Oral evidence

Taken before the Health Committee, Maternity Services Sub-Committee

on Tuesday 17 June 2003

Members present:

Julia Drown, in the Chair
John Austin
Sandra Gidley
Dr Doug Naysmith
Dr Richard Taylor

__________

Witnesses: MS BEVERLEY BEECH, Chair, Association for Improvements in the Maternity Services, MS SARAH MONTAGU, Association of Radical Midwives, MS ANNIE FRANCIS, Independent Midwives' Association, MS BELINDA PHIPPS, Chief Executive, National Childbirth Trust, MS LOUISE SILVERTON, Deputy General Secretary, Royal College of Midwives, and PROFESSOR WILLIAM DUNLOP, President, Royal College of Obstetricians and Gynaecologists, examined.

Q1  Chairman: Good afternoon. I welcome you as our witnesses to our third inquiry into maternity services, as a sub-committee of the Health Committee. In this inquiry we are going to be focussing on choice, but we will also bring together some of the work we have done in our two previous inquiries, one of which is coming out tomorrow. We are going to try a vast area with you this afternoon, and I am anticipating a vote at four o'clock, so we will probably have to finish at that point. Brevity in questions and answers will be much appreciated. Thank you all for your written evidence. I want to start off by looking at some of the lessons that we would have hoped to have learned from the Changing Childbirth report, which is nearly ten years old now, and ask you a bit about that. Then, we are going to go on and cover staffing issues, home births, litigation, who should lead on maternity care, the roles of independent midwives, caesareans, and if we have time there is a host of other questions that we would like to put to you. Changing Childbirth was very widely welcomed when it came out ten years ago. It is clear from our work so far that there were a number of recommendations that have not been implemented across the country, and the reality of women-centred care is not to be found everywhere. I wanted to know from you why that is, and throw in a particular example. The RCOG, in its evidence, talked about issues to do with disability and said that if these recommendations had been properly implemented across the country, there would not be problems now. We heard from a disabled mum who said she had to argue to get height-variable cots, and, after much discussion, she managed to get them in her area, but did not feel she had managed to get them in place beyond that. Why do we still have those problems?

Ms Phipps: As a user, I think it is worth saying that I do not think the NHS has learned the trick of putting itself in the shoes of the user of the service very well. There is an interesting example from Disney - I know a commercial organisation - where it was discovered that the reason why the cleaning ladies were discovered to be very good was because when they finished cleaning a room, they lay on the bed, sat on the loo and lay on the bath, and looked at the room from the user's perspective. Therefore, they cleaned to maximise benefit for the user. The NHS is not very good at that. Although we have a Maternity Services Liaison Committee, I do not think they are as powerful or as much listened to as they could be, although they are probably the best forum that we have. When you work in the NHS, as I have as a Chief Executive, it becomes very day-to-day, and you focus on the latest piece of paper you have from the NHSE or whatever else is the latest issue. It is very easy to lose sight of the fact that birth is a once, twice or perhaps three times in a lifetime experience and is pivotal for the people going through it; and your everyday working life is somebody's for-ever memory. The NHS just has not got that, and I do not think society supports it and thinks from that point of view.

Professor Dunlop: There are a number of issues. First of all, Changing Childbirth, which we supported in general, was quite an aspirational document, and not all the aspirations were easy to achieve. Secondly, I do not think there has been much resource put into maternity services during that period of time, and particularly in relation to midwifery staffing, we could have done with a lot more resources. Many of these things did depend on numbers in midwifery, for example. Thirdly, there has not been any clear guidance given by the Department over this period; and now that we have the opportunity of the national service framework, I hope that will be remedied.

Ms Montagu: I would agree that funding did not follow Changing Childbirth recommendations, which would obviously have helped to implement some of the things that were proposed in that. Some were put into action. Where funding was put in, it tended to be put in and very often directed more towards the hi-tech end, because you can spend an awful lot of money on a new scanning machine, when perhaps the money could have been put into more one-to-one midwifery care, but it does not have quite the same whizz-bangery effect as a new ultrasound machine or whatever, but it has a more profound effect in terms of the kind of care that that midwife would then be able to give.

Ms Silverton: I am not going to differ with anything my colleagues have said. One of the key problems is that there were never any specific targets. There were aspirations but we do have a target-driven NHS. At the moment, because the maternity service does not have targets, then there is nothing bringing it to the attention of the primary care trusts. More importantly, to some extent we have got the maternity services the wrong way round. They are based mainly in the acute trusts, which are geared towards treating people with time-limited illness episodes and coping with waiting lists. Perhaps if we were to look at childbirth as a life event, which for some women will need medical intervention, then looking at it from a more normality and community-based mode would help to take it out of the acute trust and put the ball in the court of the women.

Q2  Dr Taylor: It is remarkable that you have brought that up so early, because we were talking about that just before you came in. It seems to us that it is something that should be under PCTs rather than under the acute trusts. I have a dream myself, with these foundation trusts about to come in, that PCTs should be foundation PCTs, and the whole shooting match should be run by local people as a foundation trust. I would be interested in your comments of the practicality, Professor Dunlop, of PCTs rather than acute trusts running it.

Professor Dunlop: I think a lot of midwifery care could be delivered at PCT level, but I do not think that will be easy for secondary care. I think for acute care, especially since we are living in a situation where a marked re-configuration of maternity services is taking place, it would be very difficult for that to be delivered at primary care level. Therefore, I think there still ought to be some relationship between the two. There does need to be some sort of overarching co-ordination of services, and that really is what the NSF should be addressing. There needs to be some sort of managed network which will allow both primary care and secondary care services to integrate effectively.

Q3  Dr Taylor: Our impression is that there is very little co-ordination at the moment between primary and secondary care. Is it any better in the obstetric field?

Professor Dunlop: Not a lot, in that primary care tends to be predominantly dominate by general practitioners, who actually do not deliver much obstetric care. The best practitioners of primary care obstetrics are midwives, who are often not employed by general practitioners.

Q4  Chairman: Would the RCOG object to even the acute part, the secondary care part of maternity services actually being under the management of the PCC, which happens in Bath, as I understand it?

Professor Dunlop: That is an unusual situation with a relatively small acute trust, and I think you would have to look at that in the context of the antenatal care services and obstetric and anaesthetic services and so on. I doubt if it could work for the larger trusts.

Ms Beech: I think one of the major problems with maternity care at the moment is that midwives do not have any power, and I do not see that they are going to get any power on PCTs either, unless there is a system that will enable senior midwives to be involved at senior management level and have real power within their area. There is not a recognition either, I think, of the professional status of midwives. They all talk about midwives being the primary whatever, but when it comes down to it, so many midwives are required to fit into protocols and guidelines that are very clearly, closely defined by another professional group. Unlike GPs - you do not closely define what a GP will do. One of the problems of looking after normal birth is that there is such a range of normality that it inhibits midwives from thinking clearly about this particular woman in these particular circumstances. Unless we have midwives carrying their own caseloads and being responsible for it, and not on this system of teams and centralised care, we are not going to get that kind of change, because where those units that have introduced change and have provided the kind of care that many women want - like Torbay for instance - they have got strong midwifery leadership. The tragedy is that the midwifery leaders leave and then it goes back to the old system. AIMS has been involved in maternity care since the 1960s, and we see the same thing happening time and time again.

Q5  Chairman: You are saying that where it is a midwifery-led unit, that is good and you would support that; but where it is being run on a team basis, the midwife's voice is still not heard.

Ms Beech: It is where all the midwives are integrated into one system of care, and where they do not have very senior managers running it in the first place; and so you end up with hospital-based midwives having to go out to look after a woman at home, and they are very insecure about it. Many of the trusts have not introduced any kind of further training for the midwives. It is very unfair on the midwife who has worked thirty years in a labour ward suddenly to be told, "oh, you are going to do normal birth now; go out to Mrs Smith".

Q6  Chairman: We will be coming on to some of these things.

Ms Francis: I wanted to echo what Beverley was saying. We believe that the model of care that we offer women addresses a lot of these issues because the centrepiece is that women make choice; and when women make the choice, that is a very powerful starting-point. The way in which we work means that we are very aware of the individual woman and the issues that surround her, and what we strongly wanted to recommend is that our model of care be offered as an option, alongside the current structure - not having to dismantle what exists but to offer it as a further option to those women who would like that level of care.

Ms Phipps: On the power issue, midwifery is a very different service from what goes on in the rest of an acute trust; and because it is not generally dealt with by powerful people in the hierarchy of doctors - in the same way that the heart surgeon is higher up the hierarchy than the midwife - if you to an NHS trust, you will very rarely hear midwifery discussed, except in the context of litigation. Those people that sit on the board - there is not a midwife. The nursing director is rarely a midwife. The medical director is rarely an obstetrician. They do not have any particular interest in midwifery, which means that the decisions that the trust makes are based on sickness, not on midwifery. For example, you will get the same sort of flooring put in across the whole trust, even if it does not suit midwifery. Should we put them in PCTs, the same applies because PCTs are dealing with all the disciplines across the board. I wonder whether we would be better to have something like a midwifery trust, a virtual body, where the board is focussed on midwifery, where there is a director of midwifery in the place of the director of nursing, looking after the services that are located out there. They are going to get a true understanding of the range of what needs to be available in midwifery. They are going to get good at both the end where you do need medical intervention and the end where you need to be very good at supporting and enabling normal birth. They are going to be able to spend the time on the issue that Annie has raised about making sure that women have the opportunity to use independent midwives and to use the services that they provide; whereas it is very much a low level, low key, not properly considered issue, and choice is squashed as a result of that.

Q7  John Austin: You have said that one of the reasons why things have not been driven forward has been the absence of any targets. Throughout the rest of the NHS we get complaints that there are too many targets, but what are the key targets that you would like to see set in terms of midwifery? How could they be arrived at?

Ms Silverton: There are a number of areas that we could look at. We could look at setting targets for the percentage of women cared for in particular models of care - for example, the percentage that had caseload care, where one midwife with a partner look after a defined group of women. We could look at the percentage that have domino care, where they have mainly community care and are brought in for birth, or the percentages for home birth, as they have done in Wales; or you could set percentages for the number of women who see a midwife as their first point of contact rather than being put into the medicalised system by seeing a general practitioner. More importantly from the point of view of college, on the targets on the number of hospitals that need to have undertaken BirthratePlus analysis of the requirement for midwifery workforce, and the number of percentage of units that they find the funding to match the shortfall in midwifery numbers.

Q8  John Austin: How can you be sure those targets are not just arbitrary and that they do actually reflect women choosing and being empowered to make choices?

