Government pledges on choice in maternity care are at odds with widespread reports of midwives crumbling under the pressure of slashed budgets, writes Daloni Carlisle

There is nothing new about choice in maternity care. The idea has been around for the best part of 15 years, ever since the Department of Health published Changing Childbirth in 1993.

At the time, midwives were jubilant at the promise of midwifery-led, women-centred care with built-in choice about where to give birth. Five years later, they were disillusioned at the lack of implementation of the plans but hopeful about what New Labour might introduce.

Fast-forward to April 2007 and the publication of Maternity Matters: choice, access and continuity of care in a safe service. Even more ambitious than the 1993 document, it holds out four pledges for the end of 2009, namely on the choice of access to maternity care; choice of the type of antenatal care; choice of the place of birth, including home birth, midwife-led or medically staffed units; and the place of postnatal care.

By the end of 2009, all women will be able to choose where and how they have their baby and what pain relief they use, depending on their circumstances. This is a national choice guarantee. In addition, every woman will be supported by a midwife she knows and trusts throughout her pregnancy and afterwards so as to provide continuity of care.

So are midwives lining the streets in collective joy? Not noticeably. The gap between policy aspiration and reality is just too great. 'Midwives back choice but they have long memories,' says a weary Frances Day-Stirk, director of learning, research and practice development at the Royal College of Midwives.

'They remember Changing Childbirth, when there were lots of fantastic pilots that worked well but were not funded and were allowed to die out. This is very similar. Unless there is some investment, how will it be implemented? It is a pie-in-the-sky scheme.'

Ms Day-Stirk details the evidence from RCM members, which shows that choice for women may in fact be diminishing. 'Trusts are closing antenatal classes and postnatal services are being diminished,' she says. She argues these areas are seen as a soft target by cash-strapped primary care trusts.

In some areas - parts of Kent, for example - there is no longer any NHS antenatal education programme, leaving women to rely on private or voluntary sector services.

Beverley Beech, director of the Association for the Improvement of Maternity Services, which takes up women's complaints and concerns, believes cuts are having a major impact.

'We are getting more and more calls from women who are not getting the antenatal care they need. They are not able to see a midwife until late in their pregnancy.'

This contradicts the Maternity Matters pledge that a woman will see the same midwife she knows and trusts throughout her antenatal care or will have direct access to midwifery care.

Complaints to the association about postnatal care are also rising. 'Women don't get the standardised visits for 10 days any more,' says Ms Beech. 'Instead there is a telephone call to ask: 'Are you OK?'.

'Suicide is the major cause of maternal death and the purpose of midwives visiting was to pick up the signs of women who were depressed. If they are not being visited, women are at risk of quietly going downhill with no-one knowing what's going on.'

Ms Day-Stirk adds: 'I would hate to see us move to the North American model where women and babies are not seen at home. There, if you can afford it, you take your baby to the paediatrician and the women see a gynaecologist. That's not a good model. It does not pick up problems early and people end up bringing their babies into hospital. In the short term, it saves money but in the long term is more expensive.'

Demand for maternity services is growing. Contrary to expectations, there is a rising birth rate, up from 1.8 children per woman in 2005 to 1.87 in 2007. 'It's at its highest for 26 years,' says Ms Day-Stirk.

Frozen posts

Meanwhile, the RCM is concerned about staffing levels. Its workload analysis tool sets out the minimum staffing requirements that the college views as safe. 'We have calculated that we need, as a minimum, 3,000 whole-time equivalent midwives to maintain a safe service. One-third of the trusts that have used this tool have found they have insufficient numbers of midwives.'

This is not a question of there being too few qualified midwives to employ, adds Ms Day-Stirk. 'There are posts frozen and newly qualified midwives who cannot get jobs. We are also seeing large numbers leaving the profession.'

