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Lord Bach: My Lords, I can give the noble Lord that reassurance. So far as concerns research and development and industry, the Memorandum of Understanding that will be signed by the United States and by us will assist British industry. We believe that the American Administration already know what an important part British defence industry can play in relation to their own missile defence.

The Lord Bishop of Oxford: My Lords, I was deeply involved in the debates about nuclear deterrence in the 1980s. I was totally opposed to any concept of missile defence because it undermined a fundamentally stable system of mutual deterrence. I accept the Government's point, as stated, for example, in their public discussion paper, that we have now moved into a very different world where the possibility of nuclear weapons being used against us is thinkable. That is, indeed, a very worrying thought. Deterrence will not work against terrorist rogue states in the same way as it did previously. It is doubtful whether any use of nuclear weapons against them in an effort to deter could be morally justifiable.

Therefore, does the Minister agree that, because we have moved into a very different world where the use of nuclear weapons is once again thinkable, there needs to be a new imperative to move to a system of international order where states' legitimate security needs can be taken care of without resort to nuclear weapons? Whether it is a post-Saddam Hussein Iraq, a North Korea, an Iran or an Israel, to mention some states, there needs to be a new impetus. Of course, we have eaten the apple of nuclear knowledge and we cannot return to a pre-nuclear Eden. But we can move into a safer world than we have at present.

Lord Bach: My Lords, I am grateful for the question and comments from the right reverend Prelate. With regard to what he said about deterrence, we have moved into a new world. But there is no point in our arguing—we do not do so—that to enter into a missile defence theory is somehow to remove the need for deterrence as well. It is because mutually assured destruction and all that went with it does not apply to a number of states of concern that the Americans, the United Kingdom and other countries—those in NATO—must consider how best to react to the undoubted threats that such countries now represent for us.

Of course, we face those threats not simply by setting up a missile defence system but by employing all the other methods that are still important, such as non-proliferation, diplomacy and others that have been mentioned many times. It is interesting to note that at one stage when the missile defence debate was taking place, there were fears that Russia, for example, would respond extremely badly to this new state of affairs. In fact, the Moscow agreement between the United States and Russia to dispose of a large number of nuclear weapons is, in one sense, a consequence of the debate about missile defence.

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I agree with the right reverend Prelate when he says that there must be a new world order in terms of nuclear weapons. I mention, in passing, the new code of conduct, which the British Government played a significant part in putting forward.

Lord Hunt of Chesterton: My Lords, I ask the Minister to comment on the absence from the Statement and from the speeches of other noble Lords of any reference to the European role. We are moving into a world of European technology in terms of space, space detection and European-wide radar systems. How is it that this whole discussion is taking place entirely within a British-American context? Can that aspect be elaborated on?

Lord Bach: My Lords, for some time this argument was seen in terms largely concerning the United States, and it still is. When repeating the Statement made in another place I said that NATO considered the issue at Prague. It resolved to look into the whole question of missile defence to see whether it would be appropriate for Europe and for the NATO alliance. Our view, and I am sure that of the United States, is to take a NATO and allied view as regards missile defence. I believe that my noble friend is wrong to say that there is no European dimension to this issue.

As regards theatre missile defence, we have been working with our NATO allies to see how practical it is, what form it should take and whether we should be part of it. We are talking to our NATO allies about territorial missile defence. They have already expressed a view.

The Earl of Mar and Kellie: My Lords, very recently the Minister referred to discussions with the Russians. I ask about discussions with the Chinese. Until now they have been fairly reluctant, to put it mildly, about missile defence. What sort of response has the United Kingdom Government received from the Chinese?

Lord Bach: My Lords, the Chinese remain suspicious that United States missile defence plans are directed at negating their own nuclear deterrent. China began its strategic nuclear force modernisation programme a long time ago, in the mid-1980s, and long before the emergence of recent missile defence concepts. Therefore, it is hard to argue that it began its nuclear force modernisation programme because of the missile defence concept. Discussions have taken place. China knows that missile defence is not aimed at Russia or China but at those states of concern, as I have called them. The United States has made that clear to China on many occasions. The United States missile defence proposals are intended to deal with very limited threats, beginning with a handful of warheads in the hands of states of concern and the emergent missile capabilities. It is not intended to defend against responsible states with established strategic forces. China comes into that category, and what is more important, China knows it.