Ms Silverton: At the moment, part of the problem is that the definition of what we mean by "choice" is rather difficult to define. You could say that some people may say, "choice is choosing you what I offer you", which is a very cynical way, but unfortunately does happen. Certainly, the issue of choice about caesarean section seems to be much more acceptable in some circumstances than it is to choose a home birth. We need to look at women having good advice that they can understand, and having time to make decisions - not being expected to make a decision there and then. The informed choice leaflets are a very good guide to this, although they are not geared to women from ethnic minorities and they do tend to be written at quite a high level of understanding. If they give time for the woman to read them and then come back to the midwife and discuss them, having considerable time to think about what it is she wants to do, then choice can be made real.

Q9  Dr Naysmith: We want to look at staffing and choice and the inter-relationship between them. We have heard from Beverley and Annie about situations where choice for women is limited because of the way things are structured. To what extent does the lack of choice for women contribute to the staffing shortages?

Ms Phipps: Most women want to have a baby and come out of the experience physically and mentally whole, in a good state to be a parent. For most women, that means a straightforward vaginal birth. That is the option that is most likely to give that outcome. When enabled to choose that and when they have the information in front of them that shows them in order to achieve being physically and mentally whole at the end of a straightforward birth is the most likely to do it, women choose those sorts of services. We have seen that in other countries: women voting with their feet for midwifery services that are very good at increasing straightforward birth. That, overridingly, is what women want. If we are going to measure anything, we need to measure those outcomes and measure our ability to enable women to have a straightforward birth. It is a treble win, because not only is straightforward birth better for the vast majority of women, but it is also cheaper for the NHS and it is a much nicer way for the vast majority of midwives to work. Midwives enjoy being able to spend time to get to know a woman, and feeling a sense of achievement, as the woman does, in getting to the stage of having a baby and being able to look back on the experience as a positive, joyful experience rather than a traumatic horrible memory that she would like to forget. We know what works. We know that independent midwifery works; we know that birth centres work and that home birth works. Those are the very choices that are not easily available for women at the moment.

Q10  Dr Naysmith: I am trying to get at whether because they are not available, that in itself reduces the number of staff available.

Ms Beech: It is not a question of reducing the numbers of staff available. The problem is that because most women do not have normal births and they do not get it in the hospitals - Sue Downes' research showed that only one in six first-time mothers have a normal birth in large centralised consultant units. It gets very demoralising for the midwives; they are not happy about the kind of care that they are having to provide that does not enable women to have these kinds of births. They are not able to go out and help the women deliver at home because many of the trusts are very antipathetic towards home birth, and the midwives become disheartened and discouraged. One midwife said to me recently that she was leaving midwifery. We asked her why because she was such an experienced midwife - a lovely midwife. She said: "I am not prepared any longer to continue abusing women in these large centralised units and I am giving it up." That is a terrible indictment, and there are thousands of midwives who feel similarly.

Ms Francis: What we understand is that there are between 5,000 and 7,000 registered, qualified midwives currently not practising. One of the reasons for that is because of the way in which care is given to these people in these systems. Those midwives have expressed an interest in working in the independent area. If we were to offer that, we believe that you would solve the staffing crisis, or would certainly work towards solving it.

Professor Dunlop: Can I say that none of us wish unnecessary intervention in maternity care, and that includes our college. However, when we say that we know things work, I actually disagree with that. We have very little knowledge about maternity services, and I think that is a major defect that somebody ought to be putting right. The NHS statistics for 2001/2002 have just been published, and there is some improvement in data collection from NHS hospital deliveries from 57 per cent in 1989/1990 to 70 per cent in 2001/2002. This is data that is usable, interpretive data. When you look at home deliveries, there has been a decline from only 20 per cent in 1989/1990, to 14 per cent in 2001/2002. I do not know how anyone can say we know what is happening in relation to home confinement because I certainly do not know. One could hypothesise that one does not have data from 86 per cent of pregnancies which may have gone terribly wrong. We just do not know.

Ms Montagu: I would agree that data collection is important, but there quite a large number of very robust studies which reflect the outcomes of one-to-one care, and the importance of having a known, trusted carer throughout a pregnancy and a birth, and the difference that that makes. I very much second what Beverley was saying. I am frequently rung up by midwives who are desperately frustrated at the kind of care that they end up having to give, and the processes by which women have come in, ostensibly normal, and end up with birth that is definitely not normal, that is predicated by the way in which the hospital system works. Midwives just cannot stand having to collude in that kind of care any longer, and they give up and leave. Those are the very midwives that you want to keep.

Q11  Dr Naysmith: What kind of evidence do you think is needed in order to provide for women? Is it not simply enough to say that there are a fairly large number of women who have births that do not require intervention, and many of them are at home and trouble-free; or are you looking for a bit more scientific evidence?

Professor Dunlop: We want to be able to audit what is happening in the National Health Service, and I cannot do that. We cannot do that with the data we have. We are drawing conclusions about home confinement and about free-standing midwifery-led units that are not based on substantial evidence. The number of women having births under these circumstances is small, and there are not properly conducted studies. I do not accept that the studies are robust enough.

Q12  Dr Naysmith: I was about to ask you about evidence from overseas, somewhere like the Netherlands, where it is a significant number of home confinements: is that evidence not good enough?

Professor Dunlop: No, it is a totally different system and a totally different population with different ethnic mix and a different history. There are lower perinatal mortality rates. In Sweden there are virtually 100 per cent hospital births.

Ms Phipps: But they are low-tech hospital births. There are many more normal births in Sweden.

Professor Dunlop: I have no problem about why, it is just the conclusion -----

Ms Phipps: And in Holland as well because there they have a 33 per cent home birth rate and they have extremely good mortality figures. Whilst I would agree that statistics are provided by the NHS, they are not good enough, and we do need them to be accurate so that we are not working in the dark. There are a number of good studies, including studies on home birth, that show that it is as safe, if not safer than hospital birth for a low-risk normal pregnancy. That has been shown over and over again, and we really do not need to go back and question that data; it exists. In addition, if you saw as many birth stories as I do, you would see that it is rare to see a home birth where there is either an experience problem or a medical problem coming out of that home birth. We know, just by looking a home birth, that you half your risk of a caesarean section or other intervention. So there is very good data. I know that the data set is not very good, and we need to address that, but they are two different factors.

Ms Silverton: There is some good data on the midwife-led units and birth centres, and also on home births, which is collected locally. The problem is that they do not fit in with the NHS statistics, because of the way in which they need to be calculated and collected. For example, home births do not have a hospital number. Then it does not appear anywhere on the system. However, we do know that the data is there, and that for women at low to moderate risk of complications, their outcomes are as good, if not better, given they do not have interventions at home. To return to the question of shortages and the effect on models or types of care, it is a chicken-and-egg situation because where midwives can plan their own model of staffing, this might result in a very mixed economy in the trust with many different models of staffing. The midwives are much happier to work in that way, and they feel that, like the women, they have got control. The midwives follow the women rather than staffing the unit and having thick shifts. What they do hate, once they have established themselves as caseload midwives or four-in-a-team midwives, or whatever it is, is then being dragged in to plug gaps somewhere else. That really upsets them. Mavis Kirkham's work for the college on why midwives leave certainly showed that this was one of the things that undermined their satisfaction. We also need to look very clearly at the demographics of midwifery. Twenty per cent of midwives are over fifty. Given that all NHS midwives can retire at 55, we have a huge problem looming. The number of training places has increased, but not sufficiently. Again, we could argue that there are not sufficient normal births for the students to get experience of, and more worryingly there are not enough midwives out there to act as mentors and to provide the correct role model. The idea is that we want to socialise midwives into doing a woman-centred model of care, and not a much more medicalised, almost a factory-lined type of care, which unfortunately occurs somewhere. We are also worryingly losing not only student midwives because they cannot survive on the bursary, but we are also losing newly qualified midwives in their first year who find that they cannot cope with the pressures of looking after two or three women simultaneously.

Ms Phipps: Women want that as well.

Q13  Dr Naysmith: I do not mean to deprecate the evidence you are giving, but everywhere we go as politicians at the moment, we hear that university lecturers is an aging profession, and if we do not do something about it, and that if we do not do something about we will not have any - and the same for teachers and every profession. GPs are a bunch that are also supposed to be -----

Ms Silverton: I think we could encourage them to stay longer if they felt they were giving the right sort of care.

Q14  Dr Naysmith: Is it right that people can just select the best bit, the nice bit they want to do about their profession, and not do some of the others?

Ms Silverton: If you take a group of a hundred midwives, you will find that a significant proportion like hi-tech labour wards. They love it.

Ms Phipps: And some people need that sort of care, and they deserve midwives that love giving that sort of care. They deserve the full attention of the obstetricians rather than obstetricians spending time with women that really ought to never come through the doors of a hospital. We have actually got it wrong. In order to safeguard the lives of women and babies, which we all want to do, we have forced many more women, without giving them proper choice, through the doors of hospitals, where actually they are subject to care they do not need, which costs the NHS money, which alienates midwives and reduces our obstetrician time. We need to be much better at helping sort out which women do need that sort of hi-tech care, and making sure they have the information they need so that they know why this is being suggested to them and they can make decisions about it, and making sure that women that have the opportunity to have a straightforward birth get the support they need and know what sort of services will help them get that.

Q15  Dr Naysmith: I did raise the question of what lessons we can learn from overseas. Are there any other lessons that we can learn, perhaps the use of maternity care assistants?

Ms Francis: I feel that the question of research is a real red herring. We do not have enough to research to show that the lesser the level of unnecessary intervention, the better the outcome; because Margaret Keys' work addresses all the statistics that are available, and has a very clear conclusion, which is that historically obstetric intervention has not improved the overall safety of the mother and baby. It is very easy to look at the continuing arguments about how you collect data, but the absolute fundamental situation is that women do better in either birth centres or at home, in the low-tech areas. Perhaps rather than restricting criteria into birth centres, we should be looking at making criteria into consultant-led units so that only those women with high risk or the problems go in, so that we turn the whole situation around on its head.

Q16  Dr Naysmith: Has there been an increase in the numbers of women who want to deliver their baby at home or in free-standing midwifery-led units?

Ms Beech: There was a study done in York many years ago that showed that if you gave women free choice of where they wanted to have their babies, 20 per cent would choose it. That was at a time when they were very much restricting home birth. If you give women choice, as the Albany practice has done, a far greater percentage of women will choose to have their babies at home. We have trusts in this country that really vigorously oppose home birth. You can pick out which trusts they are and where they are. We get constant letters and e-mails and requests from women who are trying to get their way round the system because they have been told for various reasons, many of them spurious, that they do not qualify any more. I had a woman ring me yesterday who said she has been told by her trust that they have already booked their quota for home births in an area that only has a 2 per cent home birth rate, and therefore she cannot book her home birth.

Q17  Dr Naysmith: That would suggest that there are not enough resources and facilities.

