Midwives

– in the Scottish Parliament at 5:01 pm on 6th May 2009.

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Photo of Alasdair Morgan Alasdair Morgan Scottish National Party 5:01 pm, 6th May 2009

The final item of business is a members' business debate on motion S3M-3692, in the name of Mary Scanlon, on international midwives day, 5 May 2009 . The debate will be concluded without any question being put.

Motion debated,

That the Parliament notes that 5 May is International Midwives' Day 2009; welcomes the contribution that midwives make to the health and wellbeing of women and their babies in Scotland and around the world; recognises that levels of maternal and infant mortality, especially in the developing world, are unacceptable; believes that achieving UN Millennium Development Goal 4 (Reduce child mortality) and Goal 5 (Improve maternal health) would amount to a giant leap for better maternal and infant health globally; acknowledges that more can always be done in Scotland to reduce our own levels of maternal and infant mortality, especially in remote and rural areas; supports greater international action to reduce maternal and infant deaths globally, and strives to provide ever-safer care for Scotland's own women and children.

Photo of Mary Scanlon Mary Scanlon Conservative 5:02 pm, 6th May 2009

I am delighted to secure this debate in the week of international midwives day, and I welcome the midwives who are in the public gallery.

I think that this might be the first time the Parliament has debated midwifery, but it is nonetheless important, particularly as we have three expectant fathers here in the Tory ranks. [Laughter.] I just want to put the debate into context. I can see that members are all guessing now.

Women are continually told that giving birth is the most natural thing in the world and an experience to be cherished, but for a huge proportion of the world's expectant mothers childbirth is a daunting experience filled with worry and fear. For women throughout the world, access to medical care and the services of a midwife are critical.

In 2000, the eight millennium development goals were endorsed by 189 countries. Millennium development goal 5 aims to reduce the maternal mortality ratio by 75 per cent and to achieve universal access to reproductive health by 2015. That goal is critical because, every year, more than 1 million children are left motherless and vulnerable because of maternal death and 20 million women experience potentially fatal complications during childbirth. In eastern Africa, only 34 per cent of births are attended by skilled health attendants.

The target of universal access to reproductive health is far from being achieved. Although the use of contraception has improved impressively during the past two decades in many regions, the unmet need for family planning is still unacceptably high in, for example, sub-Saharan Africa, where 24 per cent of women who want to delay or stop childbearing have no access to family planning.

Girls aged between 15 and 20 are twice as likely to die in childbirth as those in their 20s. Girls under the age of 15 are five times as likely to die in childbirth. Some 200 million women who would like to avoid childbearing are without access to safe and effective contraceptives. In the developing world, unsafe abortions result in 68,000 deaths each year. The facts are that, every year, more than 0.5 million women die from complications in pregnancy and childbirth and more than 300 million suffer from avoidable illness and disability. That means that one woman dies every minute of every day, including around 70,000 girls and young women aged between 15 and 19.

Maternal deaths are the greatest indicator of inequality between rich and poor women. In the poorest parts of the world, the risk of a woman dying as a result of pregnancy or childbirth is about one in six. In northern Europe, the risk is about one in 30,000. Some 99 per cent of all maternal deaths occur in the developing world. Children who lose their mother are 10 times more likely to die prematurely than those who do not.

Millennium development goal 5 will be achieved only through long-term investment in health services and health infrastructure. There is a need for skilled birth attendants who have supplies and equipment, improved access to family planning services and action to address unsafe abortion. Maternal mortality is currently decreasing by less than 1 per cent a year. That is far below the 5.5 per cent annual improvement that is needed to reach the millennium development goal target by 2015.

We also need to be aware of the campaign to end fistula—a rupture in the birth canal that occurs during prolonged, obstructed labour and that leaves women incontinent, isolated and ashamed. Given that nine out of 10 fistulas can be successfully repaired, that is an issue that needs to be addressed.

During 2008, significant steps were taken towards reducing maternal mortality and achieving the necessary improvements in health service provision in developing countries, but at the current rate of progress it is unlikely that the millennium development goal target will be achieved by 2015.

I take this opportunity to commend Jack McConnell for his achievements, working with many people and organisations—including, I read, the girls of Mary Erskine School—to raise £25,000 for the wellness centre for nurses and health workers in Malawi, and delighted that he has joined us for this evening's debate.