Lord Powell of Bayswater: My Lords, I join others in thanking the Minister for repeating the Statement,

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and I very much welcome the decision in principle to respond positively to the request from the United States. That must be the only proper response to such a request from a very close ally. I hope also that it will be a first step towards acquiring a missile defence capability for the United Kingdom or towards involving ourselves in an American system. In that context, can the Minister tell us what discussions are in train with the United States Government about the United Kingdom having such a capability, and what broad time scale he envisages in which decisions will be brought forward and discussed more widely?

Lord Bach: My Lords, I am grateful for the support which the noble Lord, Lord Powell of Bayswater, gives to the Government for the near-decision which we have announced today. The noble Lord has great experience in these fields. I am sure that, in turn, he will forgive me when I say that discussions with the United States are ongoing and have been for some time. On the question of the time-scale for any decision by the United Kingdom to seek missile defence for our own country, it is too early to say when such a decision would be made. As the noble Lord would expect, we are in close discussions with the United States about the issue, as we are with NATO.

Maternity Services

6 46 p.m.

Baroness Cumberlege rose to call attention to the quality of provision for maternity services in the United Kingdom; and to move for Papers.

The noble Baroness said: My Lords, I start by declaring an interest in that I am a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust—two very remarkable organisations. Together with the distinguished noble Lord, Lord Patel, I am a vice-chairman of the All-Party Parliamentary Maternity Group and the noble Earl, Lord Listowel, is our treasurer.

I suspect that the uninformed might think that in this House the subject of maternity services is a minority sport. They would be wrong. The list of distinguished speakers pays the lie to that. I thank all noble Lords who have chosen to take part this evening. I know that there is a wealth of wisdom and experience here and I very much look forward to what noble Lords have to say and to the Minister's response. I have given the Minister notice of four questions, for which I am sure he is ready with comprehensive answers.

The Minister will be aware that 10 years ago I wrote in the foreword to Changing Childbirth:

    "Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and taking on the long-term responsibility for caring and cherishing a new-born child. Generations of women have travelled the same route, but each journey is unique"—

and that is surely the point. Every woman is unique; every baby is unique; every birth experience is unique. That is why it is so important to give a woman and her

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partner choice: choice of place of birth; choice of style of care; and choice of professional who is going to accompany them in this unique and very special journey.

In the 10 years since I wrote those words, much has changed: more young women are going to university or college; more women are entering the professions; more women in the population are from ethnic minorities; more women are the single parent and more women are the sole bread-winner.

The birth rate is declining and the teenage pregnancy rate increasing. Yet the words I wrote are as true today as they were a decade ago. They are as relevant to those who are less articulate, who struggle to make ends meet, as they are to those who have an easier and more comfortable life.

My concern is that with the closure of so many maternity units, with the crisis in recruitment and retention of midwives, not only is choice a luxury, but the very basic standards are not being met.

In a civilised country, the fourth richest in the world, is it not reasonable to expect that every mother giving birth should be accompanied by a midwife, a knowledgeable and skilled professional, to accompany her through what can be a traumatic and frightening experience?

All research shows that when a woman is well supported her labour is quicker, there is less use of analgesics and there are fewer medical interventions. We also know that one intervention leads to another and increases the likelihood of a caesarean section. One caesarean section tends to lead to another, especially if it is a first baby, so the rise is expediential.

The rate has increased by l per cent a year, almost doubling in the past 10 years and is now comparable with that in the USA. One in five women in England and Wales now gives birth by caesarean section. But the rate varies enormously from 12 per cent in Shrewsbury to nearly 29 per cent in Coventry. We have to ask, "What have we done to childbirth if women feel they need to have a major operation to avoid it?"

The Parliamentary Office of Science and Technology, (POST) describes the adverse health implications for the mother and the financial cost to the nation. Every 1 per cent adds 5 million to the cost of services. I know that the Government are prepared to invest in the NHS but this is not the type of investment we should need. There should be investment in obtaining more midwives.

POST now considers the high level of caesarean section rates so serious that it describes it as a public health issue. The World Health Organisation states that there is no justification to have more than a 10 to 15 per cent rate. The Government should be worried—very worried. I know that next year the National Institute for Clinical Excellence (NICE) is due to produce some clinical guidelines on caesarean section. My fear is that yet again the emphasis will be on when to carry it out and the pamphlet for women will be about having a caesarean section.

