1.  EXECUTIVE SUMMARY

  1.1  Maternity services have a key role to play in reducing health inequalities, and they can do so right at the start of life. No other service offers such an early opportunity to tackle some of the most fundamental inequalities.

  1.2  Inequalities apparent in pregnancy are some of the widest and bleakest: mothers and children are more likely to die or to suffer illnesses simply because of their background.

  1.3  Midwives can play a vital role, but currently they are being held back by a range of factors, mostly relating to capacity issues.

  1.4  The RCM proposes some recommendations, particularly about ensuring all women can access maternity care early so that their needs can be identified and their care tailored to the needs.

2.  THE ROYAL COLLEGE OF MIDWIVES

  2.1  The RCM represents over 95% of all the UK's practising midwives, with over 35,000 members. It is the world's oldest and largest midwifery organisation. It works to advance the interests of midwives and the midwifery profession and, by doing so, enhance the wellbeing of women, babies and families.

3.  MATERNITY SERVICES: AN OPPORTUNITY TO TACKLE HEALTH INEQUALITIES

  3.1  Maternity services are an unmissable opportunity to tackle health inequalities.

  3.2  Firstly, maternity services are there right at the start of life. Maternity services represent the earliest possible opportunity to lay the best foundations for good health. Moreover, and very importantly, inequalities at this stage get locked in. Not tackling such inequalities therefore fundamentally undermines any focus on tackling them later on.

  3.3  Secondly, and referred to above, it is a time when some simple steps can have a big impact. Breastfeeding, for example, can give newborns an excellent start in life, and parents choosing to stop smoking will improve their own health and that of their children. Decisions taken at this time can have an enduring effect.

  3.4  Thirdly, maternity services that work well potentially pay dividends twice: once in the health of the newborn baby and again in the health of the mother. Maternity services are used by women when most are still at a relatively young age. 57% of all live births in England in 2005, for example, were to women aged 30 or under at the time of birth (348,658 out of 613,028)[336]. This period is therefore a window of opportunity to tackle inequalities that have persisted into adulthood.

  3.5  Fourthly, and linked to the paragraph above, maternity services are accessed by a large number of women. There were 639,666 live births and stillbirths in England in 2006, for example[337].

  3.6  Fifthly, women from every background use maternity services. Midwives therefore come into contact with women from every kind of background and so are in a position to address issues of health inequalities.

  3.7  Finally, it is not a service where contact between the service user and the NHS is over quickly, like for example treatment in A&E or a single GP appointment. Midwives are likely to have contact with the mother over an extended period of time. This potentially offers ample opportunity to identify those mothers with particular needs and to address those needs.

  3.8  In summary therefore maternity services offer a window of opportunity in the drive to tackle health inequalities. This is because during pregnancy large numbers of relatively young women from all backgrounds will potentially be in prolonged contact with midwives at a time when they can make decisions that will benefit not just their health but also the health of their newborn baby and the future family.

4.  INEQUALITIES SEEN IN MATERNITY SERVICES

  4.1  The starkest inequality in maternity services is in relation to maternal deaths. Put simply, some women are more likely to die than others.

  4.2  Every three years, the Confidential Enquiry into Maternal and Child Health (CEMACH) publishes a study into maternal deaths and their causes. Their latest report[338], published in December 2007 and covering the 2003-05 period, uncovered some very bleak findings (unless stated, statements refer to the United Kingdom as a whole):

—  Black African women (including asylum seekers and recent refugees) were nearly six times more likely to die than women who were white. The mortality rate was also "significantly higher" for Black Caribbean and Middle Eastern women than for white women.

—  Women whose partners were jobless were up to seven times more likely to die than women whose partners were in work.

—  In England, women living in the most deprived areas were five times more likely to die than women living in the least deprived areas.

—  A third of women who died were single and jobless, or they were in a relationship where both partners were without jobs.

—  14% of those who died had declared that they suffered from domestic violence.

—  11% had substance abuse problems, with 60% of those being registered addicts.

—  A tenth lived in families known to the child protection services.

  4.3  CEMACH also found that the women who died who had socially complex lives were "far less likely" to seek out maternity care early in their pregnancy, or to stay in regular contact with maternity care professionals.

  4.4  The Department of Health clearly accept the scale of the problem. They state in the document setting out their Maternity Matters strategy for maternity services that "outcomes of pregnancy for the more vulnerable and disadvantaged are cause for concern"[339].

