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Baroness McFarlane of Llandaff: My Lords, it is an honour to follow my noble friend Lord Patel, and I wish to add my name to those who want to thank the noble Baroness, Lady Cumberlege, for raising this debate and for the customary skill with which she introduced it and faced us with the facts and issues.

If I have an interest to declare in this debate, it is that last year was the 50th year since I completed my midwifery training. I hasten to assure the House that I am no longer registered to practise as a midwife, but I have a deep interest in midwifery and the welfare of women in childbirth. I view my midwifery experience now with nostalgia and through rose-coloured spectacles. Most of my deliveries, some hundreds of them, were home deliveries in a rural area of Herefordshire and it was idyllic—both the country and the experience.

Perhaps I may describe one of my last deliveries. I trudged across a ploughed field with my little black bag to get to an isolated farmhouse where the mother was in labour. Once arrived there, I found there was no running water. Unfortunately, my midwifery training had not taught me how to extract water from a pump. Unfortunately for the father, I had to rouse him from a deep sleep by the fire because he was overcome with the thought of impending fatherhood. He managed to draw water out of the pump successfully.

Later on, the feather bed on which the mother was lying burst. After that, she had a post-partum haemorrhage. We had to call out the Flying Squad, which we then used, to deal with that. However, in some ways, the case finished with every satisfaction for the family and certainly for me, the midwife.

In my state of ignorance about present-day midwifery, I have been so grateful to receive briefing papers that have brought me slightly more up to date than I would otherwise have been in this debate—papers from the National Childbirth Trust; the Royal College of Midwives; the Royal College of Nursing; the Schools of Nursing and Midwifery at the Universities of Manchester and Sheffield; from individuals and various reports of meetings of the All-Party Parliamentary Group on Maternity. These have given us a wealth of information about the present situation in midwifery.

Unfortunately, from these papers I get a very strong view that all is not well in the state of our midwifery services. Certainly the experience of some mothers is

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not now positive, and there is obviously great dissatisfaction among midwives. I therefore wish to talk briefly about the reconfiguration of the service and the kind of structure that there should be in the future; the increasing medicalisation of care, of which we have heard today; the increasing rate of caesarean section; the shortage of midwives; and patient satisfaction, if I get that far.

The reconfiguration of the service is extremely important. What shape should the service take in our present state of health service provision? As I read the papers, there seems to be a stark difference of view between those who favour home births and smaller, midwife-led community units, where care is much more easily accessible to the consumer and the midwife can give much more personal supervision throughout the period of labour. The Secretary of State has described this continued care of the mother by one midwife as the gold standard for our midwifery services.

Set against this position is the view that larger units can effect economies of scale. That is important in the present state of our health service. More importantly, a unit within an acute hospital has obstetricians and paediatricians much more readily available. It is important that this kind of medical help is readily available. I recall one obstetrician with whom I worked frequently stating, "No birth is normal except with hindsight". There may be something in that statement.

We have heard that there is an increasing medicalisation of childbirth, certainly since 50 years ago when I was practising. The increased rate of caesarean section has already been mentioned and is a cause for concern. The "Postnote" that I have received dated October 2002 states that in the 1950s 3 per cent of births in England were by caesarean section; by the early 1990s this had risen to 10 per cent; and to 21 per cent in 2001. But the national figures mask tremendous local variations of between 10 and 30 per cent.

The differential cost to the National Health Service of caesarean section versus vaginal delivery is considerable. The Audit Commission has calculated that every 1 per cent rise in the caesarean section rate costs the National Health Service an extra 5 million a year.

The parliamentary "Postnote" is valuable in regard to the caesarean section rate. It reviews the medical factors that have contributed to the increase, and the non-medical factors such as culture, organisation and maternal choice, which I believe is often influenced by the line taken by the media.

Clearly these are considerations that call for us to think deeply about reconfiguration of the service. I appreciate the paper from the National Childbirth Trust, which looks at the questions that need to be answered before we tackle reconfiguration of the service and contains a suggested reconfiguration.

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As regards the increased rate of caesarean section, I look forward to receiving the promised guidelines from the National Institute for Clinical Excellence. Although it is an extremely difficult issue on which to give guidelines, they will be a valuable help to us.