In Scotland, we still have one of the lowest breastfeeding rates in Europe and we appear to have very serious issues of maternal obesity. Recent research by the World Health Organization found that 13 Scottish women die for every 100,000 live births. I do not know about other members, but I was shocked to realise that that is more than double the European average, which is six per 100,000. In fact, the number of women who die during childbirth in Scotland is similar to that of former Soviet countries such as Belarus and Latvia. Our teenage pregnancy rate is among the highest in Europe. Drugs and alcohol issues also present huge problems for pregnant women and children.

Although the maternal mortality rate in the UK as a whole has not fallen in the past few years, I understand that many of those who died had poor general health and were more likely to smoke, that at least half were overweight and that some had chaotic lifestyles, so they did not always seek—and therefore were not given—the health care support they needed during pregnancy.

In Scotland, the plan for midwives to take over antenatal care from general practitioners has recently been implemented without public debate. As far as I am aware, no strong evidence base has been produced to show that the quality of care of mother and child will be best served by that change. It might be that the quality of care of mother and child will be best served by it, but it would be a courtesy to allow parliamentarians to endorse it. That approach is being replicated in the move to take health visitors out of GP practices and away from the family doctor, who is often best placed to offer advice and discuss the pregnancy in the context of the woman's life and family situation. I place it on record that rather than read in the newspapers that GPs are to be excluded from that part of the care of mothers and families, I would like to see the evidence base that demonstrates that the proposal will bring health benefits.

We should be proud of the fact that HIV testing is provided for all pregnant women in Scotland, which is undoubtedly enormously beneficial to mother and child. I am delighted to sponsor the debate and to acknowledge the excellent work of midwives in Scotland. I hope that their training and expertise can be used to assist in those African countries in which maternal death is devastating.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

We move to the open debate. Speeches should be of four minutes.

Photo of Richard Simpson Richard Simpson Labour 5:11 pm, 6th May 2009

I congratulate Mary Scanlon on securing such an interesting debate and on her tour de force of a speech, in which she covered so many areas so well.

I remember well my first experience of the difficulties that can occur during childbirth, which I gained in the 60s in Sudan when I saw the consequences of female circumcision. Even though female circumcision is a particularly unpleasant procedure that leads to great difficulties with birth, it is still practised widely—although it has been fully outlawed in this country.

Mary Scanlon dealt effectively with deaths during childbirth overseas, so I will not go into it again. Suffice it to say that meeting the millennium development goal by 2015 is a difficult challenge and if we do not all make considerable efforts it will not be achieved.

It is vital that we tackle the problems that exist. The number of mothers with AIDS who give birth in Africa, for example, is a massive problem. Even when societies reach a higher socioeconomic level they are confronted by tobacco companies that mercilessly exploit people by encouraging them to take up smoking. As we know, smoking during pregnancy, which leads to premature and low-weight babies, is still a problem in this country.

The problems that we face are to do with the fact that, until 2003, the birth rate in this country had been dropping steadily, but it has since gone up and it continues to increase—it has increased by roughly 10 per cent over the past five years. That is leading to greater pressures on midwives throughout Scotland. In some areas, midwives are carrying excessive case loads; I am sure that some of the midwives in the public gallery will tell MSPs of their experiences later.

The size of midwives' case loads is being exacerbated by the emergence of new problems and the growth over the past 20 years of existing ones, the first of which is drugs. We now know that roughly 50,000 children have parents who have drug problems. They must go through an antenatal process, in which the support of their midwives is crucial. Obstetricians such as Dr Mary Hepburn in Glasgow have done a lot of work in that field, along with midwife colleagues, to support patients, and the specialist team in Edinburgh that is led by a midwife is doing sterling work in that regard.

The other problem is alcohol. Foetal alcohol syndrome was first diagnosed by Dr Peter Whatmore, a colleague with whom I worked in Cornton Vale prison. We discovered that a number of the babies who were born to women in the prison had unusual features. Foetal alcohol syndrome is now well recognised. As I am sure the minister will tell us, research is to be commissioned to determine the number of babies who are born with foetal alcohol syndrome, because we still do not know the numbers involved.

I have asked a number of parliamentary questions about midwifery over the past few months, because I have concerns about the fact that seven health boards are not meeting the standards on the number of supervisors of midwives. I understand that the issue is being addressed, but it is quite inappropriate that boards are not meeting standards, which are usually a minimum. The issue needs to be addressed and I hope that it will be.

At £500 per annum, the incentive for midwives to become supervisors is pretty meagre and does not reflect the excellent work that supervisors do to support their fellow midwives and ensure that practice is safe—so that we can address the 13 deaths per 100,000 live births that Mary Scanlon alluded to.