Ms Beech: They are spending their money on hi-technology care - ultrasound for just about everybody - and it is very questionable whether every woman needs an ultrasound examination. Instead of putting the money into the more low technology, it is "paint the walls, put up the curtains and spend money ...."

Q18  Dr Naysmith: I wish they would do that in my local hospital!

Ms Phipps: If you look at the process, before a woman is even pregnant, she has been exposed to multiple images of hospitalised/medicalised/on-your-back birth, and she may not even realise that home birth is a possibility. If she does know it exists as a possibility, she may not know that it is as safe, or safer, than hospital birth if she is normal and low-risk. The most common place for a pregnant woman to go to is still to her GP - 89 per cent - despite the fact that the midwives are there for normal birth. She may tentatively say to the GP, "I am thinking of having a home birth", and GPs are woefully under-informed about the safety of home birth. They are pre Marjorie Tew. They do not understand the benefits. They may say, "you are not allowed; I will not let you; you cannot stay in my practice" - they may just suck their teeth, and that is enough to put a woman off. You have eliminated choice already up-front. If a woman actually has to struggle and argue and present her case and listen several times to the disbenefits of home, is that choice? No, it is not. Does she get a clear explanation of the benefits of home birth and the disbenefits of home birth; the benefits of a hospital birth and the disbenefits of a home birth?

Q19  Dr Naysmith: Who should provide that?

Ms Phipps: The midwife.

Professor Dunlop: I am sad that this is degenerating into an exercise in territorial issues because I actually think there are much more important issues to address, and that is how we develop maternity services as a group, as a team, as a country. We require the whole spectrum of care.

Ms Beech: But we are not getting it at the moment. That is the problem.

Q20  Chairman: We have been pleased during our inquiries to see teams working together. One of the issues on home birth is that if a trust is not providing many, it is a problem, because it is the unusual thing; whereas, if there is a critical mass, that is just like another option, and you have the staffing there. I am seeing nods from you. Is there any disagreement that we need to try and create a critical mass?

Ms Beech: We absolutely agree.

Ms Montagu: The link with the choice is obviously also the control because very often while a sensible number of choices may or may not be presented, depending on where you happen to live, the actual control a woman exerts over the choice that she is able to exercise is often very limited. A certain number of women, obviously, will need the hi-tech care; but if they feel when they end up in that place that it is because other options were exhausted - they had the choice, they had the control and they knew that that was the necessary outcome, they feel entirely differently about it to someone who comes in to the labour ward and is subjected to a whole cascade of intervention and feels afterwards that it could have been different. Equally, the person looking after her will feel very differently, because they would feel that the woman did genuinely have an input into what happened, and understand why it happened. The situation at the moment is that control is very often not ---

Q21  Dr Naysmith: My final question is: to what extent is this really related to resources? If there were enough resources available, would there be more discussion of the options?

Ms Montagu: It is very much related to resources because if you are cared for by someone that you know, that you trust, and who knows you, they know what your bottom line is, and you understand where they are coming from. You are then much more able to offer them choices and to feel that they are an equal partner in their care, than if you met them for the first time when they are already 6 cm dilated and only able to talk to you between contractions.

Ms Silverton: The Government has said that it supports the gold standard of one-to-one care in labour. It should therefore not matter where that woman is when she is in labour because she should have one midwife with her. Some trusts have said that you have to have two midwives for a home birth. No-one can provide us with any reasons as to why, although there is some sense in having two people there for a home birth - be it a midwife and a student or a midwife and maternity care assistant. It is always useful to have another pair of hands when someone else is doing something, because it is quite difficult to deliver a placenta while you are trying to get the baby to breathe. Home births for the most part do go perfectly normally because you have not used any intervention anyway. You did ask about the role of the healthcare assistant, and I wanted to go back to that. We have some examples in this country. In Wolverhampton they use them very widely in the hospital. They have actually got an access programme to put maternity care assistants into midwifery training programmes. In Hillingdon, they developed a community maternity care assistant role to help with breast-feeding and to help mothers at home. We have a community midwifery service that is quite different from overseas, and if you look at the Dutch model, they have women with a two-year training programme, and they are much more like a surrogate mother. They will take the other children to school and do the housework. I am not sure that that is what we are thinking of. Are we thinking of going back to the home-helps, which were originally established to support. You could see a maternity care assistant as a part of the team, not simply having tasks delegated but working as a part of the team, under the supervision of the midwife, providing some of the extra care that the midwives do not have the time to do. We are not talking about substitution, but we are talking about value. There is also the aspect of assisting women in their transformation from woman to mother. I think we underestimate what a huge life-change that is and how women are very much alone these days because they come from small families and do not have relatives round them. For many women, the first baby they have ever held is their own.

Q22  Dr Taylor: I would like to pick up Professor Donald's point because it is absolutely striking to me that in our previous evidence sessions we have not had the same slight clash between the obstetricians and the midwives. We have been amazed how closely together they have been talking and working. I want to try and explore why that is. Is it anything to do with litigation? Is it because obstetricians are more conscious of the tremendous costs of litigation? Is it because they are affected more directly? Professor Donald, can you think aloud on why we have this situation? Is it something to do with litigation? Is it more of a risk to obstetricians or as NHS indemnities have been taken on by a trust does it not really make any difference to the branches of midwifery - including the obstetrics - profession?

Professor Dunlop: Litigation is clearly a major factor in the way that obstetrics is practised in any country with a large litigation problem.

Q23  Dr Taylor: Does that affect midwives as much as obstetricians?

Professor Dunlop: I believe it does.

Q24  Dr Taylor: So it is not that that is making the midwives here say they could be doing a lot more; that they are less frightened of litigation than obstetricians.

Professor Dunlop: I would be very interested to hear the independent midwives comment on litigation and the costs of insurance.

Ms Francis: I do not know if people are aware, but for the independent midwives, there is no insurance available and has not been since last April. Prior to that, it was available at over £20,000 per annum. From that point of view, that was beyond the reach of most independent midwives. So we are in the unfortunate situation of having to practise, if we practise at all, without insurance. So we have been arguing for either no-fault compensation or a change in the system. We believe that CMSC and the way in which litigation is being driven within the large hospitals - policies and protocols that narrow down women's choices and which tend to increase unnecessary intervention, we believe increase litigation. If we were to look at a more midwifery-based model of care, we believe that litigation costs would decrease dramatically.

Q25  Dr Taylor: Would that be because the cases that are going for midwife care are the lower risk case in any case?

Ms Francis: No. At the moment about 56 per cent of the women we look after are classified obstetrically as high risk.

Ms Silverton: The issue of litigation is world-wide. The issue of problems of obtaining insurance for maternity services is world-wide. We know that family doctors in the United States cannot get insurance. I negotiate the RCM's insurances, and I cannot get any underwriters to even quote for independent midwives' insurance. If you used the term "independent midwives" , they run screaming out of the room because they perceive independent midwives as being the same risk as a consultant obstetrician doing caesarean sections. It is their perception of the risk.

Q26  Chairman: Is there any evidence to back that up?

Ms Silverton: There is no evidence. It is interesting, if you look at the situation in the States, where the American College of Nurse Midwives had problems about ten years ago, they had wonderful evidence that their members were not sued because they had formed relationships with the women; they had taken the women with them; the women understood what was going to happen. The midwives had never said "we will promise you a perfect baby". In a way, the NHS promises women perfect outcomes and you cannot do that.

Ms Beech: I think the NHS is also selective in what is at risk of litigation. We had a notorious case two years ago of a woman who wanted to deliver her baby by the breech and wanted a midwife to assist her in birthing this baby. She was not prepared to go in to the local hospital, because her friend had been in and had been so traumatised by the whole experience, and said she was staying at home. The trust argued that they did not have any midwives who were sufficiently trained to help her birth this baby at home, and they were not going to provide a midwife. They were perfectly happy for this woman to deliver that baby unattended. Equally, they were happy to send out finally, after they argued and argued and argued, midwives who they acknowledged did not have the expertise and training to do it. When it was suggested to them that they could employ an independent midwife who did have this expertise, they refused to do so. This litigation is very much a one-sided thing - and they are quite happy to accept risk. In our evidence, I referred to a letter in which a trust stated, "we consider this woman to be high risk and therefore should not be birthing at home; but here are the names of the independent midwives locally who will look after her".

Ms Phipps: I think it is the case that litigation may be undermining choice to a certain extent. If it prevents independent midwives from operating, then it does undermine choice. If it makes trusts so nervous that they attempt to put women off, rather than provide objective information, then it is undermining choice. One of the important things about choice is not just that it is there but that the information to enable the woman to make the decision is there. From a woman's point of view, we worry hugely when there is an apparent feeling of choice but actually the information is not being provided. I think there is some evidence that that fear of litigation may bias what is made available to women so that women have informed compliance rather than informed consent. That is a big issue. There are women who, for all sorts of reasons, might choose to want to have twins vaginally or a breech baby vaginally. It is very important they have the information and know the risks they are running; but ultimately it has got to be down to them.

Ms Beech: One of the other problems is that the Department of Health has written to the women, saying that women should be able to choose a home birth providing they fall within the category of safety, which is of paramount importance. I have written to the Department and asked whether in that case they are prepared to support trusts to say "we are not going to provide yo with any care at all because we decide you are high risk".

Q27  Chairman: What reply did you get?

Ms Beech: There has been total silence. I am waiting with bated breath for a reply.

Professor Dunlop: There is a clear problem with litigation in relation to maternity services in this country, but it is tiny in comparison with some other countries, particularly the United States, where there are huge problems. The American College of Obstetricians and Gynaecologists is in discussion with lawyers to try and change tort law. Whether they will be successful in that, I do not know. We are waiting for a report, almost daily, from the CMO about litigation in this country. It was supposed to be published last week. We are very anxious to see that published soon.

Ms Beech: Perhaps if it addressed it, there would not be so much litigation.

Ms Silverton: It is a bizarre world that seems to be straight out of something written by Swift in that you are only ever sued for something you do not do; but you never see people sued for doing unnecessary caesarean sections. There is always the issue of "just in case, we had better do it". Turning round the issue of litigation, I do not think the public understand that when they obtain damages from the NHS, it is not coming from the insurance companies, it is coming from public funds. Sometimes, when you talk about this, people are very surprised. This is NHS money. We gave evidence to CMO and said that money should be paid into a central fund, and therefore people can have money out of it for as long as they need it, but if circumstances change, they can have either extra money or less money. If they live longer, the money does not run out. It sounds very cruel, but if they do not live that long, the money stays there to benefit other people, and it does not go into their estate.

Q28  Dr Taylor: I did like your point that if the midwife has a really good relationship right at the beginning and all the way through - and that goes for the obstetrician as well.

