In March 2002 the Committee asked the Department of Health for an update on the current situation in maternity services in the context of its predecessor Committee's report (Second Report of Session 1991-92, Maternity Services, HC 29).

Information from the Department's update, on key current developments and on the main developments since 1991-92, is reproduced below.

Key current developments

Children's National Service Framework including maternity services

The Children's National Service Framework (NSF) was announced in February 2001 in order to give children the best possible start in life and is expected to take about 2 years to develop. The aim of the NSF is to improve the lives and health of mothers, children and young people wherever they live through the delivery of appropriate, integrated, effective, evidence-based and needs-led services.

The maternity part of the NSF will help set national standards of care to cover antenatal, delivery and post natal services. To start the process a Maternity External Working Group (EWG) has been set up, and its Membership has been announced. The first meeting of the EWG was held in May 2002.

The EWG is being co-chaired by Heather Mellows the Junior Vice-President of the Royal College of Obstetricians and Gynaecologists and Meryl Thomas Vice-President of the Royal College of Midwives. The EWG members are drawn from a wide range of backgrounds including medical professionals, research experts and user group representatives.

The maternity module of the NSF will look at how to make maternity services more flexible, accessible and appropriate. We will be ensuring that general health education programmes stress the importance of contact with health services early in and throughout pregnancy. We will also be aiming to ensure more active follow-up of women who regularly fail to attend appointments and improvements in translation services. This will go a long way to address the inequality of access to services that face disadvantaged groups in society.

The Maternity and Neonatal Workforce Group

The MNWG was set up in February 2001 to consider workforce issues, staffing for the various models of care and configuration of maternity services. Its work will feed into the development of the NSF and includes representatives from:

The Royal College of Obstetrician & Gynaecologists
The Royal College of Paediatrics and Child Health
The Royal College Midwives
The Royal College GPs
The NHS Confederation
Primary Care Trust Chief Executives
The Maternity Services Liaison Committee Chairs
The National Childbirth Trust
The Maternity Alliance

£100m Capital Investment

£100m capital investment over two years (2001-02 and 2002-03) was announced last May, to modernise and refurbish over 200 maternity units across England. Every unit decided on their own local priorities for a share of this investment and bids were submitted after consultation with local parents, midwives, doctors and other staff.

This investment will help improve privacy for women and their families, provide better bereavement facilities, as well as facilities for fathers to stay if the baby is ill, and to upgrade and buy new equipment. The projects include structural alterations to some antenatal and post natal wards as well as delivery rooms to better suit local needs. Improvements are also being made to modernise showers/toilets to provide women with more home from home comforts.

A few projects have been completed and most are underway. All projects are expected to be completed around April 2003.

Clinical Guidelines—National Institute for Clinical Excellence

To order to improve the safety and well being of mother and baby the Department asked the National Institute for Clinical Excellence (NICE) to issue clinical guidance on:

Use of electronic fetal monitoring—these were issued in May 2001. The guidelines will help ensure that the technology is appropriately used and should result in a reduction in unnecessary caesarean sections and instrumental deliveries.

Induction of labour—these were issued in June 2001. The guidelines help to provide clinicians in maternity units with recommendations for safe practice and reduce variations in clinical practice.

Anti D prophalaxis—these were issued May 2002. NICE have recommended that pregnant rhesus negative women should be offered routine antenatal anti-D prophalaxis preventive treatment routinely (unless their blood already contains antibodies to the D antigen) This will help prevent Haemolytic disease of the newborn (HDN) which affects the fetus. HDN can range in severity from being detectable only in laboratory tests, through to stillbirth, birth of infants with severe handicaps or death of newborn children from anaemia and jaundice.

Further guidelines from NICE are awaited on:

Use of caesarean sections—Guidelines expected December 2003.

Routine antenatal care—Guidelines expected August 2003

The Department is in the process of considering the need for clinical guidelines on post natal and intra partum care in the next wave of guidelines.

Findings and recommendations of the United Kingdom Confidential Enquiry into Maternal Deaths

Due to the development of sophisticated coding programmes with the Office for National Statistics (ONS), the latest CEMD Report published (December 2001 covering 1997-1999), has for the first time been able to more fully evaluate social and lifestyle factors that may have played a part in the woman's death.

The report shows that maternal death rates are the lowest ever, reflecting improvements in the standard of care and the implementation of recommendations made in earlier Reports. However the findings also show that maternal mortality rates amongst the socially excluded, including women from lower socio-economic classes, very young girls and minority ethnic groups, are higher than amongst the population as a whole. The findings in the Report will feed in to the development of the National Service Framework for Children

Increasing the number of midwives

The Department is also investing to increase the number of midwives so that by 2006 there will be an extra 2000 midwives working in the NHS. There were 510 more midwives working in the NHS in 2001 than there were in 2000. We are investing in order to increase the number of training places for midwives and to encourage midwives to return to practice. From 1 April 2001 midwives undergoing return to practice training have been eligible to receive a sum of £1,500.This is in addition to the returners package of support which includes payment of course fees, and assistance with childcare support of up to £135 per week for one child and £200 for two or more children.

Conclusion

The majority of births continue to be uncomplicated, resulting in healthy outcome for mother and baby. The latest figures for infant mortality rates, perinatal mortality rates and maternal deaths all show a continuing downward trend. It is therefore safer than ever before to have a baby. However, issues to do with the quality of women's experience of childbirth; and the conviction that more can be done within ante and post natal care and support to set new families off in a sound footing; and the need to find and resource new models of hospital obstetric care are the main drivers for the maternity module of the National Service Framework now being developed.