I will finish on the matter of general practice. I too think that the abandonment of the contract is inappropriate: it should have been adjusted. There is no doubt that the role of GPs has changed, but general practice is the one specialism that has an holistic role to play in the patient's life. The GP is the one person with whom all patients are registered. The abandonment of the contract is not appropriate and there should have been far wider debate, as Mary Scanlon said.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

I remind members that time is limited and many members wish to speak.

Photo of Angela Constance Angela Constance Scottish National Party 5:16 pm, 6th May 2009

I congratulate Mary Scanlon and commend her for marking international midwives day with tonight's members' business debate; there is much to celebrate in the good work undertaken by midwives at home and abroad.

I have absolutely no doubt that we need to enhance the role of midwives and how they are perceived and valued as well as to increase the number of midwives here in Scotland and in the developing world. The value of a good midwife is never more evident that when the birth of a child is not progressing as planned: I recall my birth plan going well and truly out the window.

I would like to pay tribute to two midwives—Sandra Smith and Michelle Davidson—who work at St. John's hospital in Livingston. They recently won a top award from the Royal College of Midwives for promoting normal and natural childbirth. The judges selected that project because it was innovative and reinvigorated a Cinderella service—antenatal care.

We have to remember that pregnancy and childbirth are normal and natural experiences but, as Mary Scanlon highlighted, for some women—depending on where they live, their access to health services and their own health—they can be perilous. Worldwide, a woman dies in pregnancy and childbirth every minute. Over half a million women die due to complications and 10 million women suffer debilitating illness and lifelong disabilities. Those are truly shocking statistics.

There is a huge disparity in maternal health between rich and poor countries and within rich and poor countries depending on whether one is in a rural or an urban area and whether one has had access to education. A woman's lifetime risk of dying in childbirth in the developing world is one in 76 and in countries such as Niger it is as high as one in seven, but in the industrialised world it is one in 7,000.

As we heard, mothers play a vital role in the economic health of their families and motherless children are trapped in a cycle of poverty. Worldwide, 2 million children are orphans due to their mothers dying in childbirth. Despite the progress, the number of deaths of children under five remains unacceptably high although it has dipped below 10 million—an annual death rate that is truly appalling, particularly when it is from preventable diseases such as pneumonia, diarrhoea, malaria and measles.

The situation in Scotland is very different. Nonetheless we are not without our challenges. While neonatal and postnatal deaths have decreased over the past 30 years, the rate of stillbirth remains static. Like Mary Scanlon, I was shocked that the number of women per 100,000 births who die in Scotland is 13 and how poorly that compares with rates in other European countries.

Low birth weight is a crucial issue that affects 6 per cent of births in Scotland but is related to 60 per cent of perinatal deaths. Smoking and the age and weight of the mother are factors in low birth weight. I cannot help but note that the latest figures, from 2005-06, show that 133 low birth-weight babies were born in West Lothian. It is obvious that maternal health relates greatly to Scotland's record as the sick man of Europe, and I look forward to hearing about how the Government will progress the agenda.

Photo of Elaine Smith Elaine Smith Labour 5:20 pm, 6th May 2009

I congratulate Mary Scanlon on bringing the first debate on midwives to the chamber. On this historic day, we should remember that members' business debates are an important part of the parliamentary process. I recall my own members' business debate on breastfeeding in 2001, which later resulted in the Breastfeeding etc (Scotland) Act 2005.

I am grateful for the opportunity to commend the contribution that midwives make to the health and wellbeing of women and babies in Scotland and throughout the world. Midwifery is, of course, about more than just delivering babies. It is important in the postnatal period, particularly because help with breastfeeding is crucial for many new mums. A midwife's support can make the difference between a mum deciding to continue breastfeeding, and deciding to formula feed.

A project in my constituency, which is a unique curriculum-based breastfeeding programme that midwives are involved in delivering—if members will excuse the pun—has been very successful, and has been externally evaluated with positive outcomes. It is part of the healthy lifestyle project that is based at Coatbridge high school and managed by Mr Charles Fawcett, and it offers an holistic and integrated approach to health and wellbeing. The programme educates boys and girls about the benefits of breastfeeding, which is vital, because in some council wards in Coatbridge, breastfeeding rates are as low as 3 per cent. Many young people in my constituency have no experience or knowledge of the crucial role of breastfeeding in child health and development.