I am extremely concerned, as are many other noble Lords, about the shortage of midwives and the lack of job satisfaction. This situation has been researched by Mavis Kirkham, Professor of Midwifery at the University of Sheffield. The work was sponsored by the Royal College of Midwives and the Department of Trade and Industry Partnership Fund. Professor Kirkham followed up 2,325 midwives who notified their intention to practice in 1999 but did not do so the following year in 2000. That is quite a significant loss of midwives in one year.

Making the decision to leave midwifery was often a protracted and painful business. The professor said that the research painted a depressing picture of a group of committed professional women struggling over a protracted period of time within an environment of increasing confrontation and stress. The largest group of those who left—30 per cent—were dissatisfied with midwifery. There were other causes, but the midwives had a predominant feeling that they could not practise as they were taught to practise under the conditions now existing in the health service.

Midwives are now educated in a way that gives them specialised knowledge and problem-solving skills which enable them to base their practice on evidence derived from research. Their expectation is that they will be able to practise autonomously, but what they meet in practice is very different and bears little resemblance to what is implied in the midwives' code of practice. There are matters which militate against their practising as they would wish. They are made to rotate through all the shifts and around all the areas of clinical practice and feel that they have insufficient control over their working lives. These frequent dislocations of the place in which they practice make it difficult to maintain confidence and relationships with both clients and colleagues. It is essential that we do something about the recruitment and retention of midwives.

As a final point I was going to talk about mothers—the consumers—and patient satisfaction. I shall not do so because my time is up. I wanted to recount to your Lordships the experiences that some of the younger members of my family have had in childbirth. It is not a pretty story.

7.48 p.m.

The Earl of Listowel: My Lords, I, too, am most grateful to the noble Baroness, Lady Cumberlege, for securing the debate today. Perhaps I may also say how useful I have found the meetings of the All-Party Parliamentary Group for Maternity, which the noble Baroness and Julia Drown, MP, founded some two years ago.

Indeed, at the launch of the all-party parliamentary group I was very much struck by the contribution from Cathy Warwick, a clinician at King's College

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Hospital. The midwifery unit she described that cares for mothers in south London—mothers sometimes living in bed-and-breakfast accommodation, often from ethnic minorities and often on low incomes—appeared remarkable. Its practice is an example of the case-load midwifery that the noble Baroness, Lady Cumberlege, and several other noble Lords have referred to.

According to the evaluation report published in March last year, the Albany midwifery practice was enabling such mothers to achieve breast-feeding rates of 93 per cent at birth, as against a norm for the area of 75 per cent. Breast-feeding remained high at 28 days, at 70 per cent of mothers. Health visitors reported continuing high breast-feeding rates.

Compared with the other midwifery group practices, the Albany practice had a lower induction rate, a higher vaginal delivery rate, a lower elective caesarean section rate, a higher intact perineum rate, a lower episiotomy rate, a greater use of the birthing pool and a lower use of pethidine and epidurals.

There were also benefits from the midwife's point of view. I invite your Lordships to consider what a pleasure it might be for a midwife to follow one mother from registration to birth and from birth to four weeks.

I invite your Lordships to consider how attractive it might be for a midwife to work in the community in a centre which has a safe play area for children, a swimming-pool, a well-equipped gymnasium, right next to the shopping centre in Peckham.

Please consider how satisfying it might be for a midwife to be the mistress of her employment. The Albany practice operates on a contractual basis unique in the UK. The noble Baroness, Lady McFarlane, eloquently set out the concerns that midwives feel about not being in control of their working environment and the stress that that places them under. In the Albany practice, they, the midwives, decide on salary and pay, on sickness and holiday leave. They have a practice manager to relieve them of the administrative burden of such responsibility. This control of their working conditions may be helpful in reducing the stress that is inseparable from their work.

The Albany midwives are dedicated to offering continuity of care to their patients. A full-time midwife is on 24-hour call to 36 mothers for nine months of each year.

Thirty-six weeks prior to birth, the primary midwife and secondary midwife will talk the mother and the mother's birth partner through all the options for her care. The primary midwife, the mother's key worker, will explain that she can be reached at any time, day or night, by calling her on her pager.

In practice, mothers almost invariably call during the night only in an emergency, because of the special personal relationship that they develop with their primary midwife and the respect and consideration that that engenders.

