The challenge of change in Wales

AIMS Journal 2002, Vol 14, No 4

Even in the face of an unhelpful attitude from authorities, Welsh midwives are determined to bring about a radical change in the maternity services. Gill Boden reports.

In Wales, MSLCs are coming to an end in March 2003. It seems time to review our achievements of the last few years. Since 1998, when I became chair of my local MSLC, I have seen some exciting developments within the maternity services in Wales.

In many ways, the climate over these years has not been a good one. There has been an overall trend away from normal birth, as in the rest of the UK, and the shortage of midwives has begun to seriously affect Wales within the last year.

Despite this, as user representatives, we feel generally optimistic and very positive. I put this down to the fact that midwives are determined to overcome these obstacles. They have struggled to provide a woman-centred service and they have had the leadership to encourage them to do so.

Four years ago, the members of our Cardiff and the Vale Early Child Health and Maternity Services Liaison Committee identified three priorities - to increase the low breastfeeding rates in our area; to examine antenatal screening; and to help to normalise birth by, for example, finding measures to bring down the particularly high caesarean section rate in the two Cardiff hospitals and increase the low home-birth rate.

At that time, we confess that we felt daunted and that, compared with other regions of the UK, we had a service that did not always meet women's needs and on some important dimensions was lagging behind. Since then, the progress has been considerable.

Take breastfeeding: in 1998, UK figures showed 42 per cent breastfeeding at six weeks nationally, but the rate was almost certainly worse in Wales, but we didn't know by how much as we had no clear-cut information to go on. It was estimated that initial rates in Wales were only 45 per cent vs 55 per cent in the UK, which put Wales at the bottom of the league within Europe.

We, like many others, agitated as much as we could - first, for reliable data against which progress could be measured and, second, for breastfeeding to be moved up the political agenda.

In 1999, the National Assembly for Wales set about developing a strategy, which was launched in 2001 by the Health Minister, Jane Hutt, as 'Investing in a Better Start: Promoting Breastfeeding in Wales'. It's still too early to measure large increases, but already we are seeing breastfeeding increase. There has been a flurry of hospitals gaining Baby Friendly Status, and a breastfeeding coordinator for Wales is about to be appointed. It seems to me that those midwives and lay people, who have been working away to help women to feed their babies the way they want to, have been given great encouragement and support.

The second priority, antenatal screening, has been under considerable scrutiny. This has happened locally. The Health Authority set up a group - the Brotaf Professional Advisory Group on Antenatal Screening - to look specifically at the situation in Cardiff and surrounding area, where particular problems had been identified. This was followed, in January 2002, by a consultation document produced by a national antenatal project.

This project had two phases. First, there was a baseline study and then recommendations for an all-Wales antenatal screening programme to be put in place by March 2004. We have been involved in both these initiatives as lay members. It is clear that standards of screening have already improved and become more consistent while women's active participation and informed choice have been safeguarded and underlined. There is still work to be done - HIV screening is still fairly new and still being very carefully monitored - but, overall, most of our concerns have been allayed.

The third initiative and, in some ways, the most bold was the encouragement of normal birth. First of all, the National Assembly, through its Nursing Division, set up a maternity mapping exercise, which brought together information from all the maternity units in Wales. Although this was short of a full review, it was a useful and a manageable exercise. Wales has 13 Trusts with maternity services.

The Nursing Division then set up a working party late in 2001 to develop an all- Wales clinical pathway for normal birth. The pathway is now being piloted in two units and will be available in the spring for every unit in the principality.

The working party had first to face the difficulty of definitions. What exactly is normal birth? This process gave rise to a great deal of excited argument - it was very refreshing, I think, for all of us to have the opportunity to get right back to basics. Normal labour, in the context of this pathway, is defined as 'the physiological process of labour and vaginal birth with minimal intervention without any foreseeable complications.'

When do we think labour has started? 'Active labour is established when the cervix is more than 3 cm dilated, full effaced in the presence of regular painful contractions.'

The pathway is commenced when a woman first contacts a midwife with the possibility that she may be in labour. It is anticipated that this is usually by telephone.

The pathway is ended when a woman is considered by the midwife to no longer need 'one-to-one' care - that is, when the midwife who assisted at the birth leaves the home or the transfer of mother and baby to the postnatal ward.'

The pathway will be a tool for midwives to help them to concentrate on the normal, to practise according to the evidence rather than allowing interventions out of misplaced caution. It is very woman-centred, and will allow midwives to develop and practise their skills in the interests of mothers and babies.

It is a return to the world of Changing Childbirth, but it is not vague - it is really a practical tool. It may seem a shame that midwives need written protocols to do what they have been doing for thousands of years, but I know from my own line of work in the field of education that we have no choice in 2002 when it comes to documenting our work.

But before anyone thinks that it will increase paperwork, though, let me pass on this assurance that it is intended to replace the existing paperwork.

The NCT recently estimated that, with a strict definition of normal birth, as little as 6 per cent of births could truly be described as normal. I think this pathway has come in the nick of time - before mothers and midwives stop remembering how exciting, enjoyable and empowering birth can be.

So, to sum up, those of us working as user representatives for the maternity services have been involved in all of these initiatives and have been impressed by the sheer determination of the midwives in Wales to bring about such radical change in such an unhelpful climate.

We attended a conference in June 2002 for the launch of 'Delivering the Future in Wales: A Framework for Realising the Potential of Midwives in Wales' and came away inspired. The Heads of Midwifery were there together presenting their strategy. They were united and determined. They have some radical aims - for 10 per cent of births to be at home by 2007, for example, and they looked as though they would brook no opposition!

Since then, the All-Wales Reference Group on Home Birth, made up of midwives from all Trusts, has been working. They are developing an all-Wales information book for women, guidelines for midwifery education both pre- and post- qualifying, and researching models of care that support home birth. They will be organising a conference in April to raise awareness of their work and to help them achieve that marvellous target of 10 per cent home birth by 2007.

Our MSLCs will finish in March when the Health Authorities hand over to Local Health Boards. We don't know what will take their place as a forum for user voices, but we're looking ahead with excitement and anticipation. Consultation on the way forward is coming in January 2003. All users will be invited to contribute to developing a new structure, you can be sure we'll be there with some ideas.