Although individuals make decisions about positive health behaviours such as breastfeeding, those take place in complex social circumstances that are influenced by attitudes, beliefs, motivations and community norms. The healthy lifestyle project is so important and so successful because it is rooted in the local community and takes account of the complete health context of the Monklands area. It is part of a wider strategy that has been complimented and acknowledged by many experts on the subject, including Phil Hanlon, who is a professor of public health at the University of Glasgow. In addition to the breastfeeding initiative, the project has extended its holistic approach to its aiming higher in Malawi programme. It has been supported by a Scottish Government international grant and it has, working in partnership in Malawi with the Forum for African Women Educationalists, formally evaluated a mother group training programme with the local community and schools in Luchenza market town, near Mulanje in Malawi.

I am told that that "mother group" is a deceptive term, because the group usually comprises village headmen, headteachers and influential women. That is because it is necessary to overcome resistance and rivalries to create an environment that avoids harmful historical cultural practices towards females. The mother group training addresses issues that impede the development of women and girls in Malawi, such as female genital mutilation, forced early marriages, sexually transmitted diseases, miscarriages, stillbirths and poor nutrition, especially at the stage when girls reach puberty. Girls in Malawi also face many other issues.

Malawi has an unenviable record, with an infant mortality rate of 90 deaths for every 1,000 live births; and an under-five mortality rate of 130 deaths per 1,000. That compares badly with rates in the UK of five deaths per 1,000 and six deaths per 1,000 respectively. The external evaluation of that particular healthy lifestyle programme provided a strong evidence base with positive outcomes. The programme is important because educating women so that they have fewer children, healthier pregnancies and safe deliveries ensures that their babies are more likely to survive childbirth, the vulnerable first months of life and the critical first five years.

I wanted to mention the girls go for health initiative, but I realise that I do not have enough time. I will finish by saying that I fully support Mary Scanlon's call to reduce child mortality and to improve maternal health, as set out in the United Nations millennium development goals. I hope that today's debate will help to raise awareness of the invaluable job that is done by midwives, and I once again applaud the vital contribution that they make to the health and wellbeing of mothers and babies in Scotland and abroad.

Photo of Nanette Milne Nanette Milne Conservative 5:24 pm, 6th May 2009

I am very pleased to speak in support of Mary Scanlon's motion, and to congratulate her on securing the debate.

When I was at Aberdeen medical school, I was privileged to be taught by the late Sir Dugald Baird, just before he retired in 1965. He was instrumental in developing the antenatal and perinatal care that we have come to take for granted in Scotland and, thanks to his research and practice, maternal mortality rates tumbled.

Although those excellent results stem partly from better health and nutrition, they are in no small measure due to the expertise and commitment of midwives, both in hospital settings and in the community. Sadly a few women here still die in childbirth; however, the vast majority of women can expect to come through the process unscathed, although, as Mary Scanlon made clear, there are areas in which care is still not ideal.

Women in Scotland value their local maternity services. Indeed, as many of us who have been involved in campaigns to save maternity hospitals know, whenever changes are proposed to the delivery of such services, the women make it clear that they do not want them to be tampered with. In a relatively successful campaign in which I was involved in Aboyne in Aberdeenshire, a birthing unit was retained within the cottage hospital. However, most of the antenatal and perinatal care was transferred to the community, with expert community midwives in charge of patient care.

With many women lacking the family support that previous generations of mothers could rely on, and with increasing numbers exhibiting the effects of drug and alcohol misuse, our midwives are playing an increasing role in educating mothers before the birth of their babies, giving them information on how to bring them up in a healthy lifestyle.

By and large, we like our maternity service, which is, on the whole, very successful and gives most mothers a choice about where their babies will be born. Improvements can always be made, and we must be ever watchful for complications that can affect mother and baby. However, we can generally consider ourselves to be fortunate.

Sadly, in many other parts of the world—for example sub-Saharan Africa and Indonesia—maternal mortality rates are still unacceptably high with, as we have heard, more than half a million women dying from pregnancy and childbirth complications every year. I find it shocking that in this day and age the developing world accounts for 99 per cent of all maternal deaths. It is indicative of the severe poverty that still exists in those parts of the world.

Led by Professor Wendy Graham, the University of Aberdeen is again playing a major role in combating maternal mortality, this time globally. Professor Graham, who is internationally renowned for her work in measuring maternal health outcomes and interventions, has undertaken collaborative research work in a large number of developing countries, particularly in sub-Saharan Africa, and regularly provides technical support to a number of international agencies.