  4.5  The strategy further sets out the scale of the inequalities in pregnancy:

—  An estimated 30% of domestic violence cases start or escalate during pregnancy, and that such violence is associated with miscarriages, low birth weight, premature birth, fetal injury, and fetal death.

—  Rates of infant mortality are higher among routine and manual socio-economic groups, and that higher than average death rates occur among black and minority ethnic babies, the babies of teenage mothers and those registered at birth by one parent rather than two. Babies born in the most deprived areas are up to six times more likely to die in infancy.

—  Mothers under 18 years of age are more likely to delay accessing maternity care until they are five or more months pregnant, with worse outcomes than those who access care earlier.

—  Teenage mothers are three times more likely to smoke than older mothers.

  4.6  Earlier, in 2004, the National Service Framework for Children, Young People and Maternity Services (the Children's NSF) warned: "Women living in disadvantaged or minority groups and communities are significantly less likely to access services early or maintain contact throughout their pregnancies. They are also less likely to breastfeed. In consequence, the outcomes for their own and their babies' health and wellbeing are worse than for the population as a whole."[340]

  4.7  On breastfeeding, the Children's NSF noted that women from lower socioeconomic groups are less likely to breastfeed than others, and teenage mothers are half as likely to breastfeed as older mothers.

  4.8  So, not only do maternity services offer an opportunity to intervene, for reasons explained above, but the starkness and bleakness of the inequalities in outcomes in pregnancy present a compelling moral case further to prioritise tackling these inequalities at this vital stage.

  4.9  As Sheila Shribman, the National Clinical Director for Children, Young People and Maternity Services, has passionately stated, "It is unacceptable . . . that some pregnant women in our advanced western society are more at risk than those in parts of the developing world."[341]

5.  WHAT IS HOLDING MIDWIVES BACK?

  5.1  Maternity services therefore have a real role to play in ironing out health inequalities. Unfortunately however several factors are holding the service back from delivering on its full potential.

  5.2  Firstly, priority has not been given to maternity services over the last 10 years when it has come to deciding the NHS budget. In 1997-98, for instance, maternity services absorbed 3.1% of the NHS budget in England, but by 2006-07 this had fallen to 2.0%. Indeed, total spending on NHS maternity services in England actually fell by £55 million in the last financial year for which figures are available (2006-07)[342].

  5.3  Additionally, Payment by Results (PbR) is having an (unintended) effect on maternity services. Currently, funding for maternity care delivered in maternity units is paid for under PbR. This means that activity generates revenue. Maternity care delivered in the community, such as midwife-led antenatal care, antenatal classes and postnatal visits, are paid for through a block grant. That means that more activity does not generate more revenue. As a result, much of the work that could be directed at focussing on those most in need of additional assistance is not rewarded by funding mechanisms. PCT block contracts are also under pressure, with no penalty for reducing maternity care activity levels.

  5.4  This PbR anomaly also exacerbates the problem that the focus of maternity care is increasingly based around the hospital and around birth, and decreasingly around care delivered during pregnancy and in the community. It is during pregnancy and in the community that midwives will be able to have most effect in terms of addressing inequalities, not when they are under the pressure and demands of a busy maternity unit.

  5.5  Secondly, and linked to the paragraph above, midwives lack a readily identifiable community base that women can easily drop in to. This heightens the barrier between the woman and the midwife, perhaps discouraging the woman from seeking maternity care as early as she needs to.

  5.6  Thirdly, staffing increases in the NHS overall have largely passed midwifery by. Both the full-time-equivalent number of midwives in England's NHS fell in the last annual staffing snapshot (down 87 between 2005 and 2006) and the headcount number fell at both of the last two counts (down 375 between 2004 and 2006)[343].

  5.7  Finally, England is witnessing a rapidly rising birth rate. In the five years between 2001 and 2006 the total number of births increased by 13% (an extra 71,935 babies annually)[344]. Combined with the shrinking workforce, the number of births in England per full-time-equivalent midwife rose at the last count (September 2006) from 32 to 33, with regional variations from 27 (in the North West) to 43 (in South Central)[345].

