Recorded Delivery

By Michelle Barnes

AIMS Journal 2007, Vol 19, No 3

A national survey of women's experience of maternity care

This survey was conducted using a random sample of 4800 women, using birth registration for births in one week in March 2006. The questions used were similar to the last survey which was conducted in 1995. The study findings provide a picture of current practice and a way of measuring change over the last ten years and in the future.

Antenatal period

82.5% of women still see their GP as first point of contact. Only 12.7% see a midwife first. Why?

Compared with 1995, women now have less choice in where antenatal checks take place. Almost everyone is seen either in hospital or a local surgery. Convenient for whom?

Pain and discomfort of labour worried women the most. Concerns I feel could be addressed with appropriate information and reassurance. Yet only 38.2% of women talked to a Health Professional about what happened during labour and birth. 37% didn't even receive The Pregnancy Book.

Only 71% of women indicated being offered antenatal classes, of which some of the women commented were inadequate and just skimmed over the important issues. What this survey doesn't tell you is how many of the women who were offered antenatal classes actually attended them and if they didn't attend classes, why?

The number of scans women had in 2006 was greater than that reported in 1995. What difference in outcome has this made? Not all women felt they had a choice about whether to have a scan or not.

39% of women indicated that they only had the option of going to one hospital compared with 45% of women in 1995.

97% of women gave birth in hospital or a birth centre. Just 38% said homebirth had been a possible option at the start of their pregnancy. Only 3% actually gave birth at home.

Shockingly only a third of women (33.3%) felt they had a choice about induction.

Labour and Birth

Overall only 13% of women in this study had a normal birth - that is a birth that excludes induction, the use of instruments, caesarean, general, spinal or epidural anaesthesia, augmentation, pethidine and episiotomy. As the 3% of women in this study who gave birth at home will nearly all have achieved this, it will leave only approximately 10% of this group of women having normal births in hospital. Understandably 46% of the 3% of women who gave birth at home did so to avoid unnecessary technology.

What is evident as I read through this survey is that more first time mums compared with those who have already given birth are subjected to increased intervention. For example 39% of first timers compared to 13% of women who had already given birth had continuous electronic fetal monitoring and/or episiotomy.

A lot of emphasis is put on the way first time mums 'feel' compared with those who have already given birth. Well, they are subjected to more intervention and subsequently report being in poorer health in the first few days after the birth.

Compared with 1995 there was little difference in the use of epidurals, but there was a reduction in the use of more continuous forms of monitoring commonly associated with epidurals. Evidence suggests that continuous electronic fetal monitoring doesn't alter outcomes for mothers or babies and current recommendation is that CFM should not be used routinely.

It is suggested that because more women chose to stand, squat or kneel to give birth (15% compared with 6% in 1995) this means a more flexible attitude on the part of those providing maternity services. Yet the highest majority of women still gave birth on a bed, sitting or lying (very flexible!).

Whilst reading this document I did feel like the authors tried to justify issues that would certainly merit more research. Suggesting that 89% of women gave birth on a bed because some positions may be required for medical reasons would seem to warrant further investigation.

Since 1995 the caesarean rate has risen by 6% to 23% of all births in 2006. A small proportion of women indicated that this type of birth was their choice (5%), however, this includes those who also gave other responses most commonly relating to problems with fetal growth, previous difficult or traumatic births and to previous pregnancy losses. The reasons for caesarean sections that women reported were mainly fetal distress (I wonder how many were subjected to routine augmentation?), then failure to progress (failure on whose part?), cephalopelvic disproportion and previous section.

The most controversial part of this study is the fact that more than half of the women surveyed, 56%, were left alone in labour. But that is presented as alright because only 18% were worried by this! Perhaps those who weren't worried didn't realise the seriousness of being left alone in labour. Maybe they don't understand that quiet, careful, observation from a midwife can usually spot a problem long before it becomes serious or life threatening. The women who were fortunate enough to have a midwife with them throughout commented how much they valued thier presence.

Only 18.9% of women were seen by one midwife, the same midwife during labour and birth, 38.9% were seen by two midwives, and 42.6% were seen by three or more midwives. Women would have preferred care from one midwife and evidence suggests that continuity of care in labour decreases the need for drugs, reduces the caesarean section rate and increases the normal birth rate (continuity of midwife just focussed on labour and birth). There is no mention in the survey about the midwife being known to the women previously. However, the report does say that 78% of women had previously met all or some of the midwives who saw them after the birth of their baby.

94% of women said they were treated with respect 'most' of the time during labour. Women who had longer labours and longer stays in hospital were more critical of the labour and birth environment (probably because they had more of an opportunity to take it all in).

Post-natal period

Women were more critical of staff during their postnatal stay in hospital than during pregnancy, labour and birth. 22% said that they were not treated with respect by one or more members of staff during this period. There are some comments from women who mention staffing problems in relation to their experience of postnatal care. Where women are given the chance to comment throughout this survey it is clear that staff, whether they are busy or not, have a major part to play in making an experience positive or not.

Women's health in the first few days after baby was born was significantly poorer following instrumental and caesarean delivery. Women whose babies were delivered by forceps were the highest with 46% reporting feeling tired and uncomfortable, compared with 41% who were delivered by ventouse, 39.7% by caesarean and 26.1% who had a normal birth.

Only 38% of women debriefed their birth with a health professional, most commonly a health visitor. 36% of women who didn't debrief indicated that they would have liked to.

There is a rapid drop off of breastfeeding over the early months. Most women (94%) see a health visitor so maybe the rapid drop off is something to do with the centile charts that health visitors currently use to measure weight gain. We know that these charts are not representitive of normal, cross cultural growth patterns, yet health visitors still encourage mothers who are breastfeeding to top-up with formula.

Improvements

The only real positive changes that have occurred since 1995 are a rise in the choice of positions for birth, a 4% decrease in the number of women experiencing episiotomies, a 9% reduction in the use of pethidine, a slight (3%) reduction in the induction of labour and a 12% reduction in the use of continuous forms of monitoring.

Conclusion

It is clear from this survey that women need better quality and more easily available ante-natal education. This should include comprehensive information about the risks and alternatives to epidurals. Women's rights need to be explained and appropriate unbiased information should be provided about scans, induction and place of birth. More home births would not only normalise birth but also avoid the lack of respect women have reported experiencing during their stay in hospital. It is clear that women want and would benefit from more 'one to one' midwifery care. Finally, health visitors need to get themselves a new set of centile charts that are based on the weight gain of breast fed babies for breast fed babies.

These are just a small number of highlights from a very detailed report which you can read in full at:
www.npeu.ox.ac.uk/maternitysurveys/report.php