The germ of this practice lay in the ambition of three pairs of independent midwives in the early 1990s—one of whom is present in the Public Gallery. They wanted

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to see the well-evidenced positive outcomes for their paying clients provided for free, on the NHS, to the women who most needed continuity of care. Fostered by a favourable political climate which the noble Baroness, Lady Cumberlege, did so much to engender, their goal has been achieved.

I should say that the past success of the model of caseload midwifery that I have described has been qualified. A great deal of support is necessary for midwives prepared to offer a 24-hour personal service to their clients. Such work would not suit the circumstances of some midwives.

But the outcomes for mothers, for mothers who are particularly vulnerable, are encouraging. The introduction of three months' annual leave, the careful setting of caseload and the increase in professional autonomy, supported by a practice manager, may be attractive to many midwives. The satisfaction of seeing one's patient through the pregnancy and beyond might be an incitement for midwives to continue to work in the profession, and to return to the profession, and for young people to train as midwives.

When I visited the Albany practice yesterday afternoon, I heard how satisfied the midwives felt in their work. I heard of the pleasure they had in not only seeing the infant through the first four weeks, but in also having mothers call by, so that they, the midwives, could see how well the mother's six year-old was doing, a child delivered in the clinic. So the midwives are very much part of their community and can see the children for whom they have cared in the past growing up.

I should like to ask the Minister whether he has studied the Albany model and what lessons he considers can be learnt from it. Is he undertaking research into why this particular model has given rise to high home birth rates and breast-feeding rates in an area of such high deprivation? Will the relationship between the continuity of care given, the provision of ante-natal education and the positive birth outcomes in this model be explored in further research?

I apologise for not giving the Minister notice of these detailed questions. I hope that he may be good enough to write to me if he has no response ready.

Yesterday, I also met with a manager of a children's home with more than 30 years' experience. The home had recently received a troubled 15 year-old girl who was pregnant. The manager was of the view that the model of continuity of care offered by the Albany practice would be exactly that which would be of most benefit to her new resident.

I am advised that it is easy to overlook the vulnerability of mothers during their pregnancy. Because childbirth is common, it can be thought to be unproblematic.

I believe that we still have the highest rate of teenage pregnancies in western Europe. A report by the National Children's Bureau in the 1990s found that nearly half of girls leaving care were mothers within 18 to 24 months. So, there are many groups of mothers who particularly need continuity of care during their maternity.

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YoungMinds, a charity dedicated to promoting the emotional well-being of children, advises me of the importance of relationships with midwives characterised by continuity, reliability and familiarity. It is vital that mothers should feel ready and welcoming of their baby, vital for the sound and secure attachment to the baby. It is this attachment which so much research underlines as being the sure foundation for an individual life. My noble friend Lord Northbourne may have more to say on this point.

I have no doubt that, if we can develop first-rate services to mothers during their maternity, answering their physical and emotional needs, we shall go some way to ensuring that fewer children go to prison, that fewer children are taken into care and that the cycle of failure from generation to generation is somewhat ameliorated. Hand in hand with improvements in housing, education, other health services, social services and a sound economy, we could see many more children fulfilling more of their potential.

7.58 p.m.

Lord Northbourne: My Lords, I had already apologised to the noble Baroness for the fact that I might be late this evening. I was, and I apologise to the House.

I want briefly to refer to one specific aspect which may in future become an important part of the role of the maternity services. Over the past 100 years or so, the maternity services have evolved mainly with a concern for the physical welfare of the mother and child. More recently, the emotional welfare of the mother has been of increasing concern.

However, modern research based on powerful new scanners indicates that the period in the womb and the first 33 months of a child's life are critical in the development of that child's brain.

A significant number of children today are born into, and grow up in, severely disadvantaged family circumstances—often multiple disadvantages—and sometimes with parents who have little or no experience of caring for children. In that context, maternity services and staff can be the gatekeepers who identify imminent problems. Some believe that the maternity services can play that very important role. They hold the patient's confidence. Their role should be primarily diagnostic, although some believe that they should also be trained to deliver advice and support services to parents without a clue about how to bring up their child. They could put the advice in simple, common language.