Main developments since 1991/92

1992—Expert Maternity Group

An Expert Maternity Group was set up in 1992, under the Chairmanship of Baroness Cumberlege, to review NHS maternity care including the role of professionals to ensure that the services offered women choice, continuity of care and control. The Group published its findings through the Changing Childbirth Report in 1993.

1994—Changing Childbirth Implementation Team

The NHS began implementing the recommendations in the Changing Childbirth Report for a more women-centred maternity service in January 1994. The Changing Childbirth Implementation Team was set up in Cambridge by the Department to oversee implementation of the Report. It was initially set up to run for three years, but its existence was extended until it was finally disbanded in March 1998. The Changing Childbirth Team successfully promoted and supported high quality woman centred maternity care and there has since been significant progress in changing the experience of women during pregnancy and childbirth. A report detailing the progress and outcomes of the development projects funded as part of the Changing Childbirth Initiative was issued in August 1998.

1997—Audit Commission Report

In March 1997 the Audit Commission published its Report "First Class Delivery: Improving Maternity Services—England and Wales". This was the first large-scale audit of the Maternity Services since the implementation of Changing Childbirth. The Report found that 90% of women surveyed were pleased or very pleased with the way they were treated during pregnancy and childbirth. This was a very strong endorsement of the Department's policy on maternity services.

The United Kingdom Confidential Enquiry into Maternal Deaths

The United Kingdom Confidential Enquiry into Maternal Deaths, now in it's fiftieth year was set up in 1952 by the Department of Health because of concern over deaths in childbirth. It is the longest running example of national professional self audit in the world, and it carries not only the support of all health professionals involved in maternity service provision in the UK but is held in very high regard internationally. It was run by the Department of Health until last year, but is now run by the National Institute for Clinical Excellence (NICE).

The present Director of the Enquiry is also currently helping India, South Africa and Israel to set up similar enquiries and she also acts as an expert advisor on maternal mortality for the World Health Organisation. Over the years its findings and recommendations have helped improve the health of pregnant and recently delivered women in the UK, as its findings are always incorporated into Government health policy.

The latest Report Why Mothers Die 1997-1999 was published in December 2001 indicates a lowest ever rates. For the first time, it has also been able to access much wider data sources and undertake specific sub-enquiries, which have resulted in important messages for the wider public health. It provides a unique indicator of the impact that social exclusion, inequality and other issues may have on woman's reproductive health.

Confidential Enquiry into Stillbirths and Deaths in infancy (CESDI)

CESDI was established in 1992 with the aim of collecting and analysing data on deaths in late fetal life (involving foetuses at more than 20 weeks' gestation) and infancy (children up to one year) and to use the findings to reduce the risk of such deaths. The Report covers England, Wales and Northern Ireland (Scotland has its own confidential enquiry). CESDI is funded by the Department and managed by the Maternity and Child Health Research Consortium formed of the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Pathologists and Royal College of Paediatrics and Child Health. CESDI came within the overall remit of the National Institute for Clinical Excellence (NICE) from 1 April 1999

The findings of CESDI are important to both individuals and professional bodies. The messages are wide ranging and applicable to the entire spectrum of health workers, ranging from doctors, midwives, nurses and health visitors to coroners, and at times findings are particularly relevant to parents. All the professions represented on the CESDI consortium are signed up to implement its recommendations.

April 1999—The National Institute of Clinical Excellence (NICE)

In 1999 the Department issued Clinical Governance: Quality in the NHS which provides NHS organisations and health professionals with a framework for quality improvement. The National Institute for Clinical Excellence was set up to promote clinical and cost effectiveness through guidance and audit, and provide a single national focus for appraisal of significant new and existing clinical interventions.

July 1999—Making a Difference: the nursing, midwifery and health visiting contribution

Making a Difference: the nursing, midwifery and health visiting contribution was launched by the Prime Minister in July 1999. This outlines the Department's proposals to expand the role of the midwife to include more involvement with women's health and public health. This will assist with supporting women to give up smoking during pregnancy, the early identification and referral for postnatal depression or domestic violence, and the continuation of breast-feeding.

January 2000 -National Sentinel Caesarean Section Audit

To establish the reasons for the rise in Caesarean Section rates in recent years, the Department commissioned the Royal College of Obstetrics and Gynaecologists to carry out the first ever and biggest national Audit. In November 1999 Ministers asked NICE to issue clinical guidelines based on the findings of this multi-disciplinary sentinel audit. The findings of the Audit were published by the Royal College of Obstetricians and Gynaecologists in October 2001 and the NICE guidelines are expected in December 2003.

The NHS Plan—July 2000

The publication of the NHS Plan and record additional investment into the NHS by this Government since 2000 is helping to make further improvements in maternity services. The plan sets out a package of measures to modernise the NHS and includes plans to reduce long-term inequalities in child mortality and child morbidity. This involves high quality care during pregnancy and labour as well as improvements in obstetric, paediatric and midwifery services.

February 2001—Children's National Service Framework

The Government announced in February 2001 that a Children's National Service Framework would be developed which will include maternity service. It will set standards of care for antenatal, intrapartum and post natal care.

May 2001—£100 million capital investment

Last summer the Government announced a capital investment of £100 million during 2001/02- 2002/03 to upgrade and modernise over 200 maternity units across England to improve facilities and the environment in which maternity care is provided.

May 2001—Extra midwives

Last May the Department announced that, by the end of 2002, there will be an extra 500 midwives working in the NHS with an extra 2000 on the wards within the next five years. Latest figures show an increase of 510 in the last year and we are making very good progress towards meeting our 2002 target.