Professor Graham also runs the initiative for maternal mortality programme assessment—or immpact—a well recognised global research programme. Its results should provide science-based information on maternal, perinatal and economic outcomes, with the objectives of improving knowledge of the health, social and economic consequences of pregnancy, abortion and delivery for women in developing countries, and of mobilising that knowledge in comprehensive efforts to evaluate interventions to make pregnancy safer. Clearly, that research will inform progress towards achieving the millennium development goal of improving maternal health, which is targeted at reducing maternal deaths and providing universal access to reproductive health. Key to achieving that will be the availability of skilled midwives, with appropriate equipment and supplies, better access to family planning services and action to deal with unsafe abortion.

Much remains to be done. So far, little progress has been made in sub-Saharan Africa and, as the motion suggests, greater international action is needed to resolve the global problem of maternal and infant mortality. However, I hope that, in the fullness of time and with the help of the midwifery profession, the work that has been initiated by the Aberdeen team will bear fruit and be instrumental in improving global maternal health, in the same way that Sir Dugald Baird's pioneering work last century did so much for mothers and infants in this country.

Photo of Rt Hon Jack McConnell Rt Hon Jack McConnell Labour 5:28 pm, 6th May 2009

It has been said that, under their care, midwives do not just help with births, but change lives. More so than on any other occasion, that was brought home to me four years ago this month when I visited Bottom hospital in Lilongwe to meet a group of Scottish midwives. They had volunteered to work in the most horrendous circumstances; indeed, what I saw there was certainly the closest that I have ever been to hell on earth. In Bottom hospital, more than 1,000 people give birth every month, which is double the number of women who give birth in Edinburgh royal infirmary. At any given time, there are approximately 20 midwives to support the women, who queue outside in the dirt and who, when they get inside, regularly find that there is no running water—never mind hot water—and very little medication or other support.

At the time, those of us who visited Bottom hospital thought, as many others who have visited it since have, that there was a desperate need for something to be done. Of course, midwives in Scotland have led the campaign to ensure that we in Scotland help to build new maternity services in Lilongwe and elsewhere in Malawi. I understand that a new maternity wing for high-risk cases will be opened later this year and that construction of the new Bottom hospital is about halfway through. Those are great achievements, but they address a pressing need. The midwives certainly changed lives in inspiring us in Scotland to make a difference in Malawi, and particularly to make a difference for children there. More than 100 out of every 1,000 children there will die before the age of five, and more than 800 out of every 100,000 mothers will die in childbirth.

One of those campaigning midwives, Linda McDonald, is in Malawi helping and volunteering her services. If members want to read about the combination of hope and despair that that work provides, they should read her blog on the Malawi Underprivileged Mothers recipes website. There are vivid descriptions of the life of a midwife and the life of a mother giving birth in Malawi.

We cannot turn our backs on conditions in Malawi, anywhere else in sub-Saharan Africa or elsewhere in the world. International midwives day gives us an opportunity not just to celebrate the work of midwives the world over, but to commit to the importance of that work and its importance in achieving millennium development goals 4, 5 and 6.

I praise the work of the Royal College of Midwives in Scotland, which has taken up the challenge in Malawi and elsewhere. It has brought Malawian midwives to Scotland to learn about the techniques and services that are provided here and it has supported work in Malawi financially and in other ways. I hope that its work will continue for many years to come and that it will inspire others to do the same.

I want to say something on the 10th anniversary of the first elections to the Scottish Parliament. I have said consistently that the partnership between the people of Scotland and the people of Malawi represents the best of Scotland. That partnership has been a way for us to ensure that our devolved Parliament looks outwards, not just inwards.

Today is also a day to celebrate the kind of Parliament the Scottish Parliament is. When members were elected 10 years ago, a greater proportion of women were elected than had been elected before to any institution in the United Kingdom. That has influenced our debates, their tone and the priorities that we have set and, 10 years on from those first elections, this debate is another opportunity to celebrate the fact that the women who have served in the Scottish Parliament have shaped the nature of our debates and the priorities that we have given certain issues. I hope that that will continue in the years to come, because it makes the Parliament a far more representative and caring place.

Photo of Christine Grahame Christine Grahame Scottish National Party 5:33 pm, 6th May 2009

I congratulate my colleague Mary Scanlon on securing the debate. Generally speaking, I am not a devotee of international days, but international midwives day is an exception that I am happy to support.