Professor Dunlop: I do not believe that that is true, or that there is good evidence for that. With problems such as cerebral palsy, they may not become apparent for five years. I have experience of patients who had very good relationships with their obstetricians coming back. It may well be that we could find another way of reimbursing them for the problems they face, and that that is where the problem lies, but it is not true to say, I am afraid, that a good relationship prevents litigation.

Ms Silverton: Ninety per cent of cerebral palsy comes before labour.

Professor Dunlop: Of course it does.

Ms Beech: Let me give you an example. A midwife contacted me many years ago now about a woman who was expecting her second baby and terribly worried that this baby would be as seriously brain-damaged as the previous baby. The midwife said: "I will go and find the case notes and see what happened; then we can discuss it and look at the risks of this happening a second time." She found the case notes and found that the reason the baby died was actually because of the mismanagement and mis-diagnosis in the hospital. The woman had had an abortion for an abnormality that had not actually occurred, and the baby was a perfectly fit and healthy baby. When the midwife told the woman about this, she said: "Of course you have a right to sue the hospital because of this mis-diagnosis." The woman said: "No. This is my next baby. I am happy with the care I have got. Unfortunately, people make mistakes and it is a terrible tragedy, but I am not going to do this." In our experience, women who come to us with very serious complaints are very reluctant to sue; but one of the things that drives them into suing is when they do not get an honest answer out of the trusts when they make a formal complaint.

Q29  Dr Taylor: If mums are assessed at low risk and it is suggested that they should go to the birthing centre or have the baby at home, and they do not want to do that and want to have it in a consultant unit, can that happen?

Ms Phipps: I do not think anybody should tell mothers that they should be doing anything at all. They should be saying "such and such is the case with your medical history. If you choose this, the pros are this and the cons are this; and the risks are this; and if you choose this, the pros and cons are this and the risks are that". Then they should support the woman in making her decision.

Q30  Dr Taylor: So you would not try to change that.

Ms Phipps: Some women who could quite easily have a home birth may choose a consultant unit, and so be it. They may have other reasons for needing to do that. They may feel more comfortable, being able to see that there is equipment around, and they may have a very good relationship with the consultant that is there. You have to trust that the woman will make the best possible decision; all we have to do is give them the chance to do that, by providing very good quality, evidence-based information presented in an unbiased way, and then given support, preferably from somebody like a midwife who can talk through with them. Then they can think round how they are going to deal with it in the context of their lives, their other children, their previous birth experiences, et cetera.

Q31  Chairman: Is it about complete choice, or should one be seen as the norm? It has been suggested that midwifery-led care should be seen as a norm, and you would be opting in if you said you wanted obstetric-led care.

Ms Silverton: That is an option, but if you look at the current system, where a woman makes a choice at ten or twelve weeks' pregnant, how does she know? Perhaps we should provide for the most part midwifery-led antenatal care, except where there are pre-existing conditions, and the woman decides at 30 or 32 weeks.

Ms Montagu: Or in labour. With the ordinary midwife service, that is what they do. The women have midwifery-led antenatal care, with all risks of women, and the decision about the appropriate place for the baby to be born is made right at the very end, and quite often in labour - and hence the very high home birth rate - the woman labours at home and feels comfortable to carry on at home. If women choose to go in, they can do. That is women being given a genuine choice.

Q32  Dr Taylor: Should they have a choice over the number of antenatal appointments and postnatal appointments?

Ms Phipps: The NHS is resource limited, and you have to think about that. Where there is no evidence of something of benefit - for example, nobody is going to offer me a hip replacement because my hip is perfectly fine.

Q33  Chairman: We have heard in previous sessions that disadvantaged women might really benefit from more postnatal -----

Ms Silverton: Absolutely.

Q34  Chairman: Do we automatically assume we need more midwives, or is there a case for saying that some women do not need to come.

Ms Beech: Absolutely.

Ms Phipps: It will be women-centred. Women have individual needs. If a woman does not have a good grasp of English, she may need more time and an interpreter present. Not every woman is going to need an interpreter. The service has been a little like a very broad brush and tried to do the same for everybody, and not everybody needs it.

Q35  Chairman: There needs to be more flexibility.

Ms Phipps: Yes.

Ms Silverton: The other thing is that if the midwife and the woman have formed a good relationship, they know each other so you do not need to have as much care. If the woman says, "I need to see you twice tomorrow", the midwife knows then that there is a reason for that. Also, there is mutual trust; so you trust the woman when she says, "I do not need to see you tomorrow; if there are any problems, I will ring you".

Ms Francis: Coming back to the central idea that women make the choice to start off with as to who gives them their care - in the independent model of care, we get to know the woman from the point at which she chooses us. We will talk through all the various issues that she may have. It is not necessarily just about the physical aspects of pregnancy; it is very much about the emotional journey that she goes on. That is, unfortunately, what is often lacking in antenatal care within the system, which is very busy - you have maybe a ten-minute appointment. We will sit down and really talk through all the issues. It may well be that there are no physical problems, but there is a lot of anxiety about coping as a new mother, which we can help that woman address. So in the long term, when you are looking at the new unit, the new family, you are actually talking about cost-savings: less postnatal depression, longer breast-feeding, greater rates of breast-feeding. These are things that never see the light of day in the context of what we offer as midwifery.

Professor Dunlop: It is important to say that the system has changed. Most of us doing antenatal clinics have plenty of time to talk with women nowadays, and we are seeing relatively small numbers. The days of the cattle-market are gone.

Q36  John Austin: Beverley Beech gave an indication earlier why women may seek out independent midwives, but perhaps you can expand on that.

Ms Francis: They seek independent midwives for a whole range of reasons. We see women who are pregnant for the first time, who may have heard of us now that the Internet is available; they may have come across us in that way. They are interested in having a midwife that they can really get to know; so there is continuity of care, one-to-one support is a really important part of what we offer. But they also come to us either because they have had a previous traumatic experience and they are looking to change that. For example, I had a phone call last week from a woman who had had a normal home birth, but felt traumatised by that because she felt she had had to jump through too many hoops in order to get it. She felt constantly under threat that she was going to be told that she had to transfer. Whether or not a woman needs to transfer is something that will come up in the care-giving that we undertake. We are not suggesting that women should do this or should do that, should stay at home, or do anything that may be regarded as inherently unsafe. The absolute fundamental of the care that we give is that we work with the women in partnership. We give them the information and they make the choices. We support them in their choices.

Q37  John Austin: Can I explore partnership with other care providers, including obstetricians? How does that partnership work and affect the choice a woman might have?

Ms Francis: It works extremely well. I was going to come in earlier, when we were talking about transfer and if a woman becomes high risk part way through her care. When we are working with a woman, if an issue comes up that needs to be looked at - either physical problems or whatever - we will contact obstetricians/consultants; we will help organise those appointments and go with the woman to that appt; and we work very much in partnership with obstetricians. We are 100 per cent behind the fact that there are obstetric interventions that are sometimes required. Our main difficulty is that - and the World Health Organisation quotes that in developed countries about 20 per cent of women require some form of intervention, and that at the moment 80 per cent of women are getting intervention. If we could turn those two things around, it would go a long way to improving women's experience and reduce the cost.

Ms Phipps: You would still have very good outcomes, because nobody wants to lose that; that is very important.

Ms Beech: One of the problems with judging outcomes is that there are inadequate statistics on the numbers of women and babies who are damaged by the present system of care: numbers of women with postnatal depression or post-traumatic stress disorder - and we are getting many more women suffering from this; the numbers of women that are not breast-feeding, and babies that have problems. The research by Jacobsen revealed that women given drugs in labour end up with babies who at increased risk of heroin addiction in their teens; and yet none of this has been addressed. It is very good-quality research and it has been repeated in America, and it has just been buried.

Q38  Chairman: AIMS said to us that all trusts should have in place a system to engage the services of independent midwives. Would that view be widely shared?

Ms Silverton: We have a shortage of midwives. We have some examples of where independent midwives have been contracted to supply services to the NHS with great success. The Albany practice is one of them. It is part of the mixed economy. We would like to see more of this, more of getting those 8,000-10,000 midwives who are not practising back into practice in the way that they want to work.

Ms Phipps: Again, it does provide choice.

Q39  John Austin: Can we focus on caesareans, firstly on maternal request. To what extent do you think that the increased emphasis on choice for the woman might have increased the rate of caesareans?

Ms Phipps: The number of women who are pregnant for the first time choosing caesarean section with no medical need is about 3 per cent, which is tiny, and it is not having a significant effect at all on the caesarean rates. It is only an influence in that the media have blown it up out of all proportion.

Q40  John Austin: It has not become a fashionable, lifestyle -----

Ms Phipps: No. Some of our private hospitals have very high caesarean rates and are frequented by those people who tend to appear more regularly in the newspapers; but it definitely over-emphasises the amount of choice there is for caesareans. There are, obviously, valid reasons for a woman choosing a caesarean section, the least of which is a very traumatic vaginal birth, using forceps, or something that has been badly mismanaged. I can fully understand and would want to support a woman who felt that that was her best choice the second time around. There are some women who do have phobias or whatever, and if they are not resolved by other means, that may be her best option. Some of those would not be counted as medical reasons, but they are very valid reasons for maternal choice. However, many more women have a caesarean section not by choice but by dint of not being properly cared for, and a number of emergency caesareans come under that category, where the woman, to all intents and purposes, could and should have had a straightforward birth, but by the care not being what it should be, by midwives not being available, by maybe junior doctors being a little more proactive than they needed to be without a consultant there who was able to wait, we are now having more caesareans than they want or need.

Q41  John Austin: But the choice that a woman exercises may be influenced by an assessment of risk. That assessment may particularly be taken by an obstetrician.

Ms Francis: The woman should be given the information. If she is choosing a caesarean, she must know the effect on her risk of -----

Q42  John Austin: So someone will make an assessment of the risk and possible outcomes, and that will clearly influence the woman's decision. Do you think that a woman in exercising that choice should have access to information about the rates of caesareans carried out in a particular clinic by a particular obstetrician?

Ms Phipps: If she thinks it would help her make the decision, yes, she should.

Professor Dunlop: No problem at all, but of course it is important that you look at case mix when you produce that information so that you are not preparing a very high risk unit with a lot of tertiary referrals with a very low risk unit which might have a low caesarean section rate.

Q43  John Austin: It may be that in some units some obstetricians may be more inclined to carry out caesareans where the risk may not be as great.

Professor Dunlop: We will of course have a NICE guideline on caesarean section coming out next year, and I would hope that that would lay down clearer indications for audit of caesarean section and good practice.

