Hard labour: The maternity service in crisis
Over 30 hours after her waters had broken, Rebecca Bond still had not received any pain relief.
The first-time mum had been in excruciating pain, with contractions coming more frequently, but the delivery suite was too busy to admit her. Instead, she and her husband Steve, a customer services manager, were just left to it.
To add to her anxiety, Rebecca, 25, has epilepsy, which could have caused complications; she was also suffering from a temperature, which staff dismissed as shock.
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Happy birth day? Chronic staff shortages and ward closures mean midwifery services have been increasingly stretched
“When I was finally admitted to the delivery suite, I had the overwhelming impression the staff were annoyed I’d turned up,” she recalls.
She was given an epidural and only then asked how long she’d been having contractions. The staff were shocked she’d been in labour so long.
They then discovered the baby was in distress, with a dangerously high heart rate, and Rebecca was rushed into theatre for an emergency Caesarean.
“I was terrified and felt totally out of control,” she says.
“I’d wanted as natural a birth as possible, with minimal intervention. It didn’t help that the only person who spoke to me or paid me any attention was the anaesthetist.”
Less than 30 minutes later, Rebecca’s son Charlie was born, weighing 7lb 6oz.
It was then discovered that both mother and son were suffering from a serious infection – as a result of Rebecca’s waters having broken so many hours earlier.
She and the baby spent their first two weeks in hospital on intravenous antibiotics.
Rebecca also later discovered her placenta had come away during labour, causing near fatal internal bleeding.
“I have no doubt that had there been more staff that day we would have been monitored properly and none of this would have happened,” says the trainee RE teacher.
Rebecca’s story is all too familiar. The birth of a child should be a joyous experience, but many women find it is far from it.
Chronic staff shortages and ward closures mean midwifery services have been increasingly stretched, with sometimes disastrous results for mother and child.
The problem is not individual midwives, who are working extremely hard to provide a safe and high quality service.
But as Louise Silverton of the Royal College of Midwives explains: “Maternity services are buckling under the pressure.”
The National Patient Safety Agency has found that over the past three years, 17,676 women had been injured, about 1,000 of them seriously, during labour, with many of these injuries the result of blunders linked to staff shortages.
These are extreme scenarios – over the same three-year period, nearly two million women had perfectly safe deliveries.
But talk to any group of new mothers and at least one will have had an unhappy birth experience.
Only 13 per cent of births are “normal”, with the rest requiring medical intervention.
Such are the tremendous demands being made on midwives that in some cases you’re lucky to get one.
But the problems in maternity care are not confined to the labour ward.
Professor Charles Rodeck, the country’s leading foetal medicine expert, says: “Being pregnant and giving birth with the NHS can often be an impersonal and isolating experience – the process has become an anonymous production line.”
Rushed appointments, lack of specialist equipment, patchy antenatal care and even patchier postnatal care are just some of the areas of concern – and with the birth rate at a 26-year high, things are likely only to get worse.
“There seem to be problems over the whole maternity experience on the NHS, says Stuart Campbell, former professor of obstetrics and gynaecology at Kings and St Thomas’s Hospital Medical Schools.
“There are women who haven’t been seen for a long time or don’t get the advice they need.
“It is particularly shocking that this crisis is happening in Britain, a developed, Westernised country with one of the richest economies in the world.”
Foetal and maternity medicine are not a political priority, adds Professor Rodeck: “There have been Department of Health initiatives in everything from mental health to diabetes, but maternity care was belatedly tacked on to the childcare agenda and almost forgotten about.”
Louise Silverton, of the Royal College of Midwives, said: “The Government talks about record investment in the NHS, but very little of this reaches maternity services.
“All politicians speak about maternity services being a priority, yet the lack of money put into them exposes this as simply rhetoric not reality.
“We are simply falling into the age-old pattern of boom and bust recruitment, which too often leaves women and their babies suffering the consequences.”
Here we examine the problems that plague the maternity experience. It does not make for comforting reading.
• ANTE-NATAL CARE
‘You can’t even guarantee a scan for Down’s’
The NHS has national recommendations setting out precisely the medical care women should receive during pregnancy. However, the evidence suggests there are worrying gaps in this care.
According to Professor Campbell, ultrasound scanning – one of the most important tools in ante-natal care – is a prime example of this. These painless tests use sound waves to produce images of the baby and its developing organs.