As members have said, midwives are crucial to the unborn child and maternal health before and after delivery of the child, and through the very vulnerable early years of a young child's life. Members have said that they are particularly crucial to children and mothers who give birth in sub-Saharan Africa. I will not go back over the statistics, as they have been well rehearsed.

International agencies such as the WHO, the United Nations Population Fund, the United Nations Children's Fund and the World Bank have combined to provide increased support to countries with high child mortality rates. However, I have read that, worldwide, around 350,000 more midwives are needed to meet millennium development targets. The deaths of mothers, babies and young children are, of course, highly preventable. Midwives provide expertise through all stages of pregnancy to birth and beyond, vaccines, anti-malarial drugs and bed nets. They identify, counsel and treat pregnant women with HIV and AIDS, prevent mother and child transmission, and play a vital role where there is diarrhoea, measles, malaria—Angela Constance mentioned those—or malnutrition, which accounts for 70 per cent of deaths in developing countries.

As Jack McConnell eloquently said, some countries, such as Malawi, have cut child deprivation in half, and life expectancy has improved in them, but life expectancy is still bad for mothers, babies and children in countries in which there is conflict and bad governance, such as Zimbabwe and Somalia.

It was interesting that Jack McConnell talked about women in the Scottish Parliament and the status of women. Colleagues will recall that, during the G8 summit in 2005, we had an alternative summit—the W8, which involved eight women from Africa who were trying to enhance the role of women in society across the African continent. I believe that, deep at the core of neglectful or non-existent antenatal and postnatal care lies the status of women. In some countries, women are often ranked well below the men in the community and even young boys. We could even say that, sometimes, they are dispensable. Until women are seen as being as important as the men in those societies, there will be an issue. We must fight to change the culture in those areas.

All is not well in this country, of course. We have evidence that, in Scotland, in deprived areas where there are inequalities, child care is less likely to be good and women are less likely to have healthy babies or to have a decent pregnancy. Therefore, there are issues here, too.

Elaine Smith raised the issue of breastfeeding. A huge problem in some developing countries is that formula companies target women and encourage them away from breastfeeding and towards formula, which can be mixed with water that is contaminated or dirty. As a result of mothers being put into a culture of using bottles, babies are taken away from breastfeeding and are dying because of contaminated water. We should address that issue. I am sure that, if there were more midwives out in the field, they would be able to stop that change that is taking place in some countries.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

I am minded to accept a motion without notice to extend the debate to allow us to complete it.

Motion moved,

That, under Rule 8.14.3, the debate be extended by up to 30 minutes.—[Mary Scanlon.]

Motion agreed to.

Photo of Karen Gillon Karen Gillon Labour 5:37 pm, 6th May 2009

I, too, congratulate Mary Scanlon on securing this important debate. Ten years ago today, I had the honour of being the first woman elected to a Scottish Parliament. That was a day full of hope and expectation. The Parliament was designed from its conception to be different and it aimed specifically to be family friendly and inclusive. As Jack McConnell said, it also aimed to have a different type of debate. Tonight's debate is part of that process.

Ten years on and three children later, I have certainly tested the Parliament's family-friendly nature. I have seen up close Lanarkshire's maternity and midwifery services. I have yet to manage a normal and natural delivery, but I think that I will give up before I try that any more. I have only the highest regard for the midwives who cared for me during each of my three pregnancies. In theory, the process has changed since I had James eight and a half years ago but, in practice, I saw little difference during my pregnancy last year, which led to Johann's birth. In all three pregnancies, the midwives were caring, supportive and encouraging and they provided information and reassurance. As Angela Constance said, they are there when the birth plan goes out the window, encouraging and supporting people through difficult times.

Midwives face many challenges, particularly that of an ever-increasing workload. Other challenges have come about as more and more women have become dependent on drugs or alcohol, which brings challenges during pregnancy and childbirth. In the past year or so, challenges have come about as a result of an increasing birth rate because of the increase in the number of migrant families. I would be interested to hear from the minister what analysis is being done of the impact that that is having on maternity services throughout Scotland. More and more families are coming here and having children. They are very welcome, but what audit is being done to consider what further services are needed?

When women become pregnant, they expect that everything will go well and that things will run smoothly. However, unfortunately, even here in Scotland, that does not always happen. I welcome developments such as additional scans that provide further reassurance and support for women. I also welcome the changes that have meant that midwives are far more involved in the day-to-day planning of care.

