be seen as a model for other areas of healthcare. The sectoral gap between the primary and the acute sectors is one of the key obstacles to developing a public health-focused NHS.

  Integration is also needed across the health and social care sectors. The major drivers of health and health inequalities lie outside the health service: poverty, poor housing, social exclusion, air pollution, inadequate transport facilities, crime and the fear of crime are not within the NHS remit, although their effects eventually become NHS responsibilities.

  This is clear within maternity care. Pregnancy and childbirth are not merely physical episodes, but life experiences of enormous social and psychological importance. While midwives have worked hard to integrate a social care perspective in maternity services, this is often hard to justify within a system which prioritises short-term medical outcomes. For example, providing social and emotional support during pregnancy is clearly linked to shorter labours, less analgesia and operative delivery, improved APGAR scores at birth, and higher breastfeeding rates[7]. Yet efforts to increase support for women in pregnancy—for example through the development of caseload midwifery schemes—have been undermined by staffing or funding shortages[8].

  To give another example, postnatal support has been shown to sustain breastfeeding, improve the detection and management of postnatal depression, reduce long-term maternal morbidities, reduce mother-child relationship problems and child behaviour problems, and reduce rates of childhood injury[9]. Yet postnatal care continues to suffer from poor resourcing and is the most criticised aspect of maternity care[10].


  1.  If the public health agenda is to achieve its aims, it must be given due priority as a core orientation, rather than a bolt-on extra. This priority must be clearly defined, responsibilities must be allocated, and resources must be provided.

  2.  Serious and radical efforts are needed to co-ordinate and synergise the activities of the health, social care and voluntary sectors.

  3.  Equally, it is vital to prioritise public health with the acute sector, and to further integrate cross-sectoral working within the NHS.

  4.  Income inequality is a key issue in maternal and infant well-being; urgent action is needed to improve maternity leave, maternity pay, flexibility in return to work, and childcare support.

  5.  The Government should respond to the Acheson report's recommendation that high priority is given to women of childbearing age and expectant mothers, by developing a coherent co-ordinated strategy for maternal and infant health.

  6.  The Government should recommend to the National Institute of Clinical Excellence that a national service framework on maternity care should be given high priority.

  7.  The Government should review maternity services spending, to ensure that resources are targeted to where they will have most impact on health outcomes, and to guide the apportioning of resources between medical, psychological and social care.

  8.  The NHS should invest in training and continuing professional development opportunities to enable all midwives to develop their public health role.

  9.  The Government should invest in midwifery remuneration and career development, in order to address the current crisis in midwifery staffing.

  10.  Locally and nationally, health policy and strategies should be evidence-based and should be monitored to assess their impact on public health and health inequalities.

July 2000

5   Macintyre S (2000) Prevention and the reduction of health inequalities. BMJ 2000; 320: 1399-1400. Back

6   Acheson D (chair) (1998) Independent Inquiry into inequalities in health. London: TSO. Back

7   Elbourne D, Oakley A, Chalmers I (1989). Social and psychological support during pregnancy. In: Chalmers I, Enkin M, Keirse M (eds) Effective Care in Pregnancy and Childbirth, vol 1. Oxford: Oxford University Press. Back

8   Royal College of Midwives (2000) Vision 2000. London: RCM. Back

9   Hodnett E, Roberts I (1998) Home-based social support for socially disadvantaged mothers. In: The Cochrane Database of Systematic Reviews (ed) The Cochrane Library, Issue 2. Oxford: Update Software. Back

10   Audit Commission (1997) First Class Delivery: improving maternity services in England and Wales. Abingdon: Audit Commission Publication. Back

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