Belinda Phipps on choice in maternity services

Maternity services are one part of the NHS pioneering new ways of thinking. It is worth a walk down the corridor to find out what is going on in your maternity ward because it could have ramifications for your whole service.

Developments in policy, healthcare workforce and evidence now pose major challenges to the traditional model of hospital-based and obstetric-led maternity services.

Around 97 per cent of women currently give birth in hospital, although the number of those being cared for by midwives or using midwife-led centres is growing.

Expanding choice

Hospital-based births are high for historical reasons rather than women’s choice or what works well in terms of a safe, straightforward birth for a mother or baby. These high rates of hospital birth, particularly in obstetric units, are evidence of restricted choice and a lack of belief in the possibility of change.

However, the policy environment is changing and it is time for managers to make sure services around the country respond.

There are now separate maternity standards for England, Wales, Scotland and Northern Ireland, all supporting choice, based on reliable information and joint decision-making. The national service frameworks and clinical standards reflect the demands of pregnant women and their partners and the available evidence.

In September, the National Institute for Health and Clinical Excellence published the Intrapartum Care Guideline recommending that ‘women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit’, emphasising that ‘giving birth is generally very safe for both the woman and her baby’.

This, together with the UK government’s guarantee that all women shall have choice of place of birth by the end of 2009, is an important step in the transition from traditional maternity services to a model focused on parents and their needs and preferences. It is not simply that we know birth can happen safely in a range of settings, it is now the specific intention of policy that choice of place of birth will be offered to prospective parents.

Human process

Policies focus on the type of care and support provided, with a commitment to continuous support of a midwife throughout pregnancy and one-to-one care throughout labour and birth. Importantly, birth is also being regarded as a human process - part of the social and emotional transition to parenthood. This new perspective recognises that there has been too much technological intervention in too many births, which can be alienating and unpleasant for mums and babies and expensive for the service.

These thinking shifts have long been championed by the National Childbirth Trust charity.Becoming a parent makes you responsible for another person and for making decisions on their behalf. It makes sense for the process of making choices to start early for parents.

Where choice is offered, home birth rates rise and low-tech birth centres flourish. This is equally true in areas of high deprivation such as Peckham, where home birth rates are over 40 per cent, and in parts ofSouthamptonwhere women in areas of social housing have ‘caseload’ midwifery care from a midwife who builds a relationship with them in pregnancy and is there for them during their birth.

These shifts in thinking and resultant policy changes mean that over the next five years we will see a dramatic reduction in the rates of births in consultant units and an increase in home births and births in midwife-led units and birth centres. Consultant units will merge and handle the most complex births and transfers in from community births. In other words, we should begin to see a major change in the structure and availability of the different types of maternity services that women need to have the right kind of birth for them, their partners and their babies.