Confidence in flexible community midwifery services should transform current reliance on acute settings, writes Marina Colville

Maternity issues are now politically important and government policy set out in Maternity Matters demands a revolution in service provision. It is intended to improve the working lives of staff, improve client safety and ensure long-term financial sustainability.

The central premise is that birth is a natural process that does not normally require medical intervention. Why should more than half of all births be delivered in an acute hospital? If cheaper midwifery-led birth centres and home births are encouraged, fewer expensive acute maternity centres will be necessary.

Achieving the transformation is fraught with difficulty because of its scope, scale and complexity, together with its emotional, political and financial sensitivity.

Delivering improvements

Maternity Matters requires that women have a choice of provider and mode at all stages of maternity care by the end of 2009. It intends all women to have a midwife and those in need to have a doctor. It aims to deliver most maternity care in the community, with a focus on health, well-being and social care. But there is little NHS infrastructure to achieve this, limited community capacity and a resistance to changing existing care pathways.

Extensive change is needed to move from the monolithic medical model to pluralistic mixed provision. Consolidating skilled and expensive obstetric services into fewer specialist maternity centres makes logistic sense. But people must be confident that the community midwifery service is as good as, and ideally much better than, the services to be replaced. The critical success factor is all-round confidence.

Central to this is the ability to diagnose abnormalities early and refer on to specialists in the right setting at the right time.

A sustainable community midwifery service needs to be developed across the UK. Proven models already exist on a national basis in Holland and New Zealand. In the UK, examples are the Albany Practice in London and an integrated maternity service in Devon.

Pluralistic services need credibility with all stakeholders, from the Department of Health and strategic health authorities to women and their families. This will not come without agreement about the source and level of funding, associated activity and sustainability. It will not happen until appropriate strategy, staff, premises, facilities, systems and procedures are in place. Devolved healthcare means every primary care trust has a choice of methods to ensure the policies are implemented satisfactorily.

Resource pressures and local requirements differ; historically not every maternity service has offered the same standard, hence the postcode lottery.

The way to avoid this is to have systems and structures that give local flexibility within national uniformity. Devolution encourages all localities to believe they need to reinvent the wheel but unstructured change is not sustainable. Although no single model is universally applicable, the needs of local women and healthcare providers are similar, and proven models can be adapted.

The risk is that the burden of day-to-day administration will get worse in a fragmented system. To make best use of limited resources, midwifery time needs to be more productive. By standardising processes, routine data collection and reporting are quicker and easier, as is information sharing. Accurate data collection is vital to establishing proper costing and payment by results rates - mandatory requirements for sustainability.

Maternity Matters policy demands change at every NHS level, which will be difficult and time-consuming. As usual the main constraint is funding.

NHS reality is that redistributing limited budgets creates winners and losers. Removing a lot of low-cost normal births from an acute hospital will reduce its income at the margin. This will increase its average costs for providing the more complex maternity services.

If this reduces 'unnecessary' Caesarean sections, so much the better, but it sets up a conflict that makes the transition to care in the community harder.

However, acute hospitals cannot easily reduce their overhead costs to compensate for the loss of activity. In addition, birth centres will incur extra non-pay costs and total expense will rise unless costs are recovered from increased efficiency.

Process of change

Unfortunately, resolving the financial problems is not enough. The process of change needs to be handled very carefully.

Midwives must feel confident in their birth centre and in their new responsibilities, doctors must be certain that women needing their care will be referred at the right time and women must be comfortable with midwifery-led care.

Perceptions will have to change. It is important to take into account that taking maternity care into the community is not 'going back' to a historical service. It is a step forward, with the knowledge and technology that has been gained over past decades.

Community midwifery should not be seen as unsupported midwives coping with all births in an unsupported setting.

Maternal Link works with the NHS under the DoH's Social Enterprise Pathfinder Scheme. Working with commissioners and providers, the organisation designs sustainable proposals to implement Maternity Matters.

Maternal Link has produced a toolkit to help clarify the current financial position, identify the desired service and develop the new financial structure that will ensure the development of a sustainable community and acute service.

The challenge is to bring together a variety of parties with different interests to develop a winning solution so the policy objectives of Maternity Matters can be achieved within the timescales.

By devolving healthcare in a structured, consistent and systematic way the NHS can achieve a successful national community midwifery service.

Midwifery expertise and confidence will increase along with job satisfaction, safety and value for money.