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I think that that is foolhardy. We should change the approach. We need to promote normal birth. The assumption should be that births take place either in a birthing centre, a midwifery-led unit, or at home. The pamphlet should be entitled "How to avoid having a caesarean section", and should imply that an obstetric unit is an exceptional place in which to give birth, used only when absolutely necessary. So I would like to ask the Minister my first question. What action are the Government taking to reduce the numbers of caesarean sections? As a result of their actions when do they expect to see a decline in the rate?

However, there are pockets of hope. In Southampton, at a tertiary referral centre, they have bucked the trend. In part of a challenging Sure Start area, they have reduced the rate from 23 per cent to 14 per cent. They have achieved that through the introduction of case-load midwifery, a system where one midwife, working with a colleague to cover for sickness and holidays, looks after a woman during pregnancy, birth and the postnatal period. The midwife builds trust with the woman and her family and knows the circumstances. It is not surprising that when the time comes to give birth, both are confident in the ability of the other. Applications from midwives eager to work in the scheme were over subscribed and not a single one has left since the scheme was set up two-and-a-half years ago.

Reading the very interesting survey by the Royal College of Midwives, it is clear that the majority of midwives leave the profession because they are dissatisfied with the current midwifery organisation and practice. Shortages mean that they cannot practise in the way that they know to be right. The term "midwife" means "with woman" and too many midwives are compelled to be absent leaving the woman to labour alone.

Case-load midwifery and indeed birthing centres do not require rocket science. They require strong midwifery leadership, support from obstetricians, and a presumption that birth is a normal physiological event and not a medical activity. So my second question to the Minister is: what measures are the Government taking to promote normal birth?

Choice and user preferences depend on what is available. The National Childbirth Trust has recently carried out a survey of user representatives' views on the configuration of services. That work was commissioned in response to a policy vacuum and the rising panic at the closure of so many units. The Minister will be aware of Frank Dobson's initiative, when Secretary of State, to set up a multi-disciplinary working party to examine the pattern of maternity services. The report was completed and delivered but never published. The review was prompted by the fears that changes in doctors' working hours, and difficulties in recruiting and retaining midwives and neonatal nurses, would shortly impact adversely on services. Those fears have not lessened but increased, especially with the imminent introduction of the European Working Time Directive.

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Two years ago Yvette Cooper, Minister for Public Health, set up another group, the Maternity and Neonatal Workforce Group, whose report was due to be published last summer. I suspect that it was not published, like the earlier report, because it is unpalatable and the Government do not have the courage to face up to the contents. I certainly do not want a report that advocates closures, but at the moment we have a policy vacuum. Services are closing in a haphazard, idiosyncratic and unplanned way. That is no way to govern or manage a national service.

As an aside, I could not help but smile when I read the recent leak in the Financial Times, which stated that,

    "the health department needs to do more to convert its broad strategy for improving the NHS into concrete plans".

That came from the head of the Prime Minister's "delivery unit".

At this moment there are rumours that the future of both the midwife-led units in Malmesbury and Devizes is being questioned, despite excellent care being given by midwives whose morale is high. I ask the Minister whether closure is being considered. If so, what is the Government's view? What are the users' views?

At the other end of the spectrum—the highly specialised part of the service—we still await the long promised report on the development of neonatal services. I know that BLISS, the National Charity for the Newborn, is deeply concerned. A recent study published in the British Journal of Obstetrics & Gynaecology showed that in a three-month period 258 women with high risk pregnancies had to be moved to another hospital because the neonatal unit was full or had insufficient staff. Twelve per cent of the mothers were transferred on again to a third unit. Such treatment of very vulnerable women is totally unacceptable.

There is no sensible network for neonatal intensive care baby units or pregnant women at high risk. There is no clear political support for birthing centres, midwife-led units or home births. There is no commitment to audit health outcomes. As a result the strategy to retain more midwives and neonatal nurses is undermined. There is no national framework for responding to the European Working Time Directive which is cutting the number of doctor hours. The National Childbirth Trust survey indicates that users are not fully involved in proposed changes. Access to midwife-led and community-based care, including home-birth services, is evaporating.

So my last two questions are: when will the Government publish the report of the Maternity and Neonatal Workforce Group on reconfiguration of maternity services, and what measures are the Government taking to reduce the impact of the European Working Time Directive on the staffing in maternity units? I hope that I have not been too depressing. There are some good things happening, not least the formation of a new organisation: the Birth Centre Network. However, the overall picture is pretty bleak and in many places good initiatives are withering. I am sad to see, as a whole, this crucial service go backwards—a view expressed to me by a very distinguished director of midwifery.

