My Lords, it is an honour to follow my noble friend Lord Patel, and I wish to add my name to those who want to thank the noble Baroness, Lady Cumberlege, for raising this debate and for the customary skill with which she introduced it and faced us with the facts and issues.
If I have an interest to declare in this debate, it is that last year was the 50th year since I completed my midwifery training. I hasten to assure the House that I am no longer registered to practise as a midwife, but I have a deep interest in midwifery and the welfare of women in childbirth. I view my midwifery experience now with nostalgia and through rose-coloured spectacles. Most of my deliveries, some hundreds of them, were home deliveries in a rural area of Herefordshire and it was idyllic—both the country and the experience.
Perhaps I may describe one of my last deliveries. I trudged across a ploughed field with my little black bag to get to an isolated farmhouse where the mother was in labour. Once arrived there, I found there was no running water. Unfortunately, my midwifery training had not taught me how to extract water from a pump. Unfortunately for the father, I had to rouse him from a deep sleep by the fire because he was overcome with the thought of impending fatherhood. He managed to draw water out of the pump successfully.
Later on, the feather bed on which the mother was lying burst. After that, she had a post-partum haemorrhage. We had to call out the Flying Squad, which we then used, to deal with that. However, in some ways, the case finished with every satisfaction for the family and certainly for me, the midwife.
In my state of ignorance about present-day midwifery, I have been so grateful to receive briefing papers that have brought me slightly more up to date than I would otherwise have been in this debate—papers from the National Childbirth Trust; the Royal College of Midwives; the Royal College of Nursing; the Schools of Nursing and Midwifery at the Universities of Manchester and Sheffield; from individuals and various reports of meetings of the All-Party Parliamentary Group on Maternity. These have given us a wealth of information about the present situation in midwifery.
Unfortunately, from these papers I get a very strong view that all is not well in the state of our midwifery services. Certainly the experience of some mothers is not now positive, and there is obviously great dissatisfaction among midwives. I therefore wish to talk briefly about the reconfiguration of the service and the kind of structure that there should be in the future; the increasing medicalisation of care, of which we have heard today; the increasing rate of caesarean section; the shortage of midwives; and patient satisfaction, if I get that far.
The reconfiguration of the service is extremely important. What shape should the service take in our present state of health service provision? As I read the papers, there seems to be a stark difference of view between those who favour home births and smaller, midwife-led community units, where care is much more easily accessible to the consumer and the midwife can give much more personal supervision throughout the period of labour. The Secretary of State has described this continued care of the mother by one midwife as the gold standard for our midwifery services.
Set against this position is the view that larger units can effect economies of scale. That is important in the present state of our health service. More importantly, a unit within an acute hospital has obstetricians and paediatricians much more readily available. It is important that this kind of medical help is readily available. I recall one obstetrician with whom I worked frequently stating, "No birth is normal except with hindsight". There may be something in that statement.
We have heard that there is an increasing medicalisation of childbirth, certainly since 50 years ago when I was practising. The increased rate of caesarean section has already been mentioned and is a cause for concern. The "Postnote" that I have received dated October 2002 states that in the 1950s 3 per cent of births in England were by caesarean section; by the early 1990s this had risen to 10 per cent; and to 21 per cent in 2001. But the national figures mask tremendous local variations of between 10 and 30 per cent.
The differential cost to the National Health Service of caesarean section versus vaginal delivery is considerable. The Audit Commission has calculated that every 1 per cent rise in the caesarean section rate costs the National Health Service an extra £5 million a year.
The parliamentary "Postnote" is valuable in regard to the caesarean section rate. It reviews the medical factors that have contributed to the increase, and the non-medical factors such as culture, organisation and maternal choice, which I believe is often influenced by the line taken by the media.
Clearly these are considerations that call for us to think deeply about reconfiguration of the service. I appreciate the paper from the National Childbirth Trust, which looks at the questions that need to be answered before we tackle reconfiguration of the service and contains a suggested reconfiguration.
As regards the increased rate of caesarean section, I look forward to receiving the promised guidelines from the National Institute for Clinical Excellence. Although it is an extremely difficult issue on which to give guidelines, they will be a valuable help to us.
I am extremely concerned, as are many other noble Lords, about the shortage of midwives and the lack of job satisfaction. This situation has been researched by Mavis Kirkham, Professor of Midwifery at the University of Sheffield. The work was sponsored by the Royal College of Midwives and the Department of Trade and Industry Partnership Fund. Professor Kirkham followed up 2,325 midwives who notified their intention to practice in 1999 but did not do so the following year in 2000. That is quite a significant loss of midwives in one year.
Making the decision to leave midwifery was often a protracted and painful business. The professor said that the research painted a depressing picture of a group of committed professional women struggling over a protracted period of time within an environment of increasing confrontation and stress. The largest group of those who left—30 per cent—were dissatisfied with midwifery. There were other causes, but the midwives had a predominant feeling that they could not practise as they were taught to practise under the conditions now existing in the health service.
Midwives are now educated in a way that gives them specialised knowledge and problem-solving skills which enable them to base their practice on evidence derived from research. Their expectation is that they will be able to practise autonomously, but what they meet in practice is very different and bears little resemblance to what is implied in the midwives' code of practice. There are matters which militate against their practising as they would wish. They are made to rotate through all the shifts and around all the areas of clinical practice and feel that they have insufficient control over their working lives. These frequent dislocations of the place in which they practice make it difficult to maintain confidence and relationships with both clients and colleagues. It is essential that we do something about the recruitment and retention of midwives.
As a final point I was going to talk about mothers—the consumers—and patient satisfaction. I shall not do so because my time is up. I wanted to recount to your Lordships the experiences that some of the younger members of my family have had in childbirth. It is not a pretty story.