Changing Childbirth Again? The implications for maternity care of the National Service Framework.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 11th November 2004. The meeting was chaired by Dr Luke Zander, retired General Practitioner.

The report is to be published in The Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

This link takes you to the Maternity NSF as a PDF file, read in Adobe Acrobat Reader. You can save it to your computer using Save As from the File menu of the PDF.

Who, where, when and how? The implications of the NSF for the maternity care workforce.
Jane Sandall (JS), Professor of Midwifery and Women's Health, Nightingale School of Nursing and Midwifery, King's College, London.

The organisation of health care depends very much on politics, culture, and structural forces, but maternity is different from other types of health care, being concerned with the reproduction of society and the essential task of normality. The National Service Framework (NSF) focuses on the health of mothers and inequalities in health; "Improving the health and welfare of mothers and their children is the surest way to ensure the health of the nation" is a comment in the foreword of the NSF echoing similar points made at the turn of the last century. There has been little success in achieving the hopes enshrined in Changing Childbirth, and this applies to midwives' guardianship of 'normal' birth. These disappointing facts have informed the NSF and the National Institute of Clinical Excellence (NICE) guidelines. Whatever the intentions of policy makers may be, policy is what is delivered at the front line, and the commitment of professionals to provide individualised care may come into conflict with other policies requiring equity in a system designed for the mass processing of childbearing women.

As result of the external working-time directives and the Department of Health (DoH) new workforce programme, there will be changes in professional working boundaries. There will be more hands-on care by senior medical staff, and an increased role for midwives including midwife led services, recognising that they produce outcomes at least as good as care by obstetricians for women who are not at high risk of complications. These key changes would probably take place with or without the NSF.

The NSF is committed to flexible individualised services designed to fit around the woman and her baby's journey through pregnancy and motherhood, with emphasis on the needs of vulnerable and disadvantaged women. Standard 11 of the NSF is for women to have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies. It recognises that for the majority of women, pregnancy and childbirth are straightforward processes and events, during which medical interventions should only be recommended if they are of demonstrable benefit to mother and child. The provision of information about choices and service provision in pregnancy and childbirth is paramount. The quality of care has a long term impact on children's and the public health, and partners and significant others have an important influence. The NSF aims for the location of services for childbirth to be as close to home as possible, within a maternity network affording appropriate levels of care for women and babies with complications. Thus a non-interventionist service for women at low risk, focusing on normal birth, should be community based and woman centred. The aim is for care to be provided by the right person at the right place, at the right time and with the right skills, and for more user involvement. Other aims are direct access to named midwives providing continuity of care, strong contacts with advocates and general practitioners, and multi-agency working.

Current birth care incorporates much of the above in some places already; in addition users should be offered the choice of place of birth and one-to-one care in labour. The staff and their equipment will need to be based in the community; when tasks are shifted the responsibility must move with them. In order to deliver this, midwives will have to decide what and how much to delegate to maternity care assistants during and after birth. For the specified three month postnatal care period training issues, including the examination of the newborn and the relationship with health visitors, will be very important for midwives.

Community based midwifery group practices could be co-located with sexual health and children's services in children's centres. They will have to take on new ways of working, integrate efficiently with tertiary care and manage flexible budgets. We will need full-hearted support for community midwifery care, moving the emphasis away from the specialist midwifery in hospitals which currently receives the most attention.

The NSF - delivering for women? Will the NSF change the experience of childbirth for women?
Richard Hallett (RH), Chair, Eastbourne Maternity Services Liaison Committee.

To answer the question in my title, I believe that the NSF can and will change the experience of childbirth for women.

Extracts from the NSF:

Standard 11 recognises that, for the majority of women, pregnancy and childbirth are normal life events; it aims to promote women's experience of having choice and control in giving birth to their baby. The standard seeks to improve equity of access to maternity services, which will increase the survival rates and life chances of children from disadvantaged backgrounds. It also aims to ensure that all mothers and babies receive high quality clinical services, providing high quality midwifery, obstetric and neonatal services in a culturally sensitive way, together with effective family support, focused on those with high needs. Primary Care Trusts, in partnership with local authorities, will wish to focus on some of these in setting local targets.

This NSF is based on the care pathway approach. Care pathways are used to illustrate the woman's progress through the variety of services available. They have emerged in the past decade as an important technique for continuous quality improvement in healthcare and are increasingly seen as a key NHS resource.

Services delivered through the care pathway approach will be integrated by the introduction of Managed Maternity and Neonatal Care Networks (MM & NCN). These are linked groups of health professionals and organisations from primary, secondary and tertiary care, and social services and other services, working together in a co-ordinated manner, to ensure an equitable provision of high quality, clinically effective care.

