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The government boasts about improvements. But the figures tell their own story. Staffing is falling, and the maternal death rate may actually be climbing...

Midwifery in 21st–century Britain: death rates on the rise

WORKERS, FEB 2008 ISSUE

BACK IN 2003 Jacqui Smith Minister of State for Health stood in front of the Royal College of Midwives and said: "We have seen tremendous improvements in the care women and their babies have received in the last decade but I know that midwives are not the complacent type and that you continue to strive to develop care and services."

Yet in 2007 four Royal Colleges – the Royal College of Obstetricians and Gynecologists, the Royal College of Midwives, the Royal College of Anaesthetists and the Royal College of Paediatrics and Child Health – have produced a report, "Minimum Standards for the Organisation and Delivery of Care in Labour", that tells a different story.

In the introduction they state that Britain can only achieve the minimum standards for safety of women and babies "if there is considerable expansion of numbers of both midwifery and medical staff concerned with the care of women in labour".

Government ministers speak of "tremendous improvements" while the health professionals talk about our country failing to meet the minimum standards for safety in childbirth. So what is going on?

A worrying trend
Firstly, when the government minister spoke to the midwives conference in 2003 she was wrong to say that there had been "tremendous improvements" in maternity care in the past decade. The earlier part of the decade had seen improvements but these had not been sustained.

Although the data had not been compiled into a formal national report at the time the minister addressed the midwives, the Department of Health would have been aware of a number of concerns about maternity care. Britain produces a report every three years that examines the causes of maternal deaths – deaths of women in childbirth or shortly after.

When the retrospective report called "Why mothers die 2000–2002" was published it showed a maternal death rate of 13.1 per 100,000 maternities. This was a rise from 11.4 in the previous three-year period and a higher rate than for the whole preceding decade.

Deaths are classified as "direct", usually relating directly to the labour or other aspect of obstetric care, or "indirect", usually relating to how pregnancy may have exacerbated an existing illness. The most common indirect cause of maternal deaths in 2002 was psychiatric illness, followed by cardiac disease.

Risk factors for maternal deaths for the years 2000 to 2002 included:

Unemployment: Women living in families where both partners were unemployed were up to 20 times as likely to die as other women.

Area: The death rate of women living in the most deprived areas of England was 45 per cent higher than women living in better-off areas.

Suboptimal Clinical Care: 67 per cent of those who died were considered to have had some form of "suboptimal care".

The publication of this report confirmed to clinicians that their version of reality was the correct one and confirmed their view that government ministers had an Alice in Wonderland view of the world. In particular clinicians focused on "suboptimal clinical care" as a risk factor which they could directly influence.

Now the report for 2003–2005 has been released. It shows a slight worsening since 2002, with a maternal mortality rate of 13.95 per 100,000 maternities. The authors are careful to point out that the increase is not statistically significant but that it "highlights the necessity for further vigilance".

The same social patterns of death continue just as starkly in the latest report and the concern about "suboptimal clinical care" has grown in a very worrying way.

The recent report noted that the "assessors were struck by the number of health care professionals who appeared to fail to identify and manage common medical conditions or potential emergencies outside their immediate area of expertise. Resuscitation skills were also considered poor in an unacceptably high number of cases." It was notable that most national press reports entirely ignored this aspect and focused on maternal obesity as the "new" factor in maternal death.

No wonder the Royal Colleges have decided that they have to revisit the question of standards and the resources required to meet them.

Rapidly changing times
It is eminently possible to tackle a diagnosed problem if circumstances remain relatively stable. But addressing "suboptimal clinical care" has been very difficult because of a range of other factors. In particular the birthrate is rising – a rise that is unpredictable and not following projection forecasts.

The official increase in the birthrate is 12.5 per cent since 2001. It has been difficult for Heads of Midwifery to plan their service because the birth projections provided by their local planners and by central government have been underestimates.

They are perplexed that their own data on the number of births in their service area appear to be higher than actual births counted in statistics for their local area. The Office for National Statistics recently admitted that its traditional methods of counting population are inadequate. Heads of Midwifery point out that their information reflects an actual head count and may be more reliable than many other sources of data.

The rising birth rate is primarily driven by migration into Britain, and this in turn adds another layer of complexity. In the period 2000 to 2002 black African women, for example, had a mortality rate seven times as high as white women; and in the latest report the rate is still six times as high.

The recent report points out that many migrant women "have poorer obstetric histories, have more complicated pregnancies or serious underlying medical conditions and may be in poorer general health" – all of which would require an increase in staffing levels to meet the complex needs.

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One recommendation from the Minimum Standards report is for the availability of 24-hour interpreting services, as communication problems have been a feature of some critical incidents. But the provision of such a service is extremely costly and would divert funds from other services.

In addition, births are becoming more complex for a range of reasons. The Royal College of Midwives recently expressed concern at the rising caesarian section rate, up fivefold since 1970. In some areas 25 to 30 per cent of all births are now by caesarian section, heightening demands on both staff and budget.

Another complicating factor is that more mothers are delaying having children until they are older because of housing costs and other financial reasons. And older mothers tend to have more complications, again increasing demands on staffing.

The numbers game
Listen carefully the next time you hear a politician talking about staffing numbers in any occupation. It is easy to mislead unless the interviewer is astute.

Look carefully at figures. Although raw numbers employed have gone up, many of these are part time, and a close look at the Register, Nursing and Midwifery Council from August 2005 shows that total midwifery hours have actually decreased by more than 13 per cent at a time when the birth rate is rising and births are becoming more complex.

But the changing ratio of part-time to full-time staff and a focus on numbers of staff rather than hours worked can obscure the actual trend and give scope for politicians to make their misleading statements. The Royal Colleges now point out that midwife numbers expressed as a ratio of whole-time equivalents to births are actually slightly lower now than 30 years ago.

Thousands more needed
The government's own policy and targets for maternity services, set out in a docu-ment called "Maternity Matters" in 2006, call for every woman in labour to have one-to-one care. That would require nearly 5,000 more midwives by 2012.

But all the Royal Colleges and trade unions know recently qualified midwives who cannot find jobs, as NHS trusts are not advertising vacancies, looking to accrue "vacancy savings" to stem deficits.

Nationwide, midwifery training places have been cut as trusts that commission training places have diverted training money to reduce the deficits in order to meet government financial requirements for Foundation status by 2008. Oxford Brookes University and Anglia University – both in areas where the birth rate is rising quickest – axed teaching staff in their nursing and midwifery establishments this year.

A significant number of midwives are not currently practising. Yet there is no government funding for Return to Practice programmes and most universities who offer this programme have suspended the it for lack of uptake. When there was funding, the uptake was good. The few remaining programmes are taking self-funding students, but not many returning midwives can afford this option.

So here are some immediate demands for Safer Childbirth:

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