As primary care groups are established, five years on from the Expert Maternity Group's report Changing Childbirth , what role do community maternity units play in women's choices for childbirth?
The report recommended that: 'Women should receive clear, unbiased advice and be able to choose where they would like their baby to be born.'
1The Exeter and District Community Health Service trust received funding from the Department of Health's changing childbirth implementation team to look at the role of CMUs in adding to women's choices for childbirth.
At a time when the number of women offered the option of delivering in a CMU may be as low as 10 per cent nationally, Exeter and District is well placed to offer women this choice.
2Three CMUs were studied in Honiton, Tiverton and Okehampton. The CMU at Tiverton has the back-up of two general practitioner obstetricians and three GP anaesthetists, and facilities for surgical deliveries.
The other two CMUs at Honiton and Okehampton are largely midwife-led. Over the past three years, the provision of intrapartum care by GPs at these two CMUs has declined, although a few local GPs will provide intrapartum care for their own patients there, and all GPs will provide general medical services in an emergency.
The withdrawal of local GPs from the provision of intrapartum care follows a national trend, but the units are actively supported by local midwives.
The study used quantitative and qualitative techniques and comprehensive postal surveys of GPs, midwives and women, as well as further in-depth interviews with a sample of respondents. Its purpose was to compare the perceptions of GPs, midwives and women regarding choices in maternity care and the role of the CMU.
The postal survey of women included all pregnant women in the catchment area, irrespective of their chosen place of delivery. Questionnaires were sent to 400 pregnant women antenatally, and the response rate was 80 per cent (322). A postnatal follow-up questionnaire was sent to 315 of these women, and 89 per cent (279) responded.
Twenty seven of these respondents were later interviewed in-depth. Postal surveys were sent to all 100 GPs whose practices were in the catchment areas of the three CMUs, and 83 responded. Later, 19 of the GPs were interviewed. All midwives working in the catchment areas of the three hospitals were surveyed (48) and 93 per cent (44) responded, with 15 selected for in-depth interviews.
The responses showed that health professionals and women alike highly value CMUs. Over half the women in the postal survey wanted to deliver at the local CMU, with 40 per cent choosing a district general hospital (DGH) and 4 per cent a home birth.
Their reasons for choosing the CMU were because it was convenient, it had a friendly atmosphere and the staff were flexible, supportive and more likely to be known to the woman.
Women in the survey who gave birth at a CMU reported that they were more likely to feel in control of the birth experience. These women, and others transferred post partum from the DGH, also reported more satisfaction with postnatal care and support at the CMU as opposed to the DGH.
Health professionals' views varied. GPs were more concerned than midwives about the risks involved in this option should complications arise during labour. This was particularly evident where the unit was midwife-led.
GPs were also concerned about their own role in providing emergency care at the CMU, because of the perceived decay in their obstetric skills. They wanted clearer guidelines.
For these reasons, some of the GPs in the study were not happy to recommend a CMU for delivery to their patients, and some directly opposed it. Yet there is no evidence that CMUs are less safe than DGHs for women with uncomplicated pregnancies.
3Given the inherent tension between free choice and safety, it was not surprising to find evidence of a deterioration in professional relationships between some midwives and GPs since Changing Childbirth, particularly in the localities where the CMU was midwife-led.
The in-depth interviews explored this and found that some of this deterioration could be due to misunderstandings of the roles and responsibilities of members of the other professional group. This highlighted the continuing and pressing need for inter-disciplinary training and education in maternity care.
4The study found that where relationships between professionals were reported to be poor, communication between the two groups was also adversely affected, and the service offered to women suffered as a result.
The CMU has the potential to deliver most antenatal care in the woman's locality, particularly if high-quality local ultrasound scanning facilities are available. But with tensions between the professional groups, how will these units fare with the advent of primary care groups, which will consist primarily of local GPs?
1 Changing Childbirth. Part I . Report of the Expert Maternity Group. Department of Health, London: HMSO, 1993.
2 First Class Delivery: Improving Maternity Services in England and Wales. Oxford: Audit Commission,1997.
3 Campbell R, Macfarlane A. Where to be Born? The debate and the evidence . Oxford: National Perinatal Epidemiology Unit, 1994.
4 Learning Together: Professional Education for Maternity Care . London: NHS Executive, 1997.