Like others, I have seen midwifery in another country—in Malawi, in my case. It gave me something to think about. I visited Bottom hospital and was struck by what I saw. I also visited many rural areas and saw the challenges facing women who give birth in villages without electricity and running water, and without support staff and midwives. With the right level of intervention, 80 per cent of maternal deaths in Malawi are preventable. I therefore commend all those in Scotland who are supporting midwives and the health service in Malawi to ensure that women have access to appropriate health care there. I encourage the minister to ensure that support will be provided to allow that work to continue.

It will be a real mark of this Parliament if, in 20 years' time, we are able to consider the progress that has been made and say that the Parliament has played its part in preventing maternal deaths not only here in Scotland, but in parts of the developing world.

Photo of Shirley-Anne Somerville Shirley-Anne Somerville Scottish National Party 5:41 pm, 6th May 2009

I, too, congratulate Mary Scanlon on securing this evening's debate.

I recently experienced a first-class service at a midwife-led unit, and I cannot begin to imagine the experiences of women in countries such as Malawi. When I worked for the Royal College of Nursing, I had the honour of meeting representatives from the National Association of Nurses of Malawi. One of them was a feisty and formidable woman called Dorothy Ngomo. We toured Edinburgh royal infirmary with Linda McDonald, whom Jack McConnell has already mentioned. Dorothy and her colleague could not believe the facilities that we have in this country—which we take for granted—when compared with the facilities for women where they came from.

Dorothy told us many stories of women walking mile upon mile to get to the nearest hospital to seek support. I compare those stories with my only complaint, which was about my husband's rather erratic driving at some roundabouts on the way to our excellent midwife-led unit. I also compare my worries about whether I would get access to a birthing pool with the worries of Malawian mums who do not even know whether there will be running water for them. I compare my worries about whether I would be able to plug in my relaxation tape on my iPod with the worries of pregnant Malawian women about whether there would be a midwife to look after them. Comparing my experience with the stories that Dorothy told me really brought it all home to me.

The role of the midwife is central to an expectant mother and her child. In my case, no question was too small or too daft—and I can assure members that I had plenty very small and very daft questions during my pregnancy. I had to get used to the fact that there were sometimes no right answers, but the midwives did all that they could to reassure me. Despite a scare at the start of my labour, which meant that a doctor was allowed into the room, it was midwives who saw me through the delivery of my daughter.

It was also midwives who saw me through the important first couple of days, which brings me on to what Elaine Smith said about breastfeeding. Had it not been for the excellent one-on-one support that I received from midwives and nursery nurses in the unit, there would have been no way that I would have carried on breastfeeding for more than a day. It may be natural and it may be normal, but that does not mean that it is easy. No one had told my daughter about it; she did not know that she had to take part in the process. Without the midwives, I would not have been able to continue successfully with it.

During my many hours of discussions with the midwives who were helping me, we discussed why other women give up on breastfeeding. Much of it seems to have to do with social attitudes—whether the attitudes of partners or, sometimes, of other mothers. We heard about a mother who complained about a woman who was breastfeeding in a four-bed unit. The complainer felt that it was disgusting to do that when visitors were in the unit. Midwives should not have to deal with such attitudes when encouraging women to breastfeed.

I commend midwives for what they do in hospitals and in the community, and I commend the Royal College of Midwives for its work to support women in the Lothians in particular, in our campaign with Lothian Buses, which had refused to let new mums or other parents and guardians on to buses with certain types of pram. There is no doubt that the expertise that the Royal College of Midwives brought to that process had a direct impact on the decisions that Lothian Buses has now taken to pilot a new design.

I commend the role of midwives not just here in Scotland but abroad, where midwives deal with circumstances that are more difficult than we can possibly imagine. I thank Mary Scanlon again for allowing us the opportunity to debate the subject today.

Photo of Shona Robison Shona Robison Scottish National Party 5:45 pm, 6th May 2009

On behalf of the Scottish Government, I very much welcome this debate on international midwives day, and I thank Mary Scanlon for bringing it to the Parliament. I was amused by the looks of shock on the Tory benches, however, when she mentioned the "three expectant fathers"—there were some worried-looking people when she said that.

On international midwives day it is good to remember that Scotland's 3,500 midwives are part of a huge global family of midwives of more than half a million men and women—we should remember that there are male midwives, too. Within that family, the role of midwives and the circumstances in which they work differ considerably. Indeed, many countries suffer particularly significant challenges, as has been outlined very well in some fantastic speeches. Irrespective of those differences, however, each midwife around the world shares a bond and a commitment to provide the best possible care for women and their infants during one of the most special phases of life.