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In Changing Childbirth we said that we wanted to see a service which did not jeopardise safety, yet was kinder, more welcoming and more supportive to women. Is that really too much to ask? My Lords, I beg to move for Papers.

6.58 p.m.

Lord Chan: My Lords, I congratulate the noble Baroness, Lady Cumberlege, on securing this important debate on the quality of our maternity services, particularly in the NHS. I thank the noble Baroness for inviting me to speak on an issue that is of professional interest to me as a retired paediatrician who practised care of newborn babies in a Liverpool hospital.

Maternity services are crucial to the well-being of mothers and their babies during pregnancy and particularly in labour and childbirth. Failure to maintain high quality maternity care may result in catastrophe with severe life-threatening complications leading to the death of mother and baby.

The latest report of confidential inquiries into maternal deaths from 1997 to 1999 was published in December 2001. The report, entitled Why Mothers Die, showed a small reduction in deaths from obstetric causes. Suicide in the postnatal period was the leading cause of death. But vulnerable and socially excluded women had high death rates. They included women living in poverty, those suffering from domestic violence, very young girls and women from ethnic minority groups.

I wish to focus on issues of staffing of services, patients' choice, prevention of complications to newborn babies and the care of ethnic minority women. High-quality maternity services depend on a variety of staff, in particular midwives, as mentioned by the noble Baroness.

The Department of Health is to be congratulated on its modernisation initiative of creating consultant midwives who undertake the supervision of midwife-led childbirth services. For the vast majority of women in childbirth, these services have been welcomed and are beneficial to mothers and their families.

But nine out of 10 maternity units in the NHS in England have unfilled posts for midwives, and the overall and long-term vacancy rates are the highest that the Royal College of Midwives has recorded, according to its latest survey conducted in July 2002. Long-term vacancies lasting for three months or more accounted for 59 per cent of vacancies in England.

London has critically high levels of midwife vacancies. On a personal note, my daughter resigned after three and a half years working as a community midwife in a central London maternity unit because of the excessively heavy workload resulting from the hospital's inability to recruit and retain community midwives.

The number of former midwives returning to practice still represents less than 1 per cent of midwives in post and less than 10 per cent of all joining the service. That represents a huge wastage in highly trained people the National Health Service needs

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today. So I look forward to the Minister's response about the recruitment and retention of midwives and plans to improve the situation.

Maternity services have improved the choice of care for women in pregnancy and labour. As most pregnancies are normal, midwife-supervised antenatal care in the community is now common. Women with experience of normal pregnancies and births can opt to deliver at home if facilities are optimal and community midwives are available.

The improvement in patients' choice of maternity care depends on a normal pregnancy being regularly monitored by midwives and, where necessary, by obstetricians. It is also dependent on rapid transfer of the woman to hospital in the event of complications during labour.

In addition, patients who make informed choices about childbirth preferences should also be prepared to share responsibility when complications arise. In our increasingly litigious society, highly motivated doctors and midwives need to have the assurance that they will not be taken to court for every unforeseen complication associated with childbirth.

Enormous monetary settlements in court, in particular for severe brain injury to the baby associated with complications during labour and delivery, may take place many years later. These judgments have increased substantially in the last decade in England. I question the ethics of such inordinately large cash settlements when the affected individual will continue to receive expensive and long-term care free through the NHS and local social services.

The desired outcome of every pregnancy and labour is the birth of a healthy baby, looked after by a healthy mother. Antenatal care is designed to monitor the health of both pregnant mother and her unborn baby. Midwives and obstetricians are trained to identify the at-risk pregnancy and recommend transfer of the woman to a hospital where both mother and newborn baby can be cared for by specialists.

A small proportion of all births will require intensive care for babies born prematurely. The outcome of these births depends on the transfer to an appropriate hospital before labour begins. The transfer of sick and tiny babies after delivery tends to be complicated, with problems requiring intensive care of the newborn, and their outcome is compromised.

In that regard, health professionals involved in maternity care are waiting for the publication of the report on neonatal intensive care. That inquiry was completed a year ago. The report should give recommendations on the standards for the care of very sick babies born too early to survive without intensive life-saving support in hospital. I hope the Minister can tell us when the report will be published.

I want to draw your Lordships' attention to the plight of ethnic minority women in maternity care. Their numbers are increasing because of the younger age of ethnic minority groups. According to the confidential inquiries into maternal deaths in 1997–99, published in December 2001, Why Mothers Die, to

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which I have referred, women from ethnic groups other than white and who speak little English are twice as likely to die than those in the white group.