Q44  Chairman: Some of us are not entirely clear about how much NICE is going to make judgments on these issues. One of our witnesses was quite relaxed that different consultants would come up with different judgments on the same woman in the same situation, about whether or not they should have a caesarean. Some of us round the Committee felt uncomfortable that it might depend on who you were with whether you end up with a major op or not.

Professor Dunlop: I suspect that is true throughout medicine; it is not just in relation to caesarean sections.

Q45  Chairman: There are such large variations

Professor Dunlop: I do not think ---

Q46  John Austin: We have seen a significant rise in the proportion of caesarean deliveries, and a major variation between -----

Ms Phipps: The function that has been built in there, though, is that it is the consultant making the assessment and the decision about the sort of birth a woman has. I think that does need to be turned on its head. The woman needs to be party to the discussion, and she needs to have the info so that she can, with the consultant's information on risk, draw up, along with knowledge about her own life and her own feelings, make a decision herself about whether or not she is going to have a caesarean.

Ms Silverton: There is research undertaken by CASS, which shows that there is a link between midwifery staffing shortages and caesarean section. We talked about women feeling empowered to be pregnant, to be becoming mothers. What has happened is that we have lost the time for antenatal care. Women come to labour unprepared. They are terrified of labour. They have got no idea of what it is. They try and control it. A quarter of their friends all had a caesarean section, and perhaps a caesarean section in their mind gives them some certainty; but they do not actually realise that it is major abdominal surgery. There is some light at the end of the tunnel. In Wales, with the normal care pathway, which they have been using to address various aspects of care in labour, in one trust, where they had a caesarean section rate of 18 per cent, their caesarean section rate fell down to 8 per cent, and has now crept up to between 10 and 12. That is Llandoc, which is not the high-risk South Glamorgan Trust, but has quite a good cross-section of women; it is not entirely low risk. If that can be achieved there, by midwives simply having to look at why they are deviating from the normal care pathway for women, what could be achieved across the rest of the country?

Ms Beech: One of the problems with increased caesarean section rates - we are certainly seeing many more women coming to us now who have been told, "you have got a breech baby" and thanks to the Hannah trial, you have to have a caesarean section". They very much feel that they do not have a choice, and that is happening with women with twins; they are told it will be a similar exercise.

Q47  Chairman: Women should be told about the results of that trial.

Ms Beech: Absolutely.

Ms Montagu: Some of the results of other trials show slightly different results as well. The Hannah trial is not definitive by any stretch of the imagination.

Professor Dunlop: Do let us be clear that it is the best available evidence. It is the prospect of randomised control trial which came to very clear conclusions and was recently supported by another retrospective analysis from the Netherlands suggesting that there is a risk associated with vaginal breech delivery. We should not try to pretend that that is not the case. That does not mean that we should not be making efforts to reduce the incidence of vaginal delivery - and you can reduce breech presentation by 50 per cent to about 2 per cent of deliveries, by using -----

Ms Beech: We are -----

Professor Dunlop: So you are not talking about - it is not significant, but it is not a huge impact.

Q48  Chairman: In our first report, the evidence showed that two-thirds of women were not being offered the turning-round. Why is that?

Professor Dunlop: I think that was the result of the national caesarean section audit. I think you will probably find that things are changing. Can I just say in relation to caesarean section, there is increasing evidence that if you have an experienced obstetrician available in the labour ward, that intervention rates reduce. That would be the personal experience of many of us. You probably know that our college, with the other colleges and midwives and the NCT, in a report called Safer Childbirth recommended that there should be a minimum of 40 hours' consultant cover in labour wards for units delivering more than 1,000 births. At the time of the national caesarean section audit, it was about 16 per cent of units that could achieve that. In 2001 the RCOG data suggests that that has gone to 30 per cent, and last year, 2002, up to 40 per cent; so there is clear evidence of increased consultant presence at least at delivery.

Ms Francis: I should like to suggest a quite simple way of reducing the caesarean section rate. I heard on Friday from somebody who works at St George's Hospital, Tooting, where they have finally got rid of the admission trace, use of CTGs routinely in labour. The first figures through after that decision was taken shows a 5 per cent drop down to 18 per cent in sections. It is one of those things that has been known about. All the research has shown very clearly the effect of continuous monitoring, and yet we are still seeing it happen in most units.

Ms Beech: Can I challenge the comments that were made on the Hannah trial? Yes, it certainly showed that vaginal deliveries by obstetricians have produced far less satisfactory results than a caesarean section. What that study has not shown, and what it has been severely criticised for, is that it did not examine a midwife-managed vaginal deliver; and it is a very different technique. The midwives would say that they have far better outcomes - and that is the study that we need.

Q49  Chairman: What were they studying as a comparison?

Ms Beech: The obstetricians who were doing - if you have an obstetric breech delivery, the woman is usually on her back, with her feet in stirrups, and she will probably have a forceps delivery, and then the baby is manipulated as it is born. When midwives deliver babies by the breech, they encourage the woman to adopt a position that she feels happy with - and she is usually on her hands and knees - and they do not manipulate the birth.

Professor Dunlop: Let us just get it absolutely clear. There is no evidence to support that hypothesis that would be a comparison with the Hannah trial.

Ms Beech: And there is no evidence to say that vaginal breech delivery is less safe than caesarean sections. That trial did not show it; it showed that obstetric -----

Ms Phipps: The issue is not whether the data is this, that or the other; the issue is that women who have got a breech baby should be offered the opportunity to have it turned, which they can accept or decline; and they need to know the pros and cons. They should then be talked through the results of that trial and the other evidence that exists, including whatever we have from independent midwives, so that they can make a decision. It is not about us making decisions for women. They are adults and they are just about to become parents and care for another human-being. Pregnancy is a very good time to start to make sure that they are making choices for themselves and for their future children.

Ms Silverton: The increase in caesarean section rate is further worsening the workload on midwives because it takes a lot longer to look after somebody who has had a caesarean section. It does, bizarrely, result in midwives caring for women who are having caesarean sections, whereas women at low risk in normal labour are often left alone. This is what troubles them. I think it is the fear of being left alone which is very bad for midwives. We know Grantly Dick-Read's work on the cycle of fear; and fear causes pain, and pain makes labour dysfunctional.

Ms Beech: Women feel comfortable in different settings. There are women who feel comfortable in a hospital, in a high-tech unit with all the technology you can possibly have and it is no good giving them other kinds of care because they will not do as well.

Q50  Dr Taylor: Are there enough vaginal breech deliveries for obstetricians and midwives to keep up their expertise?

Professor Dunlop: That is not part of a midwife's normal duties.

Ms Beech: It used to be but it became taken over by obstetricians who said this was now a high risk situation, so midwives lost their skills.

Q51  Dr Taylor: Are there any midwives delivering breech babies vaginally now?

Ms Francis: Yes. I would question the use of the word "delivery". Women are birthing breech babies usually at home with independent midwives because we are unable to go into trusts. They are being born very successfully.

Q52  Dr Taylor: These are breech births of which you are aware which have not been turned?

Ms Francis: Absolutely. They are breech births where the woman is aware that it is a breech presentation. She has looked at the options. We are very clear about talking through the options and the woman making the choice. We will support her in that choice. What we are missing is that the number of breech babies who are undiagnosed in labour is absolutely crucial. It is crucial that midwives know how those babies are best born. That is a big area of morbidity.

Q53  Dr Taylor: There are still, despite scans and everything, a number which come the wrong way round?

Ms Francis: Yes. It only takes a few minutes for a baby to decide to turn round.

Professor Dunlop: There have been some quite high profile legal cases in recent times of breech babies dying at home.

Ms Francis: Statistically, everybody is aware that breech babies may be presenting breech because of problems. It is very easy to look with hindsight and say, "It was because of this and that" and that is one of the difficulties. If women and their independent midwives could go into hospital and have those babies born in hospital with an independent midwife and there was a different issue, we could then have a helping hand to call. We are being denied that.

Ms Montagu: It is not just that independent midwives are not able to go in with women; it is also that the women know, if they go into hospital with a baby presenting by the breech, about the amount of pressure they will come under to conform to the generally accepted way of giving birth and if they do not want a birth like that they often feel even that home is not the ideal place. Yes, the idea would be to go into the hospital with someone skilled in attending an ordinary birthing of a baby by the breech and to have all the assistance on hand, should it become necessary. That is very often not available and the woman does not feel that there is any choice.

Q54  Dr Taylor: One of the things that has come out of our inquiry so far is that the standard of data collection is abysmal pretty well across the country and it is crucial. We were impressed with the Scottish data system. People seem to approve of that. If we had that system here, would the attitude to the importance of data collection alter? I got the impression that you, Professor Dunlop, were very keen on it and some of the others felt it was rather less important.

Ms Phipps: We are very keen that data is collected. It is not right that the data is poor because then we end up with arguments because we do not have the information upon which to base it. However, we must not assume that the data set is the only information out there because it is not. There is a great deal of research. The data set should be complete and the Scottish model is very good, but the way we do it in England is poor. If you go into an NHS trust, the front end users are collecting data for multiple purposes, many of whom never see the data to use it again. It is a well known part of any IT knowledge that if you want people to collect good data they have to have access to that data in a way they can use for themselves and we do not do that in England.

Q55  Chairman: Could we just adopt the Scottish system?

Ms Phipps: I do not know it well enough just to say yes, but it needs close attention paid to it. I think it would be a useful thing to do.

Professor Dunlop: It is a simple system. It relies on a small amount of data collection and it is consistently done. I have no doubt we should be looking at this but it is important to remember that Scotland is a small country. It has a long history of data collection in this area and it also has a larger health budget.

Ms Beech: There is however a major flaw in the data collection and that is when they are collecting data on the numbers of normal births. Ask hospitals how many normal births they have and invariably they will claim to have 60, 70 or 75 per cent. The research that Sue Down did looked at what was defined as normal and it did not include artificial rupture of membranes, inductions, accelerations, epidural anaesthesia and episiotomy. If you remove that, you get the figure closer to what is a normal birth. If we are going to be talking about an objective of having a good number of women with normal births, we need to get away from the data collection which merely talks about vaginal delivery.

Q56  Chairman: I wanted to ask you whether you would agree on what a normal birth was and I was going to ask Louise what she thought a normal birth was and then see if anybody else had a view.

Ms Silverton: I am going to talk about the Scottish maternity data system first. I do not think we could just lift it and use it. There is a maternity data service which has been developed in England. Where it has gone nobody knows but your college did contribute to developing that. I think it is important to remember that the system has to be able to collect the model of care with agreed definitions that we are giving now. It has to be able to record the midwife-led care and not only where somebody is booked under an obstetrician. It has to be able to record home births. At the moment, the Scottish system is not good enough for that but it does integrate with the child health system. They have very good breast feeding statistics which continue. As to a normal birth, this is something on which we have had very long arguments. The induction of labour has not tended to be considered as normal so that can be ruled out. The issue of epidural anaesthesia is very difficult because now in some units more than 50 per cent of women have that and it does interfere with the physiology of labour. You can again rule that one out. We are minimising the number of women. Artificial rupture of membranes: again, we need to look at the research and ask why that has been done. We have to wait for the outcome of the RCM's Institute for Normal Birth which we are currently developing as a virtual institute, which is to do with promoting those aspects of care which enhance normal outcomes and include things like women being mobile during labour, having access to food and drink, having access to the use of water and the feeling of a supportive environment for her, whatever that is.