I am pleased to say that Scotland is a leading light in midwifery practice, and we are determined to ensure that women receive the highest quality of maternity care. As our knowledge and understanding increase, we are constantly developing and improving that care. All women should have as natural a birth experience as possible, which is achieved by working with and listening to the women for whom the care is provided.

As members are probably aware, Scottish maternity policy, as set out in "A Framework for maternity services in Scotland", recognises the importance of the midwife as primary carer in the delivery of maternity services. We are committed to ensuring that women and their babies are cared for using safe, clinically effective, evidence-based models of care before, during and after pregnancy. We believe that maternity services should be based on informed choice, promoting childbirth as a natural event, ensuring local accessibility and supporting the establishment of community maternity units where possible—there are currently 22 of them across Scotland. We recognise the vital and valuable role that midwives play in delivering services in community maternity units, and the Scottish programme for clinical effectiveness in reproductive health has recognised the enormous contribution that community maternity units make to maternity care.

The keeping childbirth natural and dynamic programme—KCND—is a great example of our efforts to ensure that women have as natural a birth as possible. Midwives play a central role in that approach: under it, they play their part in implementing a multiprofessional programme of work, which will ensure that the midwife is the first point of contact, that evidence-based care is provided, that unnecessary interventions are reduced and that multiprofessional care pathways are provided. That will ensure an informed choice and provide the best possible support for vulnerable women and families, as has been mentioned by members in the debate. The work is aimed at making the experience of maternity services and childbirth the best possible.

To support KCND's implementation we have provided resources for consultant midwives in 12 NHS boards to co-ordinate the work and to implement the changes in practice. That is a significant investment in clinical midwifery leadership, and it raises the profile of midwifery practice. I am pleased that the programme is progressing so well and that all NHS boards are supportive of it.

I will turn now to some of the concerns that have been raised about that programme. I reassure members—specifically Mary Scanlon and Richard Simpson—that the programme has the support of all stakeholders, including the National Childbirth Trust. It plays well into risk assessment early in pregnancy, which enables early intervention for those who require additional medical or social support that is—crucially—tailored to their needs and delivered by the most appropriate professional. The evidence tells us that that is the way to proceed, whether we are dealing with foetal alcohol syndrome or the low birth-weight issues that Angela Constance identified. I reassure members that women who wish to continue to have their GP as first point of contact will be able to do so; there is no question about that. It is important to recognise that, and I hope that I have reassured members. The programme is positive, and it would be unfortunate to present it as anything other than that.

I am aware that time is limited, so I will turn to the millennium development goals. Mary Scanlon laid out well some of the sobering statistics on maternal deaths in the developing world and why the millennium development goals are important. Shirley-Anne Somerville made the point well that we sometimes take for granted what is on our doorstep, given what some women around the world must cope with in childbirth. What should be a wonderful life event can be terrifying for some women. That point has come across well in the debate.

The Scottish Government's international development policy focuses on poverty reduction and achieving the millennium development goals. All Scottish Government-funded projects are required to show how their activities will contribute to that. Nowhere is that more evident than in our engagement with Malawi and the co-operation agreement that our two countries signed. I pay tribute to Jack McConnell for his work on that; his speech outlined well why all that work is important.

The co-operation agreement's health strand is well established and has been developed through strong links between organisations, institutions and people. As has been said, Malawi has one of the highest maternal mortality rates in the world, so it is not surprising that it has asked us to prioritise funding to address the problems of maternal health and child mortality. We have done that: through the Scottish Government's international development fund, we are supporting several projects that build on work that is under way and in which Scotland has specific skills and expertise to offer.

In the most recent funding rounds, we announced support for projects that will target the treatment of children with severe malnutrition and work to prevent malnutrition in the long term—members identified malnutrition as a key cause of infant mortality.

We will also support projects to strengthen and speed up the referral process for women who experience complications in childbirth, through the provision of training for traditional birth attendants in southern Malawi, and projects to reduce maternal and neonatal mortality by training health workers to implement maternal health and safe motherhood programmes. Reducing maternal mortality through training in emergency obstetric skills for health professionals, particularly in rural areas of Malawi, is important.

Like members, we recognise that a lot of work has still to be done. We look forward to working together in partnership with Malawi, and we will take the lead from Malawi on what it wants to assist and complement the work that is being undertaken to address the difficult problems that are faced there.

I thank members for their contributions to the debate, and I will write to any members whose questions I did not address in the short time that was available for my speech. The debate was wide ranging and good.

Meeting closed at 17:54.