Pregnant women are meant to be offered a scan at around 12 weeks to screen for Down’s syndrome, estimate the due date of the pregnancy and test for twins.
This is followed by a more detailed scan at around 20 weeks, known as the anomaly scan, which allows the sonographer to take a far more comprehensive look at the baby’s growth and development.
But latest figures show that one in seven pregnant women is not offered, or doesn’t recall being offered, a screening test for Down’s.
Professor Campbell says the UK’s standards for screening fall far behind other European countries.
“In Europe, women have an average age of four to five scans,” he says.
“There is a very big gap between 20 weeks and the end of the pregnancy, and having the tummy felt by a midwife every four weeks – as happens in the UK – is an inexact way to assess the baby’s growth.
“Apart from missing out on the opportunity to ensure the baby is growing properly by being seen regularly by a doctor – at least every four weeks for the first 28 weeks – the lack of contact can cause immense anxiety.”
He also points out that in the UK only one per cent or less have a Doppler scan, a highly sensitive screening tool that measure the speed of red blood cells moving from mother to baby. This scan is used to predict pre-eclampsia.
The test, which he pioneered 15 years ago, is commonly used in Europe.
“There are so many things we could do to ensure a better outcome for the pregnancy,” Professor Campbell adds.
“For example, measuring the cervix at 22 weeks can predict a premature labour, yet this is not routinely done.”
Professor Rodeck is also concerned about the state of current machinery. “There are many hospitals struggling with old ultrasound machines,” he says.
And because of cuts in services, one in 10 first-time mothers is not given the chance to attend NHS ante-natal classes.
This increases to almost 40 per cent of women who already have children. In some parts of the country, NHS ante-natal classes have been cut altogether to save money.
As Mary Newburn of the National Childbirth Trust explains: “Ante-natal classes not only help you with the birth but provide you with skills that you can use after you have had a baby.”
For first-time mothers, this is particularly important since many may not live close to extended family on whom they can depend for help.
Another problem, say consultants, is that pregnant women rarely, if ever, see a consultant.
According to Professor Sabaratnam Arulkumaran, vice president of the Royal College of Obstetricians and Gynaecologists, all pregnant women should be seeing a consultant or one of his team at least once early on in pregnancy to screen for heart or lung problems.
Consultants can also play a vital part in reassuring women who are terrified of childbirth – or who had a traumatic first birth.
This is partly a problem with demarcation between midwives and consultants, suggests Peter Bowen Simpkins, a consultant gynaecologist at the London Women’s Clinic.
“A lot of the decision-making is now left with the midwife,” he says. “Some women don’t see a doctor throughout their pregnancy.
“As a consequence, obstetricians are like fire-fighters, brought in only when a situation reaches a critical level.”
Such critical problems might not arise if women were more regularly monitored by obstetricians.
‘I was left for 30 hours without any pain relief’
Maternity services are particularly struggling, say experts.
Staff and bed shortages are a major issue. The birth rate is now the highest for 26 years, yet the number of NHS midwives has started to fall.
The Royal College of Midwives says at least 3,000 more are needed to meet demand.
In addition, between 600 and 800 more consultant obstetricians are required across the UK to ensure labour wards are covered to deal with complications during childbirth.
The number of available maternity beds has fallen by almost 20 per cent over the past decade, despite the rise in the birth rate.
According to Louise Silverton, of the Royal College of Midwives, the high birth rate and drop in midwifery numbers has led to some units capping the number of births they will handle, so women can’t always get into the hospital they want.
In extreme cases this can lead to cases like that of Sally West, who gave birth in a car park after being turned away from Malton Hospital in North Yorkshire, three miles from her home, due to a shortage of midwives.
Once on the labour ward, many women complain of being abandoned.
Earlier this year, a study by the Department of Health revealed that thousands of women find themselves isolated and frightened during labour because they do not get the care they need.
Over half were left alone at times during labour.
Just 19 per cent had one midwife providing continuity of care during their labour and while giving birth, with over half of first-time mums having a stream of three or more midwives see them through the experience.
Women who are calm and relaxed during labour are statistically more likely to have a normal birth.
But if the environment causes stress, then anxiety levels rise, stopping the release of pain-killing endorphins and stimulating the release of adrenaline.
This increases the likelihood of some form of intervention such as forceps or even an emergency Caesarean section.
