Feature

Small is beautiful

Closing small maternity units is not what women want, says Christine Gowdridge

Who is supposed to benefit from maternity services? This is a timely question given the present government’s intention, expressed in the white paper Working for patients to “extend patient choice” and ensure that “patients needs will always be paramount”. It is one which would appear to have an obvious answer — the women who use them and their babies.

But the rising closure rate of small maternity units, often in the face of vehement, well organised protest, has restricted women’s choice of where to give birth. These units are usually called ‘isolated GP units’, a misnomer on two counts: they are not isolated from the women who use them — centralised units are — and most of the care is provided by midwives.

Present government policy is clear. The then junior health minister Edwina Currie said in 1987:

”By and large, it is the government’s view...that women should be encouraged to have babies in the larger and properly staffed consultant units of district general hospitals.”

”Our objectives in the maternity services are healthy babies born whenever possible at full term to healthy mothers. We aim to minimise the risks to babies by encouraging delivery in hospital preferably with access to the full range of facilities which are likely to be found only on district general hospital sites. We aim to support the services outside hospital, both ante- and post-natal, by increasing the number of qualified staff and by other measures.”

”As a result there has been a fall in the perinatal mortality rate in England from 14.6 per 1,000 births in 1979 to 9.8 in 1985. During the same period the maternal mortality rate per 1,000 live and stillbirths declined from 0.11 to 0.07.”

This policy restricts choice for pregnant women, which would be fair enough if it was based on sound evidence on safety, cost and consumer and staff satisfaction. But it isn’t. For example, supporters of the present policy can give no evidence to support their assumption that the rise in the proportion of hospital deliveries is directly responsible for the decline in perinatal and maternal mortality. They appear to have heeded George Bernard Shaw’s advice: “To advertise any remedy or operation, you have only to pick out all the most reassuring advances made by civilisation and boldly present the two in relation of cause and effect; the public will swallow the fallacy without a wry face.”

The Maternity Alliance believes it is time to re-appraise the trend towards discouraging deliveries outside obstetric consultant units. Recently it organised a seminar for the then health minister Rodger Freeman, at which a consultant obstetrician, a midwife, a health economist, a lecturer in general practice, a GP, a statistician and the president of the National Childbirth Trust presented papers which challenged the assumptions underlying present policy.

Mr Freeman heard hard evidence on safety, cost, and staff and women’s satisfaction. Midwives enjoy working in small units where they can provide continuity of care throughout normal pregnancy, labour and the postnatal period. GP unit delivery does not appear to be more costly than central unit delivery, but family costs are higher in the case of centralised maternity care.

The statistical association between the increase in the proportion of hospital deliveries and the fall in the crude perinatal mortality rate seems unlikely to be explained by a cause and effect relation. Furthermore, there is no research evidence to show that the safest place to give birth is a consultant obstetric unit. Women do not want to travel in labour. They prefer to be in familiar surroundings, attended by people they have already met.

Richard Porter, consultant obstetrician at the Royal United Hospital, Bath, described how Bath health authority was adopting a policy to increase the numbers of women delivered in isolated maternity units to 40 per cent of all deliveries, or 2,000 a year. The district currently runs seven isolated units, with deliveries numbering from 130 to 600 women a year.

Figures such as these astound most obstetricians and contradict the premise that such a policy is logistically impossible. Such a system requires: organisation, including agreed protocols for booking policies, management of minor and major abnormalities of labour; communication: Bath HA’s maternity advisory committee includes five obstetricians and seven GPs; continuing education: the HA emphases the need for the obstetricians to help update GPs in the theory and practice of intrapartum care; commitment: those GP practices with a continuing interest in intrapartum care tend to attract properly motivated applicants.

We need to know whether the Bath experience is a blueprint for the future or a local eccentricity. When we do, it should be possible to organise a maternity service for the 1990s which is safe, cost effective and satisfies the needs of women, midwives, GPs and obstetricians.