The level of unhappiness among midwives was reflected in the college's May vote to take industrial action over pay, the first in 125 years of the RCM's history. Some have interpreted this as a membership unhappy with its leadership. At any rate, Ms Day-Stirk says a strike will never happen. 'We would never leave a woman and baby without care.'

But it is a warning shot. 'Most units run only because midwives do not get their breaks and work unpaid overtime. They fear they cannot practise safely and will make a mistake that will have disastrous consequences for women, babies and their registration. They would rather leave the profession than put babies and women at that sort of risk,' she adds.

Professor James Drife, who speaks on behalf of the Royal College of Obstetricians and Gynaecologists, agrees that many in the profession are at breaking point.

'Never in my life have I experienced so many senior, experienced midwives breaking down in tears,' he says. 'They are being brought to a state of collapse because of the pressures being applied to save money by every means possible. It means being permanently short of staff.'

Major maternity units now regularly close their doors because they are too busy, he claims. It is a phenomenon reported in the media but hard to pin down in fact. The situation is compounded by no-one appearing to be keeping tabs on the situation nationally.

Meanwhile, says Professor Drife, public expectations are rising. 'The government is telling the public they can choose where to go and everything will be fine. There is a complete dissociation between what the government is saying and what is actually happening.'

Finding answers

So much for the problems. What about the solutions? Professor Drife's solution is simple: more midwives, even if it is at the expense of more obstetricians. 'When push comes to shove, we are pressing for more obstetricians,' he says. 'But my feeling is that midwives are more of a priority.'

Reconfiguration, leading to a pattern of services with large obstetric units for high-risk pregnancies and a number of the smaller midwife-led units for those free of complications, is an option held up by the government.

Professor Drife and Ms Day-Stirk harrumph at this suggestion, although it should be said both have members who will be affected by the outcome of reconfiguration and may not like such suggestions one bit.

'It's politically led,' says Professor Drife. 'It has not come from the professions. When you ask experienced midwives whether they want to practise without doctors nearby, they will say no. The worst possible experience for a woman has to be being bundled into an ambulance halfway through labour.'

Closure of midwifery-led units

Ms Day-Stirk points out that midwifery-led units are being closed, not opened. But are they? The National Childbirth Trust has been keeping records as part of its campaign for choice for women. Its evidence suggests that women want midwifery-led care in birthing centres where they can have access to water, en suite bathrooms, space to walk around and a philosophy of care that respects their autonomy and empowers them.

That is just what many midwifery-led units already provide and a quick skim through the charity's website reveals a long list that are threatened with closure.

But director Mary Newburn says things may be changing. 'Certainly a few units have closed and many more are threatened with closure, but we are beginning to see that threat withdrawn.'

She cites midwifery-led birthing units in Stroud and Grampian as examples and is much more enthusiastic about the outcomes of reconfiguration than either the royal colleges.

'It comes on the back of the effects of the European working-time directive and the consultants' contract but does throw up opportunities for obstetric units to close and midwifery units to develop in their place.'

Ms Newburn does not underestimate the challenge for midwives. 'They may be anxious if they have only ever worked in an obstetric unit,' she says. 'But once they take the plunge and provided there are sufficient midwives with leadership and skills to lead them, they regain their confidence and their job satisfaction goes up.'

The evidence on home births is also equivocal. The official version is that it has risen from 1 per cent 10 years ago to around 3 per cent now. Newburn says some places are skewing that national average. Devon has home-birth rates closer to 6 per cent and in parts of Somerset it is closer to 12 per cent.

'Where there is commitment among midwives to offer home births, there is uptake by women,' she says. 'Where women only get it if they know about it, push for it and hold out against the persuasion not to do it, then uptake is lower.'

Skill-mix, in particular the introduction of maternity support workers, is another option for supporting choice. In October 2006, the Department of Health commissioned researchers at King's College London to evaluate the role.

Managers loved them, said the subsequent report, Support Workers in Maternity Services: a national scoping study of NHS trusts providing maternity care, because they freed up midwives to spend more time with women and babies.