The number of women having some form of intervention, particularly by Caesarean is on the increase – the Caesarean rate has doubled over the past two years (the World Health Organisation says the normal rate should be between 10 and 15 per cent of all births, yet in Britain it’s 23 per cent).
As a result of difficult births, women may suffer from post-natal stress disorder, according to Sheila Kitzinger, social anthropologist and author of many books on maternity.
She says: “This causes panic attacks, nightmares and makes them feel constantly jumpy.
“As a consequence, some new mothers may find it hard to bond with their baby. They feel cheated of the experience they wanted to have and feel out of control.
“It would make an enormous difference if expectant mothers were assigned two or three midwives for the duration of their pregnancy instead of a stream of different faces.”
• POST-NATAL CARE
‘Home visits by midwives have all but vanished’
Post-natal care, according to the Royal College of Midwives, is the area of maternity services with fewest staff and where spending cuts hit hardest.
For new mothers still in hospital, it often means they get little help breastfeeding and looking after their new baby – as Rebecca Bond discovered.
Following the emergency Caesarean, her requests for help feeding Charlie went unanswered so she never fed her baby in the first two weeks of his life, let alone breastfed as she wanted to. (Breast milk gives babies all the nutrients they need for the first six months of life and helps protect them from infection.)
“Instead I was pretty much left to my own devices, feeling terrible with a new baby,” she says.
She then developed post-natal depression; the trauma has put a strain on her marriage, and her husband cannot contemplate another baby.
Melanie Every, of the Royal College of Midwives, says: “There are lots of women that go home with a lot of unanswered questions.”
The number of new mothers suffering post-natal depression has risen to 20 per cent, according to the latest survey by the Royal College of Midwives – double the figure it was seven years ago.
Another problem is that post-natal home visits by midwives – which used to be every day for 10 days after birth – are also being reduced or stopped altogether.
This means women who have recently given birth may have to travel to a clinic if they want to receive post-natal care.
According to Mary Newburn, of the National Childbirth Trust, all new mothers should have ideally a minimum of three home visits from a midwife.
Health visitors have traditionally helped women with their transition into motherhood once they are discharged from hospital.
However the number of health visitors in England has fallen to its lowest level in 12 years.
Only one in 100 new mothers breastfeeds their child for the recommended first six months, according to figures from the Information Centre for Health and Social Care.
National Childbirth Trust policy researcher Rosie Dodds says the fall-off was due to a lack of support from overstretched midwives and health visitors.
So what should be done to tackle the problems in maternity care? In Maternity Matters, the Government set out its vision of more choice and more emphasis on home births by 2009.
But consultants and midwives alike agree that improved staffing is the most important step. As Professor Arulkumaran, of the Royal College, explains: ‘Labour wards need to be staffed more like the airline industry.
“If someone is flying a plane, there is a pilot and co-pilot. In maternity wards, after a certain time, there is no pilot.
“For instance, we know from research that when things go wrong in the early hours of the morning, the outcome is rather poor.
“When a baby is born brain damaged as a result of poor care, the award in the courts is between £3million and £6million – yet £1million would pay for two consultants and 10 midwives. We need to get more staff on board.”
A better structure of care is also essential, according to Professor Campbell.
“What this country lacks is a structured system,” he says, “where every woman is offered the same consistent approach to care.
“We also need more time with patients, more scans, including a Doppler for everyone – and a system where midwives don’t try to do everything themselves but share the care with an obstetrician.”
Rebecca Bond is adamant she will not go through a similar experience again.
“If we have another child, I will be far more vocal,” she says. “Because it was our first time, we didn’t know any better and we put up with far too much.”
I have copied this, in full, as there are many valid points but also some which are open to differing interpretations. Also, please note that one opinion quoted is from a former professor of obs and gynae, Prof Campbell. As any student knows, you should never rely on old material to support an argument (I’m not suggesting that Prof Campbell is ‘old material’, just that his perspectives may be centred differently).
I do have a ‘problem’ with the concept that midwives try to do everything themselves. Yes, we do, but actually it is not always our choice. I have asked the G.P’s at one of my surgeries if they will see their women twice during pregnancy, the answer was ‘no’. I have explained that it would allow me more flexibility and more time to spend with the women who need it, but they are not interested.
Personally though I am not adverse to anything that may highlight the increasing problems within the maternity services so if this article brings the subject higher on the parliamentary agenda then I will keep quiet and bow to any Professor who wishes to exercise his redoubtable knowledge.