Back to the future

AIMS Journal, 2016, Vol 28 No 2

Gill Boden and Beverley Beech look at what has not happened since Changing Childbirth

Since our last journal the Maternity Review for England has reported. There is, unsurprisingly, emphasis on safer care, better postnatal and perinatal mental health care, multi-professional working and personalised care, all of which is to be welcomed, but the great cause for celebration among childbirth activists, and the element that we feel will most clearly improve all the outcomes of birth, is the strong emphasis on continuity of carer.

The chair, Dame Julia Cumberlege, in her foreword says:

'We found almost total unanimity from mothers that they want their midwife to be with them from the start, through pregnancy, birth and then after birth. Time and again mothers said that they hardly ever saw the same professional twice, they found themselves repeating the same story because their notes had not been read. That is unacceptable, inefficient and must change.'

Annie Francis looks at the Maternity Review in more depth on page 19.

Many of the recommendations echo previous reports, as Tania McIntosh shows on page 6, including the earlier Cumberlege report, about which Julia Cumberlege says:

'20 years ago I produced a report as a government minister, Changing Childbirth, which sought to describe a modern maternity service, as we moved into a new century. Great strides have been made in transforming maternity services in those last two decades. Despite the increasing numbers and complexity of births, the quality and outcomes of maternity services have improved significantly over the last decade. The stillbirth and neonatal mortality rate in England has fallen by over 20% in the last ten years.'

We welcomed that report too. At the time it seemed possible that the UK could achieve an enviable position internationally, with healthy mothers supported by welltrained midwives who respect their autonomy, mothers with complicated pregnancies given the specialist treatment they need and birth seen as a social, psychological and spiritual event which is part of family life.

This ideal is nowhere near being met and it must be due largely to the impact of underfunding of the services, the way they are structured around obstetric units, shortages and fragmentation of midwifery care, and a risk-averse culture that tends to concentrate resources on the acute services. This new report emphasises the preventative power of continuity of care and carer to keep the vast majority of women healthy and confident throughout their pregnancy. This could achieve straightforward births with low demands on the health service in the long run and with huge benefits long-term in public health; the research evidence shows that continuity of carer reduces pre-term birth and early fetal loss.

The current review introduces the principle of NHS Personal Maternity Care Budgets. While sufficient resources are crucial and the notion that the funding should follow the woman is important, concerns have been expressed that the principle of personal budgets and vouchers, rather than appropriate spending on each woman according to her needs, could be a Trojan Horse which could allow for topping-up with private care, causing further inequality and fragmentation of the services. This is something that we hope to explore in detail in future issues of the journal.

There is no doubt that we have an opportunity for positive change but it depends, to a large extent, on midwives and women working together. In April we helped to organise a conference, Celebrating Continuity, with Neighbourhood Midwives, the Positive Birth Movement, Sandwell and West Birmingham Trust and the Royal College of Midwives. We hope this conference will be a significant turning point in making continuity of carer a reality for many more women over the next few years: our summer journal will focus on the issues and ideas that emerged, along with a review for those who weren't able to join us on the day. A second conference is planned in the north of England later this year.

In this journal we explore some of the consequences that arise when services are under-resourced and riskaverse. The extent and effects of obstetric violence, bullying and how women's rights and confidence are eroded are highlighted particularly by Hannah Gray's account, on page 21, of how midwives attempted to use Social Services to punish her family, and Sarah Holdway's problems with her health visitor, on page 23. There is real opportunity for change: women and midwives need to make clear demands to make sure that the principles underlying successive government reports are delivered in practice.

Gill Boden and Beverley Beech