  5.8  These stresses are impacting in many different ways on the quality of maternity services delivered to women.

  5.9  In its study of women's experiences of maternity care in the NHS in England, published in November 2007, for example, the Healthcare Commission[346] found that:

—  Of those women who had seen a midwife for their antenatal checkups, 43% had not seen the same midwife "every time" or "most of the time".

—  36% of women who wanted to attend an NHS antenatal class said they were not offered a place on one. For first-time mothers the figure was 14%.

  5.10  Clearly, women are not currently receiving the first-class maternity service that they deserve, and with the service, and particularly antenatal care, underperforming in this way it seems unlikely that midwives will be able to deliver the kind of personalised care needed to tackle inequalities.

6.  RECOMMENDATIONS

  6.1  The RCM is not only going to recommend more investment and more midwives, but these are vital if we are to tackle inequalities successfully.

  6.2  As set out above, not only the share of the NHS budget spent on maternity but the actual sum of money spent on NHS maternity services is down. NHS maternity services in England received £55 million less in 2006-07 than in 2005-06, despite a rising NHS budget overall and a rising birth rate. This must be reversed.

  6.3  At the same time, the number of midwives in the NHS in England, expressed as a simple headcount or on a full-time-equivalent basis, is down. The hard work of tackling health inequalities, and at such a crucial time as pregnancy and birth, cannot be undertaken successfully by a midwifery workforce that is shrinking just as the number of babies born is rising fast.

  The RCM will not only recommend more investment and more midwives, but more investment and more midwives are needed now.

  6.4  A recurrent theme in the evidence of inequality in pregnancy is accessing maternity care late in pregnancy. This is absolutely fundamental because if the woman is not in the system and not accessing maternity care then everything else is of no significance. Maternity care could be the best in the world, but if a woman is accessing it late then she will have missed out. Additionally, the shorter the period of time for which the midwife will be caring for the woman the less time she has to work with the woman and tailor the care she gives to the needs the woman has.

  6.5  We welcome the performance indicator on early access to maternity services included in the new Better Care for All Public Service Agreement, announced in the autumn. This will measure the percentage of pregnant women who, by the twelfth week of pregnancy, have been seen by a midwife or other maternity healthcare professional.

  6.6  The next step is of course how to make that happen. To improve early access to maternity care, Southampton PCT reorganised its services, according to report by Sheila Shribman, the National Clinical Director for Children, Young People and Maternity Services[347]. Midwives work with community workers, Sure Start children's centres, interpreters, social services and GPs. Peer groups are used to support breastfeeding.

  6.7  This kind of outreach work is very important, and to complement it, midwives need a base in the community. Women need to know where they can easily find a midwife and access maternity care. The obvious place for them is in children's centres.

  6.8  Government policy on this was reiterated recently: "All Sure Start children's centres should link to maternity services. The Government's Practice Guidance (2006) for local authorities and the health service says that in the most disadvantaged areas we expect to see midwives working from Sure Start children's centres, or having strong links with centres."[348]

  6.9  This is not enough. Official guidance should be that midwives should be based in every children's centre.

  6.10  The advantage of this would not just be felt by midwives, but by every service using children's centres. This is because basing midwives in children's centres would bring into the centres women who are pregnant. They could then very easily find out about all the other services that the children's centre offers. If pregnant women can access information and help with such things as good parenting, budgeting, and healthy eating, then those are lessons they will hopefully have learnt before the baby is born, not afterwards. Moreover, if there are lessons that help the woman herself improve her own health, through for example eating a healthier diet, then the earlier change can occur the better. Bringing women in earlier can only help.

  6.11  There are also other locations where midwives could be based, at least at certain times of the week. Midwives in Kent, for example, run an antenatal clinic in a Sainsbury's supermarket in Broadstairs[349]. It is open every Thursday from 8am until 10pm. The supermarket has free parking, plus pregnant women can use the bus service to and from the clinic free.

  6.12  With reconfigurations occurring right across England, we need also to be sure that in the event of a unit closing there is something useful left behind. If a unit closes and the remaining nearest unit is many miles away, it is those disadvantaged women who will no doubt find it hardest to access.

  6.13  Where a consultant-led unit is closed and a midwifery unit left in its place, for example, perhaps a medically-led clinic could be held onsite once a week or once a fortnight. Those needing medical supervision could therefore continue to attend appointments locally, without the demands on the local NHS of the unit offering 24-hour medical cover, or local women facing the cost and time of travelling.