Access to care is an issue for many of these women. One in five who died booked late for maternity care—that is after 24 weeks' gestation—or they had missed more than four routine antenatal visits.

In a large number of cases, professionals used family members to interpret for ethnic minority women. The report stated that there were several difficult cases where children were used inappropriately to interpret intimate personal or social details of the mother, and vital information was withheld.

I am appalled to read details of such poor quality practice in the NHS occurring today regarding interpreting for women who speak little English. For the past decade, recommendations have been sent out to all public services, including the NHS, about the need to arrange for a trained interpreter to assist people and patients who do not speak much English.

Many local reports throughout the NHS in GP practices and hospital clinics have demonstrated the importance of using interpreters who are trained to observe confidentiality and who are competent in the vocabulary of healthcare. In that connection, it is totally unsatisfactory for bilingual professional staff in hospitals to be called to interpret for patients outside their units. That practice disrupts the work of clinical units and leads to poor ratings for bilingual staff who are identified as not fully committed to the work they have been trained for and for which they are being paid.

Now that the Race Relations (Amendment) Act has made it compulsory for all NHS trusts to write race equality schemes, should we not ensure that the provision of trained interpreters is of the highest priority? The excuse of some managers that I have met is that interpreters are expensive and not required daily. Therefore, they are not considered essential. Will the Minister address that essential issue, which has caused the deaths of many women from ethnic minority groups using our maternity services?

Finally, The National Sentinel Caesarean Section Audit Report, published in October 2001, showed that in many regions in England one in three women have a caesarean birth. The highest rates are among ethnic minority women who speak little English. More research needs to take place to find out whether these surgical interventions are a consequence of poor antenatal clinic attendance with complications during labour. If that is the case, trained interpreters, bilingual midwives and doctors could run clinics in order to identify pregnancy problems early and avoid caesarean births.

Our maternity services are clearly of high quality, but we must address issues of staff shortages, the need for trained interpreters and guidelines on intensive neo-natal care and claims for medical negligence, to make those services even better and the best ever in the history of the NHS.

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7.10 p.m.

Baroness Greengross: My Lords, I congratulate the noble Baroness, Lady Cumberlege, on initiating this debate, which is terribly important. I am saddened that it must take place at all. We know very well what is best practice in this country. We can make childbirth an experience that women remember with awe and happiness. We know exactly how to do that because our best practice is magnificent.

Unfortunately, as my noble friend Lord Chan said, it is the most vulnerable young women who suffer the worst as a result of existing inequalities. We lack a strategy to ensure that those vulnerable women obtain access to best practice across the country.

We talk a lot about giving women choice, but we know that choice means having adequate knowledge, and it is obvious that many women, especially the most vulnerable ones, do not have that information to hand. We also know that women—especially young, first-time mothers—need someone who will listen to their fears with sympathy and understanding to make them feel that they are an important part of the journey that they are undertaking, which was so eloquently described by the noble Baroness, Lady Cumberlege. If people feel that their concerns are being taken seriously, they can then understand when they are not always met in the way in which they thought that they ought to be.

However, the ideal is a one-to-one service for all women. Where that is impossible, we should at least have community midwife teams, so that women know their names and know that one of them will be available to go with them to their scans, when they go to have the baby and afterwards, when they return home from hospital. We ought to be able to offer that to all women. However, we know that one-to-one services demand large numbers of trained midwives working long hours. Not everyone is willing to undertake such work. Staff concentration is expensive. I wish that our goal was to make that choice available to all women.

Everyone acknowledges that the shortage of midwives is a tragedy and must be addressed as a priority. Being a midwife can give people enormous job satisfaction, if we can get it right. We ought to set targets, and I hope that the Minister will tell us that he will. For example, we should aim to get the caesarian section rate at least down to the same level as that of the Netherlands and Scandinavia.

If a one-to-one or similar service was available throughout the country—it is not; in London, it is not even available from one part of a borough to another—we could inform women of the real implications of caesarean operation, future difficulties that they may experience as a result and why it is important to avoid them if one can. It would be ideal if we could develop dedicated birth centres, which the noble Baroness described, away from but near enough to an acute care centre so that, where necessary, women could be sent there. Normal birth would then be the norm for all our women.

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I want there to be an on-going contact point for all women, from early pregnancy right through the experience of having a baby, delivery and early childhood and leading to contact with a health visitor, which takes them through until the child is five years old. Together with excellent initiatives such as HomeStart for the most vulnerable, that would begin to ensure a healthy, secure and supported start to life for all our children and a healthier and better adulthood, with genuine support for Britain's women—one not of isolation but of pleasure and happiness for them and their families.