In my view, there is little argument about whether there is a role for the maternity services in identifying problems. The question is whether their role should be purely diagnostic; whether it should be signposting; or whether staff should be trained to deliver support services relating to the mother's emotional condition and the child's cognitive and emotional development needs.

The maternity services should be trained in three aspects: to recognise potential problems; to gain parents' confidence—which they do anyway; and

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successfully to transfer that confidence to other services. For that, they must be trained, and the other services must be available. I shall explain what I mean by "transfer that confidence". Consider a health visitor who, at the end of the six-week visiting period, tells a mother, "I am sorry, Molly, I am not coming anymore, but I will refer you to Social Services". Contrast that approach with the health visitor who says, "Molly, I am terribly sorry; I shan't be able to help you anymore because I am not allowed to. But my friend Susan is really nice and I think you'll like her. Would you like me to give her your name so that she could call and you could see if you like her?". The difference is between acceptance and rejection in the case of many vulnerable people.

I regret to have to say that Social Services are not the people to do this job. Unfortunately, and through no fault of their own, Social Services have become the enemy to many deprived and disadvantaged families. They are thought of as the people who take your child away and are perceived by many as policemen rather than support services.

There is a role for the extended family, but often relatives need support, co-ordination, help and resources. There is a potential role for neighbours, the community and the voluntary sector. These services, wherever they come from, will probably need to be co-ordinated, possibly for training or accreditation. Who should be in charge of accreditation, training and co-ordination—the Department of Health, the Department of Education or local authorities? I do not know. But I know that the criterion ought to be: which will be the most effective? I ask the Minister to take into account what I have said.

8.4 p.m.

Baroness Thomas of Walliswood: My Lords, like others, I welcome this debate. The noble Baroness, Lady Cumberlege, does us all a service by reminding us regularly of the enormous importance of the birth process. I apologise for the absence of my noble friend Lord Clement-Jones, who has an unbreakable arrangement abroad. It is a pity because I am sure that he knows much more about these matters than I.

Birth is a process we have all undergone. It is natural and normal and in most cases it has a healthy outcome. The death of mother or child is now a rare result, although no less dreadful when it occurs. Eighty per cent of women have babies, and 90 per cent of those babies are healthy. Of the others, very few require more than a little help with breathing in the first few hours, treatment for jaundice or suchlike. A tiny minority need the highest level of care—on the whole, then, a success story for Mother Nature and the advances in healthcare working together. However, we should heed the words of the noble Lord, Lord Patel, on our place in the league table.

Yet, in preparing for this debate, I was struck by the chaos that seems to hang over the service and policy discussions about it. I was also struck by a lack of relevant statistics. What is the best sort of service for mother and baby? Are midwife-led, low-tech

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procedures in special birth units more appropriate than obstetrician-led procedures in hospitals, with all the high-tech support available? What are the cost benefits of each? Why is the rate of caesarean sections rising so inexorably? Why do rates of so-called "normal" births vary so much between places? Do those two variations not suggest a lack of consensus among practitioners on what constitutes good practice? What is the right level of home births? Why is the percentage rate in single figures in this country while it is around 30 per cent in Holland, to take but one example? Where should we provide care for the most fragile or sick babies? How can we secure the very best service from paediatricians? Why are the statistics so incomplete?

Inevitably, the question arises of why the Government have not given a steer? There have been no responses yet to the National Childbirth Trust Report and no action taken on their own report on neo-natal services. When will the framework document on children's services be published, and what aspects of maternity and neo-natal services will be covered? It appears that NHS trusts require guidance from the Government to assist them with the difficulties in prioritising and judging between the main options for maternity treatment. There can be no doubt about what women want, once someone gives them a chance to talk. They value good advice given in a way that they can understand. They want to be in contact with the same professionals, preferably midwives, during pregnancy, through the confinement and on into aftercare. They prefer the homely surroundings of a local birth unit or community hospital to a more impersonal district hospital.

I hope that the Minister will take on board suggestions from the noble Lord, Lord Chan, and others that more effort needs to be made to take the message of how to access maternity care to the most underprivileged and vulnerable members of our society. It was a very important point which has been echoed by other speakers.

