How the push for local choice in childbirth is foundering

Despite national pledges to provide women with a range of local options, choice in maternity services has largely failed to materialise. Alison Moore investigates how local organisations? decisions to close units are flying in the face of national policy

Patient choice may be a new concept for many areas of the NHS; but in one service it has been around for well over a decade.

The idea of the patient choosing where and how 'treatment' takes place has been common in maternity services since the 1993 Cumberledge report on childbirth. But a combination of financial pressures and staff shortages means choice is becoming restricted. So what does this mean for other policy areas on choice and delivering more services in the community?

Choice in childbirth is not just about being offered five maternity departments at differing distances. It is about the kind of environment a woman gives birth in and whether the focus is on technological intervention or a 'natural' birth.

The national service framework for children, young people and maternity services envisaged women being able to choose from 'a range of local options, including home birth and delivery in midwife-led units'. Labour's manifesto last year promised that by 2009 'all women will have choice about where and how they have their baby'.

Yet many would argue that this is further away than ever - and health secretary Patricia Hewitt recently admitted it would be difficult to meet the aim of one-to-one care from a midwife during delivery.

Closure threat

The threatened closure of many midwife-led units, the trend towards fewer and larger units, and financial pressure affecting recruitment of midwives have all combined to limit women's options.

As many as 19 midwife-led units and birthing units are either closed or under threat, according to the National Childbirth Trust. Many of these are 'standalone' units, which are not co-located with obstetric units. Stroud birthing centre, where more than 300 women gave birth last year, could be closed shortly because of financial pressures.

Centre midwife Mandy Robotham says: 'All the research and policy supports our existence and expansion, yet locally health organisations are able to close units with no consequences from central government.'

In Hampshire, birthing centres in Petersfield and Gosport have been closed for over a year - initially because so many midwives were on maternity leave but then because of restrictions on hiring staff.

The trust says it is 'committed' to reopening the units. It has recruited 12 newly qualified midwives, but says they are not yet able to work on their own in a remote unit.

A trust spokesperson points out that women still had the option of giving birth in a GP-led unit, a midwifery-led unit or a consultant-led unit in Portsmouth, or a midwifery unit in Gosport. However, the area's home-birth rate has doubled since the birthing centres closed.

There has been a strong trend towards centralisation of maternity units and inflation of the number of births considered 'optimal' in such units. Many trusts with two hospitals are planning to bring services together on one site.

For example, East and North Hertfordshire trust is consulting on centralising services at the Lister Hospital in Stevenage, and Maidstone and Tunbridge Wells trust is pushing ahead on its timetable to create a single maternity unit. In the West Midlands, there are plans to move maternity out of Alexandra Hospital in Redditch to Worcester, and consultation has recently ended on plans to centralise maternity services in Greater Manchester onto fewer sites.

Money is a significant driver in this. East and North Herts will save£1.5-2m a year by centralising maternity and paediatric services.

But there are also arguments around critical mass. NHS Confederation chief executive Dr Gill Morgan says there are good clinical reasons for bringing together maternity and paediatric units in one hospital. Bigger units may also make better use of midwives' time - an important consideration in a shortage.

In a recent consultation document, the former Surrey and Sussex strategic health authority suggested that the ideal size for clinical quality in a maternity unit was 4,000-5,000 deliveries a year. That would mean just six such units across the two counties: East Sussex trust would not have enough births to support one unit, let alone the two it has now. Many district general hospitals have a delivery rate far below this.

Close to home

Such centralisation comes at a cost: easy access. Even in the South East women may end up an hour or more's drive from one of these super-units. Yet research by the NCT for the former Bedfordshire and Hertfordshire SHA found that 88 per cent of women said being within 20 minutes drive of the place of birth was very important to them, but 60 per cent also rated not having to be transferred if there were complications very highly.

In some cases, where these larger units are being created through amalgamations, there is talk of leaving a midwifery-led unit at the hospital which is losing the main obstetrics service. NCT chief executive Belinda Phipps says these units are sometimes later closed.

She argues that 85 per cent of the cost of maternity services is midwifery costs - and those will remain in any location. 'If you shut a midwife-led unit the women still need a midwife,' she says. 'It's not acceptable to put them in a consultant-led unit with a midwife running between two or three women in labour. If you do that you end up with a higher Caesarean rates and your midwife turnover rate rises.' There is evidence that low-risk women in large maternity units are more likely to end up with interventionist procedures, and caesareans are much more expensive than 'normal' births.