Support staff

Roles taken on by the workers included breastfeeding advice and support, outreach services to women in vulnerable situations, running antenatal and postnatal groups, assisting midwives at home births and in birth centres and working in operating theatres.

But although they were making key contributions to the care of women and babies, their training and roles were not standardised, potentially putting women and babies at risk.

Professor Jane Sandall, who led the research, says: 'There is a danger that support workers could cease to become 'another pair of hands', freeing the midwife and other members of the maternity team from administrative and routine duties in order to look after women.

'Instead, they may be called on to substitute care provided by midwives, without sufficient investment in their training or development. This is a less desirable situation that needs careful management at a local level to ensure public safety.'

There are those who do see the reform agenda delivering real innovation - and therefore choice. Maternity Matters is chock full of examples of good practice, as is the DoH-sponsored Modernising Maternity Care toolkit.

'I do not think it is all doom and gloom and I think some people and services are not only doing a fantastic job, but they are providing choice already,' says Sally Marchant, editor of the midwifery information service Midirs.

A clearer picture of the state of play should be available later in the year when the Healthcare Commission releases results of a national review of maternity services. This will incorporate a survey of women who have recently used maternity services, together with a full review of staffing levels, outcomes and facilities, including population and statistics. A focus group of disabled mothers will inform the review to ensure units are assessed on accessibility and consider the needs of this special group.

In the meantime, the challenge for commissioners and providers is on. How can you use the reform agenda to deliver choice in maternity services in the face of the current financial regime? Closing the gap between reality and aspiration is going to be hard.

Including the excluded

One major challenge of the maternity choice targets is how to reach vulnerable groups. Socially excluded women are 20 times more likely to die in pregnancy and childbirth.

Maternity Matters places choice in maternity services clearly in the context of public service agreements to reduce health inequalities, including reducing maternal mortality and smoking in pregnancy.

The Department of Health has already carried out an equality impact assessment of the document and expects local commissioners to do the same.

Views on how well choice for vulnerable groups is progressing are mixed.

Rosalind Bragg, who leads Reaching Out, a project aimed at improving access to maternity services for marginalised black and minority ethnic women at health charity Medact, is pessimistic.

'The choice agenda is a really good idea,' she says. 'But some basic access issues will need to be resolved before women from vulnerable groups can make a choice.'

The research found failed asylum seekers being charged£1,000 for NHS maternity care. Since such women cannot work and do not get benefits, that meant incurring high levels of debt or forgoing care.

Current guidance gives trusts the discretion on whether to charge or not in such circumstances. Some don't - but many do.

'We know of women arriving on the steps of the hospital for the. first time when they are in labour,' says Ms Bragg.

The study also found women who did not understand what was happening because they did not speak English or who did not understand that they could challenge what was being done to them.

'There is little point discussing where to have your baby with a woman who doesn't understand why she is having a blood test,' says Ms Bragg.

Another charity, Health Link, has also looked at the development of choice in maternity services and how it affects vulnerable women.

Director Elizabeth Manero says: 'Our view is that you need to start by asking what is a quality service, specified by the characteristics of the users.

'If you are a disabled person, a key aspect will be disability access and staff who are trained to understand disability issues.'

Ms Manero is keen to see choice in maternity used to create a quality dynamic. 'It is a question of listening to what people say about what matters to them, capturing it and planting it in your commissioning. Then you are using choice as a quality driver rather than a privilege driver.'

Find out more

HSJ is holding a conference on redesigning maternity services on 27 September. Chaired by Healthcare Commission strategy manager for children and maternity Sue Eardley, speakers include DoH national clinical lead for maternal health and maternity services Dr Gwyneth Lewis. For more information go to

Support Workers in Maternity Services: a national scoping study of NHS trusts providing maternity care

Modernising Maternity Care: a commissioning toolkit for England

Reaching Out Project: report on preliminary consultations May-July 2005