It is very important what mothers think and feel. An experience of childbirth which leaves a mother with postnatal depression can, untreated, result in a four year-old with behavioural problems who turns into a problem teenager. Mothers who are taught to breastfeed will have healthier babies. It is amazing what good midwives can achieve. One practice in a deprived area of south London has achieved a 40 per cent rate of home births with no adverse consequences. With the percentage of home births so low nationwide, it is easy to see what a good and cost-effective achievement that is.

The variation in "treatment"—I put it in inverted commas on purpose—seems extreme judged by the standards of other specialties. Indeed, the very word "treatment" seems wrong. In the majority of cases the mothers do not need "treatment". They are not ill. They just need professional help and support.

I entirely agree with the noble Baroness, Lady Cumberlege, on the subject of caesarean section and the need to promote normal birth. As she said, last

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year Shrewsbury had the lowest rate in England of caesarean section, at 10.4 per cent, and the highest rate of normal birth, at 67.7 per cent. Yet, in Worcester, women have no choice but to go into the infirmary, where the rate of caesarean section is 25 per cent. The mothers seem to have little choice. As others have pointed out, the cost of this high rate of caesarean section is great: each costs 1,000 more than an ordinary delivery. Saving 30 unnecessary caesarean sections buys one midwife. So the opportunity costs are clear. The costs to the child also can be considerable, especially when the procedure is carried out before term.

The reasons for the apparently inexorable increase in caesarean section are not clear. One idea often put about by the press is that it results from the personal choice of smart or busy mums. It could be the result of concentrating births in district hospitals. Again, better statistics would help. Whatever it is, caesarean section must be the only major surgical intervention which seems to be available if asked for, even when it is not necessary.

One thing seems clear—namely, that mothers who have had a caesarean section are almost invariably advised to have another, although I know from experience in my own family that that is not necessarily required. So the most important thing is to try to ensure that the first caesarean never takes place unless strictly required for the health of mother or child.

The problem of a shortage of midwives has been mentioned by many, but particularly by the noble Baroness, Lady McFarlane. There seems to be a vicious circle at work here. For example, a hospital loses its baby acute care beds and closes the maternity beds as a safety measure, or midwives are transferred to an even larger general hospital where they lose their status, cannot keep in touch with their patients, feel they are not giving the service they want to give, and leave. Something similar can happen when local birth units are closed, as has been happening in recent times, despite the evidence that they can deal with the majority of normal births at least as satisfactorily as any hospital. Any policy which the Government propose will have to recognise the very special role that midwives play in the care of mothers and babies. They will also have to attract back into the NHS those who have left.

This evening a wide measure of agreement has emerged as to what would make a good maternity service. First, proper prenatal care is essential to assess correctly which mothers, or their babies, are likely to need the medical attention that only a hospital can provide—although not even hospitals and senior medical professionals are entirely foolproof. I know of a horrible case, reported to me by one of my colleagues, in which a young woman being examined two months after an ectopic pregnancy was told that a small shadow on the x-ray was nothing to worry about. Two and a half months later, she nearly died after a severe loss of blood from a second ectopic

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pregnancy. The Ectopic Pregnancy Trust says that such cases of misdiagnosis are common even where there is a history of ectopic pregnancy.

Returning to more cheerful subjects, however, the healthy woman should have a choice of where to give birth: at home, in a reasonably local birth unit or in hospital. In the first two at least, she will be able to have continuous care from the professionals who have looked after her during her pregnancy. If a large number of women chose the first two options and good practice secured the same levels of success that have been mentioned in particular instances, a considerable saving in beds would accrue to district hospitals. I am sure that those beds could be used for things other than housing perfectly healthy women. Post-natal care could be given in the same unit and then in the home.

A real effort should be made to establish breast-feeding, which is cheaper for the mother and better for the baby. Differential rates of breast-feeding are really surprising, with the lowest rate for the least number of weeks among women from more deprived backgrounds—just where the additional protection against illness and obesity given by breast-feeding would be most valuable.

A back-up service would be required should complications arise during the birth, just as for any other medical emergency. Very sick or fragile babies should be treated in specialty centres, if that is the only or best way in which to get the constant presence of a paediatrician and the quality of nursing care that such children need.

I look forward to hearing the Minister's response to the many questions that have been raised, and his idea of what maternity services should be like.


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