Ms Phipps argues there are other benefits that the NHS may not be looking at: midwifery units are also good at promoting breast-feeding - and breast-fed babies are far less likely to be admitted through accident and emergency with gastric problems, for example.

Dr Morgan says that midwifery-led units are 'a legitimate choice', but warns that 'when something goes wrong in obstetrics it goes wrong with a bang'. Even a delivery which has been assessed as low risk can develop serious problems such as a cord round the baby's neck. While it has been argued for decades that midwife-led births are as safe for low-risk mothers as those in a consultant-led unit, this is now being questioned in some quarters.

She also points to changes in society, with more women choosing caesareans or epidurals - which require a doctor's input.

Home support

Home births are probably always going to be a minority choice, but the government is committed to supporting them. In some areas, where there are supportive midwives, they have risen to 10-15 per cent and Beverley Beech of the Association for Improvements in Maternity Services suggests that, when women are given a clear choice 10 per cent will opt for a home birth.

But some areas have refused to support them: Peterborough and Stamford Hospitals foundation
trust stopped briefly in 2004 and recently United Lincolnshire Hospitals trust said it was unable to provide home births in some areas for a short period.

So do women in childbirth get effective choice? Dr Morgan points out that the NHS is not about offering completely free choice in any area, and patient choice has to be seen within the context of safety and the best use of resources.

'A manager or a doctor cannot ethically say &Quot;let's keep a service running for 200 people if that means sub-optimal care for 4,000&Quot;. That trumps choice; we do have responsibilities for the greater good of all patients.'

Ms Phipps suggests that the policy framework is well ahead of the reality in accepting that there should be a choice. What is lacking, she argues, is the evidence-based information women need to make that choice - presented in an appropriate, non-judgemental manner - and support in carrying through that choice.

'The policy has moved forward enormously, but the health service does not do it. There are little candlelights in a great mass of darkness,' she says.

She points out that research in Hertfordshire found 71 per cent of women said no-one presented home birth as an option for them - yet 43 per cent would consider it if reassured it was safe. 'How can you have a choice if you don't have awareness?'

The issues surrounding choice in childbirth, she suggests, 'have applications across the NHS.'

'Until the NHS understands what choice means, it won't really offer it.'

To some extent, patient choice is addressing this by ensuring that patients are given more information about different hospitals. However, the suspicion is that patients are still very much guided by GPs - and they tend to recommend what they know.

And choice is essentially limited to setting rather than the type of care. Patients are not likely to be offered an explicit choice of the consultant who recommends conservative management and physiotherapy against the keyhole expert and the traditional surgeon. If they do get this choice, do they get the evidence to support it?

A question of finance

And there seems to be evidence that tight finances restrict choice - especially where the same organisation is providing similar services in two settings. But it could also mean services devolved into the community in line with the recent healthcare outside hospitals white paper could come under threat. That would seem to be the case with standalone birthing centres,
especially when they are not seen to be popular enough - suggesting choice can only be exercised if enough people are choosing with you.

Could this happen with other services that are seen as unviable - and when the parent organisation is under pressure? For example, health secretary Patricia Hewitt's recent announcement of£750m to boost community hospitals will lead to some acute services being duplicated in the community. Will these survive if the local health economy comes under pressure? Much will depend on how the tariff is unbundled - and intentions of commissioners.

Dr Morgan suggests that there has to be a utilitarian aspect to this - the greatest good for the greatest number. Although there may be instances where services can be provided in community settings, there may also be cases when it makes sense for patients to travel to make best use of, say, a specialist's time or an expensive piece of equipment.

But maternity services have long been marked by territory disputes between highly trained midwives and the medical establishment. Midwives would argue that low-risk births are best handled by them, with medical involvement as a fallback. Obstetricians may lean towards the argument that anything can go wrong and births are only normal in retrospect. This argument has swung to and fro for decades, but the closure of so many birthing centres suggests the medical model may be on top at the moment.

There could be lessons here for services run by nurses and other skilled practitioners; independence may be hard to maintain unless there is real evidence of financial benefit and multidisciplinary agreement on roles.