Q57  Chairman: I can tell even from your description that I am not going to get an agreement from you all about what a normal birth is. In terms of us as a Committee making recommendations, when we talked to the individual units one of the things that came across was they all wanted to do more particularly to look at the Caesarian rates, to try and give more choice to the women but they were all under huge pressures to do so. It was as if they did not have the time to think, to change. One obvious solution to that would be to have a change team in each trust that wanted it to help support them, perhaps using independent midwives or other medical staff, to give the people there time to think about their model of care and how they could change it. Would you think that sort of thing would be a good idea? I know that happened with Changing Childbirth and it did not deliver. I do not want us as a Committee to give exactly the same recommendations as happened ten years ago and fall into the same trap.

Ms Francis: That is why we wanted to put forward our model of care, sitting parallel to the existing structure. The difficulty is that when you look at the whole system as it stands at the moment it is overwhelming. Where do you start? How could you start to change it? The idea of critical mass is very much part of that. There is a very simple step, if it was to be offered as an option, so that women could choose the model of care that independent midwives offer. The midwife is paid a set fee by the trust, or whatever organisation could best do that, and that midwife then looks after a set number of women. The midwife is able to decide for herself. That way, midwives are happy; the women are happy and, in the long run, what will happen, we very strongly believe, is that those numbers will grow. Word of mouth etc., will be such that more and more will opt for that.

Q58  Chairman: The issue is still to solve the various insurance issues?

Ms Francis: Yes, except that if we were able to contract in, in the same way as pharmacists do, into the medical model, we would be able to be covered by vicarious liability. The midwives at the moment are short within the system. As a starting point, we would be offered vicarious liability in exactly the same way. However, we would like to see a change in the system towards no compensation or something similar.

Q59  Chairman: You would be covered by the trust insurance in that case. Would that be an honorary contract for each independent midwife?

Ms Francis: No. It would be about contracting in. It would be an agreement but the midwives are self-employed and agree a set number of women that they would look after. We believe it would be very simple to set up.

Ms Silverton: I think a change is a good idea but you need to give them some resources. If you look at what is happening in Scotland with the Expert Group on Acute Maternity Services for their maternity services framework, they have put quite a lot of money in for training midwives to be able to move from being medicalised and hospital based to being much more women centred and working in free-standing maternity units.

Q60  Chairman: The Department will always be concerned about having to put money into anything but the NCT has said that the existing model is probably more expensive, so we could at least encourage the Department of Health that there should be a one-off to make changes.

Ms Silverton: And to consolidate those changes. We already know that there are changes going to happen to some maternity units. This is an opportunity to try them out as lower-tech units and to have a much more mixed economy than we do at the moment and also to look at what is happening in Wales with their Normal Labour Pathway.

Ms Montagu: One of the problems with Changing Childbirth was, while everyone very much liked the ideas that were in it, the schemes that were set up were supposed to be cost neutral. This was very difficult to achieve obviously. We need to look at pump priming schemes, for instance, latching into things like Sure Start. Some of the very successful Sure Start midwifery one to one teams run for a length of time and they can be picked up by the service as a whole. We need to be taking a rather more long term view and putting a certain amount of money in in order to have schemes that achieve the critical mass that will then be able to carry on within the system.

Professor Dunlop: It is quite difficult to predict how much money we might save by transferring care from one environment to another. The costs of Caesarian sections are quite difficult to calculate because there are costs involved in setting up the maternity unit in which you can do Caesarian sections from which you cannot escape. It is quite a complicated area. It is not nearly as straightforward as people will tend to suggest, so I would not place too much reliance on persuading the Department of Health that it would save money.

Ms Phipps: I have worked in three sections in my working life, the commercial sector, the public sector and now the charitable sector. I am now going to betray those. The received wisdom is you need to have a vision if you want to change something. That is accepted by everybody and I do not think the NHS has a strong vision for what maternity care should be and could be. If you have a strong vision, it acts as an attractor and everybody moves towards it. Something needs to happen at the very top to have that vision accepted across the whole NHS. Managers fundamentally are responsible for the system and they need to set the system up so that it is likely to achieve the vision that we have. We do not have a system that works that way. Maternity is not taken enough notice of. 80 per cent of the births ought to be in midwives' hands and do not need any significant intervention. We need a system that gives power to midwives for the majority of births. Obviously obstetricians need power and money to because 20 per cent of women definitely need obstetric support. The way we work now does not work like that. One thought is the Midwifery Trust Idea but there must be other ways of achieving this. It would be very wrong to go to the front line and expect the front line to work harder when they are working quite hard enough already. If we do go to the front line and ask them to change without a vision, without changing the structure, it will not work. If we change the structure slightly and the vision, we can go to the front line, but they will need change teams and pump priming money. I do not think longer term we should put more in because we know there is money in there that is not being used appropriately. We need to expand the choice for women to make sure that women can access other services like that. We know from the Albany practice that the very women who need that individual support now get it because they have access to an Albany midwife. For women who have a good grasp of English, women who are new to this country, women who are disabled, very young, the Albany practice gives them something that we find it very difficult to give them in the system in which we work. I would say do not do Changing Childbirth again. It did not work. You need to do something more at the top. We need to measure outcomes, not activity, so let us measure how many women have a normal birth. Let us make sure we keep a grip of mortality and morbidity and let us measure some of the long term outcomes so that we do not become very short term focused. We also need to measure breast feeding because it is a significant public health issue that we do not have the breast feeding rates that we should.

Ms Francis: When you are looking at the financial implications of change, I agree that when you are trying to set up birth centres or midwifery led units, initially there may well be greater cost but we are saying we should look beyond that to the longer term. There has been a lot in the press recently about the huge increase in type two diabetes linked to obesity. If you look at breast feeding, both for mothers and babies, there is a strong correlation between breast feeding rates and reduced rates of obesity. If you could have a long term vision, you would then have massive savings.

Q61  Dr Taylor: Do you think the opportunities for choice for women have improved in the last ten years?

Ms Beech: Absolutely not. Choice is an illusion. The majority of women are conned into thinking that they have a choice. What they have is a specific menu that is offered to them. If they choose within that menu, that is fine. If they choose outside that menu, they have an enormous battle to get what they want.

Ms Francis: With CNST and the tighter protocols and policies, there is an ever more restricted choice.

Professor Dunlop: Either you say there is more choice within a menu or you say there is not. I think there is a wider menu now available than there was ten years ago. I would not agree that there is no choice. There may not be sufficient choice. I would not dispute that but I do think women have more choice now.

Q62  Dr Taylor: Could the addition of patient fora improve the way actual mothers and potential mothers, feed into the service?

Ms Phipps: They are not patients. Patient fora are not the thing to deal with maternity. You are dealing with well women going through a major, life change. The NHS has a brilliant system of involving users. MSLCs are a fantastic way of involving users because they are multidisciplinary teams of people who are given a reasonable amount of clout. The user representatives, if the MSLC works well, should be involved in not just what colour should the wallpaper be but the strategic direction of the service they are going to use. It is important for MSLCs to continue and to be strengthened.

Q63  Dr Taylor: I would agree with you that they are not patients but they are users of the health service.

Ms Phipps: Maternity is so very different from everything else. There are very few other parts of the health service where you are changing from a woman to a mother. That is a significant life change. The only equivalences are getting married or that sort of thing.

Q64  Dr Taylor: As this is the government's main aim in user involvement, rather than patient involvement, I would have thought that it is absolutely crucial for you to get people interested in maternity care involved with patient fora.

Ms Phipps: The NCT will do that as well but fundamentally one of maternity's problems is that it runs alongside other services which are life and death, fascinating, with lots of research, cardiology, heart transplants, and this is all about normal people having an every day but very special life event. It is overwhelming when you sit in a room with the most horrifying chronic or acute situations and all you have done is have a baby. It does not match up.

Q65  Chairman: Louise, in your evidence you talked about the problem of MLSCs and some being disbanded and funding issues, needing to get more people with disabilities, people in ethnic minorities and so on.

Ms Silverton: There are concerns because the statutory basis of the funding for MSLCs was with the health authorities. As an unintended drop off of the demise of health authorities, the requirement to fund MSLCs fell off. A number of primary care trusts are seeking not to fund MSLCs because they simply do not have to. That is a big concern. MSLCs are patchy. Some of them are brilliant. Some of them are of very doubtful use and effectiveness. Perhaps we ought to learn from the ones that are effective. We have talked about the professional patient but how do you get the hard to reach people to come forward, to find out what the experience of a Bangladeshi person in Tower Hamlets is of using maternity services? How do you get someone with restricted mobility or someone who has a sight impairment? How do you make sure that they are represented? The College of Health has done some excellent work on involving hard to reach groups, particularly in maternity services.

Q66  Chairman: If there were any magic solutions, we would like to hear them. In the RCOG's evidence you questioned whether the remit was right for MSLCs.

Professor Dunlop: There is enormous variability. Some are quite effective; many are not.

Ms Phipps: The NHS could make use of market research. There has been talk about over-use and focus groups but market research has a very valuable part to play in reaching people who would never come to an MSLC meeting, whose voices would never be heard. You can do quantitative surveys or small qualitative surveys among specific groups to give you fascinating information. That needs to be fed in via something like the MSLC and taken notice of. You do not always have to have round the table discussion or whatever. It would be very difficult for somebody with a disability. The only way you can reach people is to talk to lots and lots of people with disability, put their views together and make sure they are taken on board by the NHS using something like the MSLC.

Professor Dunlop: I strongly support the idea of consumer research. There is far too little of it done. As we said in our evidence, there was some work done on a pilot basis by Tina Lavender as part of the Maternity and Neonatal Workforce Working Group which produced some answers which we were not expecting. I do not think we can read too much into but it certainly needs to be followed up.

Ms Francis: One of the things that came out of that particular piece of research that I saw as well was that women do not necessarily know what their choices are. That is our argument. There is a degree of low expectation within the maternity services. When women have gone through our care and when we discharge women at 28 days, one of the most frequent comments that we get is, "We could not believe how fantastic that whole experience was." When we are asking them about their choices, we need to be sure that they are understanding what their choices are.