The Vision. Flexible individualised services designed to fit around the woman and her baby's journey through pregnancy and motherhood, with emphasis on the needs of vulnerable and disadvantaged women. Women being supported and encouraged to have as normal a pregnancy and birth as possible, with medical interventions recommended to them only if they are of benefit to the woman or her baby. Midwifery and obstetric care being based on providing good clinical and psychological outcomes for the woman and baby, while putting equal emphasis on helping new parents prepare for parenthood. Community-based facilities are fully equipped and staff have the skills for initial management and referral of obstetric and neonatal emergencies. Consultant-led services have adequate facilities, expertise, capacity and backup for timely and comprehensive obstetric emergency care, including transfer to intensive care.

The vision gives some very clear messages, and the scope of the NSF is as wide as you could wish:

The danger for maternity services is that any one emphasis within the vision becomes too dominant. Medical care has become too centralised in large hospitals; the normality agenda can express hostility toward anything medical, and the vulnerable and disadvantaged may be sidelined by both.

The balance of these tendencies will need continuous reassessment, and the imperatives of the NSF provide balance, partly by encouraging new integrated ways of working, but also by placing the woman at the centre of the service.

Evidence-based care, monitoring and data collection are to be characterised by honesty and openness, and reinforced by programmes of user feedback. We all, doctors, midwives and users have to be the change we want to see, not leaving it to others.

The success of the NSF will depend also on the resources available to it, on adequate staffing, midwifery leadership, and a clear plan of implementation. Will it have teeth? The teeth are there to be used. The decision of the Nursing and Midwifery Council (NMC) to require The Commission for Healthcare Audit and Inspection (CHAI) to include in their trust audits an assessment of user involvement can be effective, provided users are prepared to be involved constructively. A business would die if it did not keep close to its consumers; the MSLC is a conduit through which maternity providers can keep close to their consumers, and self audit will ensure that its activities and effectiveness are constantly under review.

The NSF's expected standard is that women will have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies. Will it change the experience of childbirth for women? I believe it can, because everything recommended in the NSF is being done well somewhere right now.

Pounds, Preference and partnership: the challenge of managing choice.
Sue Eardley (SE), Chair, Mayday Healthcare NHS Trust, and member of the External Working group contributing to Standard 11.

The NSF includes four phrases which are keys to the care of expectant women and their families:

  • Flexible individualized care
  • Emphasis on the the needs of vulnerable and disabled women
  • Good clinical and psychological outcomes
  • Kindness, support and respect

    The NSF challenges us to change the way we work to offer all women real choice to suit their individual needs, which while it may not mean choice of hospital, guarantees choice of the type of care and birth of their baby. It means having the right, consistent information from all health professionals with whom they interact and trusting confident relationships between them.

    The challenge of this choice lies in having sufficient trained staff able to support the maternity process and refer between organizations depending on the women's needs and wishes. The NSF provides a framework for new ways of working and changing roles to attract midwives back to the profession and to encourage other supporting roles so that midwives do what only they can do. This is probably the biggest short term challenge to all units, as without sufficient, motivated staff few of the aspirations of the NSF are wholly possible.

    Meeting the specific needs of vulnerable and disabled women may be seen as hard to implement and hard to audit, but there are many examples across the country where these are working well – the NSF encourages such initiatives in partnership with community support. It aims for good clinical and psychological outcomes, with important implications for mental health, child protection, and the wellbeing of the whole family, and midwives are perfectly equipped to lead the co-ordination of holistic care during the maternity journey.

    The profile of maternity services must be raised to achieve greater priority with hospital and primary care trusts; for many families maternity care is their earliest major experience of the NHS, and it could influence their future choice of care provider. This is best achieved by evidence of improved quality of care, modernisation of techniques and flexible, motivated staffing. No new money is associated with the NSF beyond support for Health Authorities to facilitate networks, but since everything the NSF requires is being done now somewhere in the health service, we must look around, learn, and plan the necessary changes. The maternity workforce is hugely understaffed, and will need clinical strong leadership and support to reorganise using, for example, maternity care assistants in clinical or clerical settings. Midwives may become the focal point leading the professional team to ensure women in their care move seamlessly through the systems of advice and help available, towards a birth experience that meets their expectations.

    None of this happens in isolation, and building partnerships with trust boards, the voluntary sector, Patient and Public Involvement (PPI) Forums, and local authority departments is essential. Maternity Services Liaison Committees (MSLCs), linking professionals and users across the care pathway, will have an important role in monitoring the NSF. Stimulating change, building and developing partnerships, the NSF offers the challenge to professionals and the public of real involvement in the success of the service.

    With all the possibilities ahead it is easy to become disheartened by current pressures and priorites. We must remember that the NSF is a ten year plan, moving towards the aspirations shared by most maternity professionals and communities – making work what works locally. The professionals need to use it to create that service.


    Following Professor Sandall's presentation the chair recalled the excitement with which Changing Childbirth was received over 10 years ago, and compared this with the lower key reception which the NSF has had, despite its many promises of improvement in the maternity services.

