A celebration and a warning

AIMS Journal, 2016, Vol 28 No 2

Tania McIntosh looks at Changing Childbirth

Being a historian as well as a midwife brings rewards and challenges. It gives me a different slant on things, and can be helpful in putting shortterm worries about maternity care into a longer-term perspective.

Mostly this can be a positive experience, but occasionally it gives me the sense of being trapped on a merry-go-round. Things change but they also stay the same. A case-in-point is national reports into the maternity services. Since 1959, when the Cranbrook report was published (recommending that beds should be available for 75% of women to have their babies in hospital), reports seem to come round on average every ten years. The Peel Report of 1970 worried about the cost effectiveness of domiciliary midwifery services and said that there should be hospital beds available for all birthing women. The Short Report (1980) decided that birth was analogous to an intensive care situation in terms of the catalogue of dangers it unleashed, and came within a whisker of outlawing home birth. Both Short and Peel are remembered and condemned by midwives and consumer groups for their one-size-fits all approach to birth; with the one size very much being a hospital birth, preferably in sterile conditions. The last big report was Maternity Matters, which came out in 2007 and which, until recently at least, the government was claiming was still the foundation for maternity policy in England and Wales. And now we have a new report, the National Maternity Review, chaired by Baroness Cumberlege and charged with having another look at the organisation of maternity services.

Ok, so I have missed something out: a title that is still referenced and remembered by midwives and consumer groups with affection and pride. That publication is Changing Childbirth, which came out in the early 1990s and changed everything. Although it focused on England and Wales, the debate it unleashed crossed continents. The talismanic power of Changing Childbirth is, I suspect, one of the reasons why there is hope around the current National Maternity Review. Julia Cumberlege, who chaired the group who developed Changing Childbirth, is also leading on this current review. This article explores why Changing Childbirth was so revolutionary and so powerful and why, ultimately, it was unable to change everything in the ways that it seemed to promise. It is a thought provoking tale, reminding us that whatever the long view of history, time and place are everything.

'Changing Childbirth' is mostly used as something of a portmanteau term to bring together what were in fact two separate reports. The first report was arguably the more significant, but lacked a catchy title or the fetching orange cover we associate with the printed version of Changing Childbirth. In 1991 the House of Commons Select Committee on Health, under the Chairmanship of Conservative MP Nicholas Winter ton, took it upon itself to explore the state of maternity services. This was done at the behest of another politician, Labour MP Audrey Wise, who had been horrified at the content of the Short Report and the way in which it demonised the experience of pregnancy and birth.¹ Consumer groups such as AIMS had been rubbing against government policy and obstetric will for some years; the active birth movement was growing, as was debate around the safety and utility of increasingly routine interventions such as ultrasound. However, in terms of taking evidence, what the Winterton committee did, and how they did it, was revolutionary. As Winterton said:

'We allowed virtually any interested body or individual to give evidence... we were able to interview individual women who had actually given birth at home... allowing a mother who had recently given birth actually to breastfeed while giving evidence.'¹

The committee took evidence from women, consumer groups and midwives as well as policy makers and doctors. The idea of taking submissions from midwifery groups, never mind lay people, when considering the maternity services was startling. Cranbrook, Peel and Short had relied primarily on 'experts'; by whom they meant medical practitioners in one guise or another. Needless to say, obstetricians were not enamoured of the Winterton report when it came out, feeling their point of view and expertise had been marginalised in favour of mere women.

A further clue to the revolutionary nature of the committee's work can be found in the AIMS quarterly journal for the autumn of 1991, which across three pages reviews the submission the organisation made to the Select Committee. In some ways the submission has a slightly off-kilter quality, because it seems so recognisable yet somehow so different. This is partly because of the use of language; concepts like 'control' and 'continuity', which were to first have expression in the Winter ton Report, are only hinted at in AIMS's work, but the direction of travel is clear.

AIMS said:

'... women should be able to choose a midwife as the first point of contact for maternity care... the midwife should be able to decide, with the woman, on the most appropriate antenatal care for each mother booked...'

Choice, partnership working ... concepts which now we take for granted in terms of rhetoric if not always of action but which were almost subversive at the time (as evidenced by the Medical Defence Union, which, as AIMS pointed out, used to advise doctors that women did not need to consent specifically to anything that happened to them in hospital; the act of walking through the door was taken to imply consent).