7.15 p.m.

Baroness Perry of Southwark: My Lords, I, too, thank my noble friend Lady Cumberlege for introducing this important topic, and for her elegant and knowledgeable speech. I also declare an interest as the chair of the research governance committee of Addenbrooke's NHS Trust and Cambridge University Clinical School, and as a former non-executive director of Addenbrooke's NHS Trust.

Like so much of the NHS, maternity services are under severe stress—some might even call the stress in some areas intolerable. Despite the excellent work undertaken by consultants, midwives and technical and support staff, staff shortages mean that services are having to be cut back and wards are closing, decreasing the service available to women and their babies and causing mothers a great deal of anxiety and distress.

In the modern age, young mothers have high expectations—far higher than when most of us underwent our pregnancies. For the modern woman, scans, screening, blood tests and management of all kinds of abnormalities are available. Excellent though it is that those services are now available—many mothers and babies are healthy because of them—they all require a huge increase in specialised time, which is increasingly difficult to find. As my noble friend Lady Cumberlege said, the biggest issue is the shortage of midwives. The Rosie Maternity Hospital in Cambridge, part of the Addenbrooke's NHS Trust, is 20 per cent below its funded numbers—that is, it receives funding for 20 per cent more midwives than it can possibly find. That is a terrible waste of government funding.

No doubt, at the end of our debate the Minister will tell us about the large sums of money that have been invested in the NHS, but I hope that he will also acknowledge that there can be no adequate return of money supplied for services where the goods and services for which it is given are simply not available. Money for non-existent nurses or doctors and the beds that they make possible is a recipe for inflation and bad management and produces no improvement for patients.

According to the Government's research measurements for workforce planning, Addenbrooke's needs another 60 per cent more midwives than it has currently. At present, it has only 105 midwives; using the Government's workforce planning measure, it needs 169.

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That is a serious situation, but there is little hope that it will be solved, because the number of midwives entering training is also thinning to a small number.

The traditional route was 18 months of post-registration training. Those places are now not being taken up as people who have become nurses consider the stresses of the midwife's job. The shortage of other midwives, long hours and inadequate pay, especially for those who work in high cost areas such as London and Cambridge, are not an inducement, even though the 18-month route has the advantage of paying a full salary while in training.

In response to the low take-up of the 18-month post-registration route, the Government set up an alternative route of three-year direct entry training. That was a good idea, but unfortunately there is no funding for students on that course. That is a real difficulty, especially for the kind of person that the course was intended to attract: the more mature woman, who thinks carefully before undertaking three years of training that will be a heavy burden on her pocket and, perhaps, that of her family.

I am told by senior midwives that the profession aspires to the status of an all-graduate profession, but the lack of student support and the introduction of fees in higher education makes that a very distant prospect. What is more, there is developing a severe shortage of trainers of midwives. Midwives now have three alternative routes to promotion and to higher status. They can become teachers, as midwifery trainers; they can become managers; and, under a new government initiative, they can now become consultant midwives.

Of course, the consultant midwifery initiative was introduced with the best of intentions. It is a good idea to offer a promotional route to enable staff to stay in the clinical environment. Unfortunately—or perhaps one might even say fortunately—that has proved to be a very attractive route to midwives because most like to remain in the clinical area. However, because so many midwives are choosing the consultancy route, the teaching and management routes are experiencing severe difficulties in recruitment. Therefore, the number of teachers available—even if it were possible to recruit candidates for training—is becoming a major problem.

As other noble Lords have said, there is the related problem of the shortage of neonatal cots and neonatal nurses. Noble Lords mentioned the long wait for a government response to the report on neonatal services. Because of the delay and shortage of neonatal cots and neonatal nurses, women in labour find themselves being piled into ambulances—quite often at a late stage in their labour—to be taken to a hospital where provision is available for their baby. In one recent case, a new mother was even told to get on a train so that she could catch up with her baby who had been taken to a neonatal unit. That must be a terrible experience for a woman a few hours after childbirth.

The position on consultants also gives little cause for optimism. Recent changes in training conditions, and the results of the European Working Time Directive, mean that there are now fewer available hours of

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consultant time. Already the European Working Time Directive means that all time "on-call" is counted as working hours, which will be reduced to 48 hours by 2009. Working hours are being reduced with the best of intentions, but that reduces the number of hours of consultants being available to help in the most difficult cases.