    Beverley Beech of AIMS: There is a lack of balance in the maternity services, with the medical model heavily outweighing normality. Less than one in ten women are getting a normal birth. Is the NSF going to restore some semblance of balance? Government and trusts have not to date shown enthusiasm for change, and I cannot see how the service will change for women until it is community based with midwives carrying their own caseloads. We are still knocking on the same doors ten years after Changing Childbirth.

    Change will require extensive retraining.

    (Wendy Savage) For this to work the majority of midwives will have to come out of the hospitals and work in the community. So much has been lost since the advent of risk management. We need many primary care midwives and secondary care specialist midwives in the hospitals.

    (Lesley Page) Continuity of care is very difficult to achieve in large institutions. I am concerned that with the establishment of MM & NCN, which are key to a successful service, the system does not become unbalanced by higher recruitment numbers to the hospitals than to the community, as is the case in London at present.

    JS: Community midwives too often have their offices located in acute hospital trusts; how then can they know their communities? I am concerned that best care of women with complicated pregnancies and labours should not take second place.

    SE: Other NSFs have been published and implemented in the past few years, and we have been able to learn from them; they have led to demonstrable change, bringing the NHS up to date - they do have teeth. Different ways of working have been accepted, and sensible contracts agreed. The NSF is saying "If you think it works and can prove it works, go ahead and do it", and that goes for community midwifery. Nothing in the NSF rules it out. The detail of change is for local decision. The opportunity is being recognised; as the agenda for change comes in everyone's skills and competences are being assessed, as never before with Cumberlege and Winterton. Furthermore this government is taking user involvement seriously; women and their families will now have some clout.

    RH: If you want to set up midwife led units or keep them going, visit those which are succeeding and find out how they did it. Achieving results means contacting all the providers and users of the service: district general hospitals and their obstetricians, GPs, midwives, and users. We have to work together rather than blame each other.

    A former NHS community midwife now working independently: If pay structure, recruitment and retention are to be adequate, the work of community midwives needs to be understood and respected, by managers, obstetricians and hospital midwives. Too often when a mother is transferred from the community to hospital the foregoing work of the community midwife is completely ignored.

    SE: We will need to accommodate staff preferences where flexible working is concerned; the NSF gives the opportunity for midwives to earn respect by proving that they can work in different ways. The maternity service is one of a hospital's shop windows, and families become involved with it at a time in their lives when they have very little other contact with the health service. A good maternity experience will form their opinions of a hospital as a whole. This, and impressing the clinical governance committee, are useful ways for a maternity service to come to the notice of a trust board.

    Seldom if ever are women asked for their opinions of a maternity service.

    The appointment of consultant midwives will usefully increase the influence of midwifery as a whole.

    Responding to a question from the chair it was reported that more than enough midwives are keen to work in the community. A manager, however, expressed the anxiety that the drain from hospitals could result in a loss of consultant obstetricians, paediatricians, and anaesthetists.

    A Royal College of Midwives questionnaire has shown a preference for working in teams in the primary care setting.

    A NMC visitor has identified a funding problem: despite the stated preference by midwives for midwife led units, trusts are reluctant to support them financially. There are significant training implications which will require investment.

    There are midwives at present working in hospitals who are keen to move to the community, but they are waiting until there is adequate funding there. I believe that this funding should come from Children's Trusts and not from acute NHS hospital trusts.

    The chair picked up on this reference to the Children's Trusts, and asked Heather Mellows (Junior Vice President, The Royal College of Obstetricians and Gynaecologists and Co-Chair of the External Working Group: Maternity of the NSF)  to comment on whether they would indeed be the physical base for midwives working in the community. She could not confirm this, but the children's centres might serve this purpose. She believes that managed maternity networks, which reach widely into the social system, will have an important place in the working of the NSF. These should guarantee a woman's smooth passage through the system of maternity care, ensuring that she gets any necessary advice and support in a coordinated way from the time of her first contact. The best way for this NSF to improve the maternity services is by reacting to measures of patient satisfaction as gathered by all the professionals and by the Health Care Commission reviewers; a numerical target for this cannot be achieved. Success will depend on teamwork between midwives, obstetricians and all concerned in maternity care.

    RH: It is a great privilege to be a member of a multidisciplinary team such as the MSLC which is in a position to effect change.

    JS: The policy context has changed in the past ten years, and this gives us opportunities to make improvements with or without the NSF. We will make the best of these opportunities by looking at the services from a woman's point of view.

    SE: Always keep equity in mind. This NSF is a ten year plan, so do not expect everything to change at once. Other areas of health care have shown that a NSF can be made to work within the financial constraints; it is up to you and your teamwork.

    From the chair Luke Zander reflected in conclusion that one template is not likely to suit the whole country; flexible working within localities will probably become the+ norm. If everything is being done well somewhere now we need a clearing house by which to share the knowledge and experience which exists. JS referred the meeting to the Caseloadmidwifery website (then click on Join or leave the list). Reference was also made to the MSLC website where guidelines and shared practical examples of practice can be found.