However, the document, together with those from other groups such as NCT, was revolutionary not just because of the language it used and the ground it covered, but in the way it brought evidence to bear on issues. 49 separate pieces of evidence were cited by AIMS in support of their arguments. The submission included evidence around place of birth, types of birth, birth attendant and interventions; it ran to 30,000 words and was apparently produced in eight weeks. Using evidence was still a new concept in maternity; as Archie Cochrane had once complained, the maternity services were a notoriously evidence free environment where the expert held sway.² Evidence given to the Winterton Committee by various groups including AIMS challenged the message around maternity care by using evidence instead of simply belief.

Apart from the ideas discussed and the evidence brought to bear, the other revolutionary element of the submissions by AIMS and others was that the committee accepted it at all. Shock piled on shock when the report came out in March 1992; AIMS had not only been received sympathetically, they had been listened to and heeded. Beverley Beech commented in the AIMS Journal that the presentation of the report by Winterton had 'the quality of a dream' and that to hear women put centre stage meant that 'some of us burst into tears'.

It was not hard to see why; the Winterton report accepted there was no evidence that hospital birth was the safest option and no reason why women should not have choice in maternity care. In the same edition of the journal, Beech hinted at ructions to come; midwives were gleeful, obstetricians harrumphed, insisting that honestly they did know best and had ever yone's best interests at heart. Once the initial euphoria wore off, AIMS reflected the concern that the government of the day more or less buried the report alive by damning it with faint praise and 'offering an expert committee' to look in more detail at the issues raised by Winterton. There was a strong sense towards the end of 1992 that the Winterton report had flared briefly and brightly but would quickly be forgotten.

If the government hoped that 'the Expert Maternity Group' would bury Winterton, then they were very much in for a surprise. In the spring of 1993 Changing Childbirth, as the Group titled their report, was published and many at AIMS burst into tears all over again. Changing Childbirth put the woman at the centre of care, calling for known carers and respectful and meaningful communication between all involved. Some of the language mirrored the submission put forward by AIMS: 'The woman must be the focus of maternity care. She should be able to feel that she is in control of what is happening to her and able to make decisions about her care, based on her needs, having first discussed matters fully with the health professionals involved.'³

It was about more than just language however ; the whole point of the document was that it was a call to arms and that it would be a catalyst for real change. Looking back, Cumberlege reflected that:

'So we were determined it wasn't just going to be a philosophical document, it was actually going to have action plans, targets and we wanted a grip to try and get things to happen...'⁴

In some ways the Winterton and Cumberlege reports changed everything. They were helped by the simplicity and power of the message, a fact that was recognised by Cumberlege:

'I do remember having to go before television cameras thinking this is really a very comprehensive report, how am I going to put over in three minutes the essence of this report, and that is where the three Cs arose, because I had to boil it down in my head, and so it was about choice, continuity and control.'⁴

The language of Changing Childbirth has remained embedded in the maternity services. However, the simplicity of the message masked the complexities of translating words into action. As Nadine Edwards pointed out at the time, the report was not government policy, only a consultative document.⁵ The imperative to action could be twisted, watered down or ignored. The challenge was to take the power of the rhetoric and translate it into practice and in this Changing Childbirth stumbled. This was partly because it skated over the difficulties of bringing different groups and disparate services together in a coherent whole. More fundamentally it missed the signs that medicalisation, yoked to obstetric and social complexity, was increasing and would continue to do so.

The challenge of the current National Maternity Review and everything it brings in its wake is to learn the lesson of Changing Childbirth. The language can be as powerful as you like, the research as clear-cut and definite, but without coherent strategies for managing different stakeholders and demands, the move to action is easily lost.

References

1. McIntosh T (ed) (2014) Changing Childbirth Seminar. Unpublished.
2. Cochrane AL (1972) Effectiveness and Efficiency: random reflections on health services. Nuffield Provincial Hospitals Trust. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/Effectiveness_and _Efficiency.pdf
3. DoH (1993) Changing Childbirth: Report of the Expert Maternity Group Pt.1. Stationery Office Books. London.
4. McIntosh T and Hunter B (2014) 'Unfinished business'? Reflections on Changing Childbirth 20 years on. Midwifery, dx.doi.org/10.1016/j.midw.2013.12.006
5. Edwards N (1993) AIMS Journal Vol:5 No:3.