  6.14  Wherever midwives are based and whatever facilities are offered however there needs to be comprehensive local "signposting"—in GP practices, in pharmacies, on the NHS website, in local newspapers, and so on. Not only that however. Outreach work of the type identified above is needed too. Pregnant women need to know as early as possible how and where to access maternity care.

  6.15  All this needs also to be recognised in the financial systems within the NHS. This must be a priority as PbR is developed.

  6.16  Improving rates of early access to maternity care is hard work. The Government's PSA performance indicator will no doubt prove helpful, but we need to see committed action locally to make early access a reality not just for most women, but for all women.

  6.17  Breastfeeding is also a specific issue that needs to be addressed. Breastfeeding has positive health benefits for the newborn baby, and this is recognised by the Government[350].

  6.18  As spelt out above however rates of breastfeeding are known to be lower amongst disadvantaged or minority groups and communities, amongst those from lower socioeconomic groups, and amongst teenage mothers. This reinforces existing health inequalities experienced by their children.

  6.19  To close the inequality gap, breastfeeding needs proactive promotion amongst these groups.

  6.20  The Children's NSF progress report, published in November 2007, illustrated how this has happened in Lancashire, with dedicated support for those finding it hard to breastfeed[351]. The percentage of women breastfeeding at six-eight weeks has risen from 20% to 56%.

  6.21  A similar approach needs to be taken with smoking during pregnancy. As noted above, this is more prevalent amongst pregnant teenagers than amongst older pregnant women.

  6.22  Maternity services have a key role to play in reducing health inequalities, and they can do so right at the start of life. No other service offers such an early opportunity to tackle some the most fundamental inequalities.

January 2008

337   Live birth statistics provided in answer to a Parliamentary Question from Andrew George MP, House of Commons Hansard, 25th June 2007, c362-64W. Stillbirth statistics provided in answer to a Parliamentary Question from Mark Lancaster MP, House of Commons Hansard, 13th December 2007, c819-20W. Back

338   Confidential Enquiry into Maternal and Child Health (2007) Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer-2003-2005. Back

339   Department of Health (2007) Maternity Matters: Choice, access and continuity of care in a safe service. Back

340   Department of Health (2004) National Service Framework for Children, Young People and Maternity Services. Back

341   Department of Health (2007) Making It Better: For Mother and Baby. Clinical case for change. Report by Sheila Shribman, National Clinical Director for Children, Young People and Maternity Services. Back

342   Statistics on NHS spending have been taken from answers to two Parliamentary Questions. Figures for 1997-98 - 2005-06 appeared in answer to a Parliamentary Question from John Baron MP, House of Commons Hansard, 6th March 2007, c1954W. Figures for 2006-07 appeared in answer to a Parliamentary Question from Mike Hancock CBE MP, House of Commons Hansard, 12th November 2007, c59-60W. Back

343   Staffing statistics provided in answer to a Parliamentary Question from Anne Milton MP, House of Commons Hansard, 29th October 2007, c1044-46W. Back

344   Birth statistics provided in answer to a Parliamentary Question from Andrew George MP, House of Commons Hansard, 25th June 2007, c362-64W. Back

345   Information provided in answer to a Parliamentary Question from Norman Lamb MP, House of Commons Hansard, 18th December 2007, c1374-75. Back

346   Healthcare Commission (2007) Women's experiences of maternity care in the NHS in England. Back

347   Department of Health (2007) Making It Better: For Mother and Baby. Clinical case for change. Report by Sheila Shribman, National Clinical Director for Children, Young People and Maternity Services. Back

348   This is part of the answer given by the Rt Hon Beverley Hughes MP, Minister of State for Children, Young People and Families to a Parliamentary Question from Mike Hancock CBE MP, House of Commons Hansard, 18th December 2007, c1259W. Back

349   A report on this clinic is available online, at Guardian Unlimited, the URL of which is http://www.guardian.co.uk/society/2007/oct/31/guardiansocietysupplement.health. Back

350   An example of the kind of endorsement given by ministers to breastfeeding is given in answer to a Parliamentary Question from the Rt. Hon. Keith Vaz MP, House of Commons Hansard, 18th July 2005, c1455W. Back

351   Department of Health (2007) Children's health, our future: A review of progress against the National Service Framework for Children, Young People and Maternity Services 2004. Back