Q67  John Austin: Someone was talking about the number of drop-outs in the training of midwives and you mentioned bursaries. We are aware that midwives' training is funded in a different way from other university courses. Is it materially different? Are there particular problems in the way it is funded and do training employers have access to other means of financial support through the social security system that other students have?

Ms Silverton: We have two ways of funding students. Those who are on undergraduate programmes for the most part are on the student loan system and are paying fees. They are subject to the usual problems of all those students plus, for the most part, they are working many more hours than the traditional undergraduate in mediaeval history, to quote the Secretary of State. However, the majority of students who are on an NHS training basis are on a bursary of about £5,000 or £6,000 a year. This unfortunately removes some of their eligibility for things like top-up loans. They cannot get free school meals, for example, so it does create problems when accessing funding. We find particularly as our students do not tend to be 18 year olds as they come into midwifery -- many of them are single parents and of far more mature years -- they cannot survive. The drop out rate is towards the end of the second and into the third year, when they have almost finished. Unlike student nurses who are similarly funded, they do an awful lot of on-call because they want to work with their midwife and provide continuity of care and to attend home births. They are working many more hours so the ability to get a job in McDonalds, for example, is not there. They also travel a very long way on their placements and although travel costs are reimbursed we have had instances of students being up to £4,000 in debt because they have not received their travel allowance. There are bizarre systems. If you are based at home and are moved to another unit for part of your experience, you do not get your cost of rent in that unit paid. In the west country, students are going 80 to 90 miles for clinical placements and this results in them driving every day. I do not think people have looked properly at this. We are not arguing for a salary. We think students need the very minimum of between £10,000 and £12,000 a year to survive and to be able to concentrate on their training programme. Then we are not wasting money on giving them two years' training and then they have to leave because they cannot afford it.

Q68  John Austin: You mentioned that many of them will be single parents.

Ms Silverton: They are parents. They do get an allowance if they have dependents but if they have a partner the partner's income is taken into account. This seems extremely unfair where you have a low earning partner who essentially is managing to keep the student midwife and supporting the NHS in doing so.

Q69  John Austin: What about provision of childcare support?

Ms Montagu: It is hugely difficult for student midwives and often that is the straw that breaks the camel's back. Some students are single parents and if you are going to be called out at two o'clock in the morning it is not easy to get childcare. It is easy to get childcare cover nine to five but not at three o'clock in the morning. A lot of students end up being unable to find childcare that is affordable or manageable. They never finish their courses because of that.

Q70  Sandra Gidley: I ought to declare an interest because I was quite heavily involved in NCT many years ago. One of the things that concerned me particularly about NCT, although it was mostly brilliant, was we only seemed to reach the white, middle class women on average. It was very difficult to expend any sort of provision out towards other women who could not afford classes and who maybe lived in areas where there was not an NCT. I also saw last week in The BMJ an article saying that the articulate patient took up too much time and deprived other people of time. Have we reached a situation where choices are available for white, middle class women but are probably not relevant to disadvantaged groups?

Ms Silverton: It should be even more relevant.

Ms Montagu: It is not that it is not relevant; it is not available.

Ms Silverton: If you look at the Albany practice, they are looking at a group of socially deprived women who are getting one to one midwifery care and a lot of social support which will be improving their outcomes. I am not arguing against providing care for the articulate middle class because of course you do get the cascade down from that but something needs to be done to make sure that choice is available for all women and you do not simply assume that because a woman does not speak English hospital care is best for her. If she is at home, she has her family around her and she does not feel so isolated. That is what we should strive for. Also, if we are looking at employing maternity care assistants, in the same way as the midwives should reflect the local population, it is easier with maternity care assistants who live locally to make sure that they match the local population as well so that the women are cared for essentially by their own community.

Professor Dunlop: We do tend to assume that the needs of white, middle class women are what the service should cater for. I am not suggesting it should not but there is some evidence to suggest that other women may choose other things and the service does not necessarily provide them. The Tina Lavender Study highlighted that. It came up with some results that people were not expecting and that is why I said we need to support market research.

Ms Francis: As independent midwives one of our biggest difficulties is that we have to charge to offer the model of care that we give, which is why we feel so strongly about it being offered as an option within the NHS. We believe you would then address that inequality of access. If it was offered as an option to any woman wanting it, you would then be able to offer that model of care to those who could not afford it.

Ms Beech: Because AIMS has a helpline, we are approached not just by middle class women but also by working class women. We can tell that from their accents and where they are living. We have not found that they are asking for anything significantly different from what middle class women are asking for. The difference that we perceive is that some professionals take a different attitude towards them and presume that because they are inarticulate, working class or whatever they do not give them the information and they find it a lot more difficult to get the information. When they come to us, they are quite surprised at the amount of information that they can get and they act on it. They do not act any differently from middle class women. They have the same aspirations and the same beliefs. They want a fit and healthy baby and they want to be able to have an influence on the care that they have and the care that is appropriate to their needs.

Ms Phipps: The Tina Lavender Study did look at groups of women that were not white and middle class. The common theme was all women were wanting a level of control, to be involved in the decision making. Those groups are harder to read, which is all the more reason that we should offer a range of models of care, particularly the ability for women to choose their place of birth. I think the NHS is woefully inadequate in providing interpreters. I was talking to one deaf woman. Somebody who can speak to her in her own language rather than having to mouth and shout at her when she is having contractions is an issue for all organisations, the NHS and the NCT. White, middle class women have insufficient, proper, informed choice. Women who are disadvantaged or excluded in some way are far worse off; yet they want the same things.

Q71  Sandra Gidley: When it comes to breast feeding, there is a class divide. It is something that concerns a number of people because most of us would sign up to the fact that breast feeding is a good thing. Bearing in mind that you often do what friends and neighbours do, is there anything we can do to improve the breast feeding rate?

Ms Phipps: Yes. We should cease to have advertising of formula in this country. We should implement fully the WHO code. We know that, particularly with young or disadvantaged women, poor women, peer support works really well when you have somebody in your road or that you know who has breast fed. They can sit and talk to you and it becomes a group thing and you feel supported in doing that. We should train our midwives much better. Many of our midwives arrive on the wards having had very little breast feeding training, certainly nothing like the two years that a breast feeding counsellor working for the NCT gets. Those are just three things for starters.

Q72  Sandra Gidley: Would people agree with that? There is a big drop off rate. The support you get in the early days which is often hospital based or local midwives based is crucial. Do midwives have enough training?

Ms Silverton: I do not think midwives have enough time. You need to be able to sit with a woman for more than half an hour for the first breast feed to explain to her the physiology of breast feeding, to explain how she will know the baby is attached properly. You then need to do it perhaps twice more so that when the baby is five to six weeks old and that women is feeding every two hours, she thinks herself not, "I do not have enough milk" but "My baby is having a growth spurt." If women are not given the information, if they do not understand the physiological basis of breast feeding, you undermine the process. We say breast feeding is natural but being natural does not mean it is easy. It has to be learned. If we look at other societies where the final act of parenting for a mother is to assist a daughter in childbirth and to ensure that she breast feeds well, we have lost that technique. In south Yorkshire -- I think it is Pontefract; it might be Doncaster -- there is a team where they have young women who have breast fed and they are getting more young women to breast feed. It is becoming acceptable to do so. Until we can remove the perception that breasts are only sexual organs rather than being there for nourishing babies, we have major problems. Work has been done with young boys and they think breasts are dirty from the age of about nine.

Ms Phipps: We need some work in schools as well. There is a section in the infant part of school life where children of about four learn about what babies eat. The number of displays of formula tins appearing without any concomitant discussion of breast feeding is horrendous. It starts very early in life.

Ms Francis: Going back to continuity of care, one of the difficulties is that a lot of women, especially on a post-natal ward if they are there after a Caesarian section, for example, for a few days will have a huge number of different midwives. We hear very often that each midwife will have their own particular way of showing you and women end up thinking they do not know what they are doing. It is absolutely crucial that there are very straightforward, simple ways of talking to women about the best way to breast feed that will give them the information so that further on down the road, when the midwives are not there, they will be able to continue with.

Ms Beech: Two years ago I visited a hospital in Poland. They have a policy that no advertising material about bottle feeding is available anywhere in the hospital and they have a 98 per cent breast feeding rate. I said, "What do you do with a woman who wants to bottle feed?" They said, "That is fair enough. She brings in her own bottles and we will help her prepare them." It is not available and they cup feed the babies. They do not give babies bottles.

Ms Montagu: In virtually every maternity unit in the country, if a woman decides she wants to bottle feed the bottles are ready mixed with milk and they get passed out with gay abandon. If women decide they wish to bottle feed, they can but they would have to bring in their bottles, their teats, their powder and so on to make up the feeds for their babies. I think we would see an instant drop. It is so often that women say, "I would like to breast feed" and they come out of the hospital bottle feeding. That single step of making women bring their own bottles in if they want to bottle feed would make a huge difference. In Birmingham, where I am based, there are schemes called Bosom Buddies where peer support from women living in inner city areas is supporting women who want to breast feed and that has made quite a bit difference, particularly in continuance rates.

Professor Dunlop: We are all very keen to see breast feeding rates increase but it is important to remember that we are talking about informed choice and some women do choose not to. It is important that they feel supported. The other thing to remark on is the marked reduction in the amount of time women now spend in post-natal wards in hospital and therefore the reduction of availability of support within the hospital. If we are going to overcome this, there is a need for support within the community to a much greater extent than we have now.

Q73  Chairman: Louise, you were speaking about the time midwives spend with women. Are you satisfied that in training midwives are being given enough training in breast feeding?

Ms Silverton: I think they are getting enough theory. Whether they are getting enough time sitting near an experience midwife to see how it is done and working through the woman who is breast feeding, I do not know. I would say that is very variable. One of the reasons for suggesting experience maternity care assistants is that they can be trained to support breast feeding mothers, to provide additional support for midwives perhaps when the woman is at home. When I was a student midwife, women who were having Caesarian sections were in for eight days. You knew if you did not get that baby on the first day you had eight more nights and it was going to get worse so you got good at it. I was taught by the auxiliaries who had all breast fed their babies.

Q74  Chairman: What would be the recommendation from this Committee?

Ms Silverton: Student midwives need access to good role models and to see midwives helping women to breast feed, but many midwives do not have the time.

Q75  Sandra Gidley: My local unit at Southampton's Princess Anne Hospital a few years ago employed a breast feeding specialist. I think she was a nurse originally but not a midwife. She was a trained NCT breast feeding counsellor. That seems to have worked extremely well. Is that fairly unique to Southampton?