For reasons best known to themselves, the Government reduced the number of consultants in obstetrics' training in 1998–99. There appears to have been no account taken in the 1998–99 report—which resulted in the reduction of training places—of the effects of the European Working Time Directive and the changes in training conditions. Therefore, the number of consultants in obstetrics training was cut back and the Royal College of Obstetricians and Gynaecologists in its 2000 report, Blueprint for the Future, predicted a major shortfall by 2003 as a result of that reduction in training places. That is already becoming apparent in key areas.

I ask Her Majesty's Government to act and act very quickly to remedy this situation. I hope that the Minister will give us some reassurances. Incidentally, by action, I do not mean throwing more money at the NHS; I mean a hard look at what is needed to solve some of the problems.

In spite of the problems, there is good news to report. With the leave of the House, I should like to pay tribute to the hospital that I know best—the Rosie Maternity Hospital—for the initiatives that it has managed to introduce and its achievements in recent years. In the past two years two new consultant posts—one, a professor in the university clinical school—have been established. That means that women who have difficulties with their pregnancy and birth are now being referred to the hospital from the whole region. At the same time, that has driven up the quality of provision for all women, including those with normal births.

A high dependency unit is being established for women with difficulties. The training is already in place; the unit will move into action soon. Plans are also moving ahead for a multi-disciplinary perinatal service, bringing together neonatology, neonatal-surgery, genetics and radiology. That means that a splendid service will be provided not only for women in difficulties but for all women in the region.

For the healthy—one might say—normal birth, a midwifery-led unit has been established which includes a birthing pool—a thought which I find terrifying, but which seems extremely popular with young mothers. A newly appointed consultant midwife is leading that service. There is closer collaboration with neighbouring hospitals enabling women to be cared for in the way which is most appropriate for them. As my noble friend said, every woman and every baby is individual and deserves individual, carefully tailored care.

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With those initiatives the hospital and the trust are able to provide a service tailored to individual needs. All they ask is for less government direction and interference. They believe that the maternity services can deliver and should be left to do so.

7.26 p.m.

Lord Patel: My Lords, I, too, should like to thank the noble Baroness, Lady Cumberlege, for initiating this debate. There can be little doubt about her commitment to improving maternity services. Her report, Changing Childbirth, familiarly known as the Cumberlege report, may not have been universally well received, but it certainly raised the profile of maternity services and changed the thinking from looking at maternity services from the profession's point of view to putting mothers and babies centre stage.

Irrespective of any changes in the services introduced now or in the future, we should not go backwards. We run the risk of doing so with some of the recent reconfiguration of services. Frankly, our maternity services are in a mess. However, there is still time to stop the situation worsening if there is recognition from the centre that something needs to be done.

Much of today's debate is about the reconfiguration of maternity services that is going on ad hoc—for example, as a response to the pressure of reduction in junior doctors' hours, shortage of staff, lack of resources, cost saving initiatives, falling birth rate, smaller units, and so forth.

In an attempt to cope with the pressures, managers and clinicians embrace changes that do not serve the needs of mothers and their babies. Amalgamation of maternity units into bigger units, without capacity building in the number of staff and facilities, leads to further reduction in the quality of care delivered, and standards fall. Evidence gathered from midwives, the National Childbirth Trust and the Royal College of Obstetricians and Gynaecologists demonstrates that.

Every time there is a crisis of confidence in maternity services an inquiry is held. It happened with the Peel report and again in 1992 when the House of Commons Health Select Committee conducted an inquiry into maternity services—to which I was one of the advisers. That led to the then government report, Changing Childbirth.

It was announced yesterday that the Maternity Services Sub-committee of the House of Commons Health Select Committee is to start an inquiry focusing on variation in maternity services, data collection, staffing structures, caesarean section rates, and so forth. There are also other initiatives. We heard about the initiative from the National Institute for Clinical Excellence, which has commissioned guidelines on caesarean section following a national audit. I hope that the guidelines will define standards of care that women undergoing caesarean sections should expect, including who makes, and has the responsibility for, the decision to carry out a caesarean section.

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I understand that in future there will be guidelines for antenatal care and screening in pregnancy. Other initiatives have already been mentioned—the workforce group on children's and maternity services, a department initiative report on criteria to be met when reconfiguring maternity services. The Secretary-General of the Royal College of Midwives and I, with the former Secretary of State, Frank Dobson, asked for that initiative report to be carried out. Neither of these reports is in the public domain. I wonder what the recommendations were that cannot be made public.