Ms Phipps: No. It happens elsewhere and it is something we would like to see more of. The NCT does have a middle class membership but we aim to reach all women and we probably reach every single woman in the country, directly or indirectly, in one way or another. More and more NHS trusts are taking on either volunteers or even paying NCT breast feeding counsellors to come into the unit and do their own thing, spending however long it takes with individual woman breast feeding for the first time. Initially, we set up a breast feeding line and publicised it last year using a poster of a woman with quite a lot of tattoos and rings and a mobile phone message. As a result, we have seen the number of calls from mobile phones from young women rise hugely. More and more the NCT is reaching people we would not otherwise reach, particularly on breast feeding issues. It is very important that women who want to bottle feed can choose to do so if that if their wish. Bottle feeding women can only get information, by and large, from formula companies. We need a leaflet out there which is not produced by a formula company but by somebody independent so that women who want to bottle feed can get objective information. Formula companies have every excuse to send out an awful lot of promotional material but if we had a straightforward leaflet on bottle feeding and on the different types of formula, what has benefits and what is irrelevant, that would help and make choices easier for women.

Q76  Chairman: For the purposes of the record, there is a lot of nodding going on in response to that.

Ms Beech: We need to take on board the insidious nature of bottle feeding advertising. Hillingdon Hospital, many years ago, was given a hearing testing machine by Milupa and above the door all they had was a tiny sign that just said "Milupa" on it. The amount of bottle feeding of Milupa products in the area went up over 300 per cent. It had a huge effect.

Ms Silverton: I want to go back to the issue of informed choice for women. Yes, we would like women to breast feed and if we do explain to them the values of breast feeding many of them will choose to breast feed. However, bottle feeding well is not easy. Many midwives have not had experience of teaching women how to make the feeds up properly. The more babies a woman has, the less likely she is to feed properly. We must not lose sight of the bottle feeding woman's right to be taught how to bottle feed safely and well for her baby.

Q77  Chairman: The RCM sent us some quite powerful evidence on racism, pointing out that the experience of older midwives from minority ethnic groups might deter younger ones from coming through. What is the solution for us in terms of making sure there is proper support for everyone? Do we need some champions?

Ms Silverton: Some work is being done led by the chief nurse assisted by the College, looking at supporting black and minority ethnic midwives, particularly midwife leaders, because in some areas it appears there is a glass ceiling. It is an issue of having appropriate role models. Valuing diversity is important in the NHS. It is something that is often trotted out but it has to mean it and it has to mean that all midwives have access to opportunities for development, training, progress on the basis of being a good midwife, not on any other basis.

Q78  Chairman: We have seen fairly unequal access to things like birthing pools and TENS machines. Are there any views on whether there is a big, unmet demand in these areas? TENS machines tend to be rented or bought by individuals. Should these be more freely available across the NHS?

Ms Francis: The problem with birth pools is not the birth pools; it is finding midwives who feel comfortable with water births. A huge number of women come to us saying that is what they would like and they cannot find a midwife able to provide that.

Q79  Chairman: There is an unmet demand there and not enough training?

Ms Beech: Yes. One of the problems is that the trusts will provide a pool and then they do not provide a rolling programme to ensure that every midwife on the unit knows how to deliver a woman in water. They are quite prepared to rely on informing the woman that she has to get out of the water. I think they are putting themselves at considerable risk of litigation if they end up with a woman who sits in the pool saying, "I am not moving" and the midwife says, "What am I going to do now?" The risk managers do not seem to factor that into their calculations when they are thinking about risk.

Ms Phipps: There are two issues. One is the availability of pools. Every woman in labour should have access to one and that means she has to have the midwives around to do that 24/7, not that it is okay except for Bank Holidays or whatever. There is a huge amount of evidence about how beneficial water is in labour.

Q80  Chairman: There is not enough access at the moment?

Ms Phipps: Physically there need to be the pools and that is a problem in some places but over and above that they be there but they are not being used.

Ms Montagu: It struck me as quite bizarre that it seems optional for management that if midwives from a unit feel they do not want to support women in water, they do not feel they can force the midwives to train to look after women in water. If a midwife said, "I do not feel I want to look after women having epidurals or Caesarian sections" the managers would tell them not to be stupid and that it was part of their job.

Professor Dunlop: I wonder if I could ask my colleagues whether they feel that a water birth is a normal labour.

Ms Beech: Women are perfectly capable of having a normal labour in a pool.

Professor Dunlop: Is it not a form of intervention?

Q81  Chairman: What about the TENS machine issue? Some women are able to bring in their own TENS machines. Is there any evidence that some people are put off because of the costs?

Ms Francis: The idea is that you put a TENS machine on quite early in labour. If you are trying to access it through a maternity unit, hopefully you are not going in until you are further down the road. Unless it was available through antenatal clinics, where they will be able to show women how to use them, they are not going to be of much use.

Q82  Chairman: On wider staffing issues, we have evidence from many people in many different professions. I wondered from your point of view whether there are other staffing issues? We have talked about midwives but are there other issues? Somebody mentioned a neonatal review. We have had mention that there could be advanced nursing, neonatal practitioners, who will in future take on more roles that junior doctors are currently doing. Is that a big issue that we need to look at? We have had evidence from anaesthetists saying we need more consultant anaesthetists and that some of the work consultant anaesthetists do in terms of giving women information about analgesia could be done by other people, say, physiotherapists. Physiotherapy services are not always available in labour as much as they should be. From your perspective, are these issues that come up in your organisations?

Ms Silverton: To go back to midwifery, separate from the shortage of midwives, we have very uneven coverage of consultant midwives. Some units might have four. Other units have areas where there are not any at all. For the most part, the consultant midwives are in posts which enhance the role of the midwife. They are in labour wards looking to encourage normal labour. They are running active birth centres attached to consultant units. They are in public health posts, increasing breast feeding rates, working with disadvantaged communities, and we would like to see many more consultant midwives.

Professor Dunlop: There is a crisis facing the health service but in particular the maternity service in relation to the European Working Time Directive. There will be problems in 2004. There will be a major crisis in 2009. Part of the problem is that a lot of care in this country is delivered by untrained doctors in sharp contradistinction to most of the rest of Europe and North America. We have relied for far too long on people who have not completed training to give care and that cannot continue under the new regulations. There is a big need to increase the number of trained individuals to provide care. We are not going to be able to do that in the timescale we are talking about. There have to be other ways found of trying to find specialists. One of the things we have been suggesting very strongly to the Department is that we know there are 180 doctors who were sent letters by the Specialist Training Authority at the time of the transition into the new arrangements of the Carman training scheme, who were told that they required two additional years of training to complete their training to get on the specialist register. I am not suggesting that all of these individuals would necessarily become specialists but there is a group of people who could very rapidly train and we are trying to address that. For years we had a very effective overseas doctors' training scheme which brought may overseas doctors to this country where they completed training and many of them remained in consultant posts. That scheme has effectively been dismantled. We now have an overseas doctors' fellowship scheme which caters for very much smaller numbers of more highly selected individuals. Looking at overseas recruitment, it would be much more profitable to look at doctors who require a small amount of training in this country to complete their training than to try to import specialists. Ms Francis: It would seem sensible on that basis that anything that reduced obstetric intervention and the Caesarian section rate would help that problem.

Professor Dunlop: I do not think that is the case. That is an over-simplification. We are talking about staffing a reducing number of consultant units day and night by a trained obstetrician. I do not think that reducing intervention will make the slightest difference to that. We still need people on the ground, 24 hours a day, seven days a week, in order to provide emergency care.

Q83  Dr Taylor: I think we are very well aware of that and a number of us are trying to get an adjournment debate that will bring in just this subject. When we are looking at the future work that the Committee is going to do, I and perhaps others will be pushing this as something we ought to look at because it does threaten hospital services as we know them in all specialties.

Professor Dunlop: Yes. It is important to realise that obstetrics are different from any other specialty. There are initiatives looking at covering the acute hospital at night, for example, that will not apply in other specialties. The same is true of paediatrics. There is one hospital in this country where there is a group of advanced neonatal nurse practitioners providing care. It is not certain that that is economically viable or sustainable and at this stage I do not think we would be backing it. When we asked our members, both registrars and consultants, whether they thought an obstetric unit should have 24 hour neonatal cover, the answer was yes.

Ms Beech: There are two issues here. One, if we accept that 80 per cent of women are expecting to have normal births and that the midwives are responsible for referring on, why have we consultants covering 100 per cent of women? We really need to be looking at what precisely the consultant is there for. As I understood it from the report that recommended 40 per cent increase in consultant cover, it was for high risk women and the low risk women would be looked after by the midwives. The very serious problem that we have is this dreadful shortage of midwives. That is an even greater problem than the shortage of obstetricians and trainee doctors. It does not seem to surface anywhere.

Ms Silverton: I would support that. Midwives do a considerable amount of on-call. If we are going to go to different models of care with core staff and midwives providing case load or small team care, the level of on-call will increase. Shortly, midwives will not be able to be rostered to be on duty the morning after they have been on call so it is going to further exacerbate the shortage of midwives.

Ms Phipps: We have omitted a really important part of the whole birth and parenting process and that is fathers. I do not think we need a different sort of member of staff to support fathers but fathers definitely do need support. I would urge that our midwives are better trained to communicate directly with men. They tend to communicate with fathers through women and we know that is not satisfactory for men. It is really important for families that dads feel very involved and able to support the mum and the new baby after the birth and to feel part of the whole process.

Ms Beech: Going back to choice and home births, one of the issues that concerns AIMS at the moment is the numbers of women who are having unattended home births because they cannot get the staff to attend them or they lose confidence with the discussions and arguments with the trusts about what is or is not allowed, what they will or will not do. We are seeing more women saying, "I do not trust the midwives to do what I want them to do." They are fixated on the hospital policy and if you look at the Nadine Edwards PhD research on the negotiations that women and midwives have to do there is huge pressure on midwives when they come out to a home birth if it does not fit this very restricted criterion of low risk. The midwife is then trying to balance between trying to give the woman the service that she wants and trying to keep the director of midwifery off her back or the trust off her back, who is criticising her for staying out there. It puts so much stress and strain on some women that they say, "I am going to give birth on my own and I am going to call them afterwards."

Q84  Chairman: That is actually happening?

Ms Beech: Yes.

Q85  Chairman: The solution to that is obviously better training and using independent midwives.

Ms Beech: If we have targets for home births and we have a community based midwifery service and the ability for independent midwives to contract in, I think we will then get more midwives who are going to be confident at helping women birth at home.

Ms Francis: As independent midwives we would be very keen to be involved in apprenticeship schemes or some sort of training where students can come out with us.

Professor Dunlop: We have heard a great deal about roles this afternoon and I think we should be concentrating on team work. We have not heard nearly enough about that.

Chairman: To comfort you, I am pleased to say that when we have had each unit we have had that really strong team approach. Can I thank you very much for all your evidence today? We do appreciate all the information you have been able to give us.