Another initiative set up by the Department of Health is the National Service Framework for Children's Services, but it will include a section for maternity services. Will the Minister say whether this section defines the framework for maternity services?

It all seems to be rather haphazard planning. What we need is a co-ordinated strategy, initiated by the Department of Health, together with maternity services, in the same league as our near-neighbours in Europe, or better.

We have a serious shortage of staff. All of the previous speakers have referred to this. We have a huge shortfall in the number of midwives, a profession that is key to delivering high-quality care to all mothers and their babies during both pregnancy and the post-partum period. We have a shortage of obstetricians, particularly of those who are able and willing to deliver hands-on care at all times of the day whenever women need their help.

The noble Baroness, Lady Perry of Southwark, eloquently described the problems and how they occurred, and I will not dwell on them again, but I am grateful to her for highlighting them. Apart from obstetrics being a more demanding specialty, obstetricians and gynaecologists may see the choice of taking one of the ever-expanding, sometimes esoteric, gynaecological sub-specialties as a better option. If so, there may be a need to look at the training and remuneration for obstetrics as distinct from gynaecology. The training of doctors and all health professionals should reflect the health needs of society. I hope that a new postgraduate medical education and training board, when established, will have the responsibility and authority to make sure that all training programmes reflect this.

I am pleased to see the current president and vice-president of the Royal College of Obstetricians and Gynaecologists, Professor Dunlop and Miss Mellows, attending this debate. I am sure that they and the college will look at ways to improve recruitment to obstetrics, for it is important that women who need care from obstetricians receive it from fully trained and competent doctors. Managers, also, should recognise the need to recruit more obstetricians.

My noble friend Lord Chan has already alluded to the problems with paediatrics and ethnic minorities. I simply concur.

Staffing is not the only issue. We have a lack of appropriate facilities. This leads to an early discharge of mothers and babies from maternity units. It could

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affect rates of breast feeding and confidence building, particularly in first-time mothers. We have examples of women in labour, sometimes with problems identified in the antenatal period, being asked to stay at home until a bed is found somewhere, risking both themselves and their babies.

In terms of outputs we do not feature in the top league. While our perinatal mortality is not the worst in the developed world, it is well down the league table. We have not seen a reduction in the unexplained antenatal still birth rate for more than a decade. We have the second-highest rate of low-birth weight babies in the developed world, second only to the United States of America.

We have a high a premature birth rate. Now I know that social deprivation is an important factor for poor outcomes for mother and baby. Therefore, it is even more important that our services can deliver care to these at-risk mothers. Our data collection system is inadequate and we are not able to compare outcomes related to different models of care in the whole population.

We have a rising caesarean section rate. The noble Baroness, Lady Cumberlege, referred to this. It will keep on rising until we have a service that provides one-to-one support to all women in labour by midwives and care by trained and competent obstetricians for those women who are at risk of requiring caesarean section. Both midwife and obstetric support is essential if we are to reduce caesarean section rates.

We also have one of the highest rates of litigation: 50 per cent of all medical litigation is related to pregnancy and child birth. It is estimated that the cost of settlements of currently pending cases may well be in the region of 2 billion to the NHS. I understand that the department has on-going initiatives through risk management and clinical governance to reduce the level of litigation in obstetrics.

I return to my theme of haphazard, uncoordinated stabs at tackling the problems. Does the Minister not agree that it would be better now to produce a Department of Health- sponsored maternity services framework, with clear targets for implementation and monitoring, which the future commission for health auditing inspectorate could monitor? Both Scotland and Northern Ireland have done so and I would commend to the Minister the Scottish framework and implementation documents.

I agree that the current configuration of maternity services is not sustainable for all the reasons mentioned earlier. We need to develop services which recognise this, but which also recognise that the potential of all professionals involved in caring for mother and baby needs to be harnessed in a co-ordinated way, working across boundaries, while at the same time they retain their own professionalism.

This has implications for common, continuing education programmes. For this to happen, there needs to be committed and strong leadership from the centre and all health professions, with the focus on the needs of women and their babies.

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It is not too late. Here is an opportunity for the Minister to give a lead and bring our maternity services into the 21st century, for a model service that we can all be proud of. He could start by establishing a framework for maternity services.

Finally, I did not declare an interest at the beginning. My credentials are all too clear. I feel passionately about the care of women in pregnancy and labour. For most of my life I have been an obstetrician.

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