Community Maternity Units article

Paper for North of Scotland Maternity Services Framework Group/NES, Nairn, 15-16 February 2006

Community maternity units
- what can they do?
Standalone community maternity units have been confirmed as an integral part of future maternity provision in Scotland (RCOG, 2005; SEHD, 2005).  Avril Nicoll and Phyllis Winters use the example of Montrose CMU to answer crucial questions about their benefits.

Montrose community maternity unit is 30 and 45 miles from the nearest consultant units. It has a team of 9.8 wte midwives who offer an integrated service to women in Montrose, Brechin, Edzell and the surrounding rural areas. In 2002 this unit hit a low of 47 births, only 21% of women coming through the midwives’ care. By 2005, this figure had risen to 156 (54%) as a result of various changes in practice implemented by midwives and backed by user representatives (Leatherbarrow et al., 2004). We scrutinised the 2005 outcomes to see what else they tell us.

Q1: What percentage of women can realistically have their babies in standalone community maternity units?
A: Over 50 per cent…
Some women do not live in the Montrose unit catchment area but choose the unit because of its reputation. To get a clear picture of a real ‘clinical population’, and to avoid presenting skewed statistics, we recorded ‘in area’ women (i.e. those living in the catchment area or with a GP in the catchment area) separately. In 2005, 52% of the 259 ‘in area’ women gave birth at Montrose (n=135). This proves that the majority of maternity services, including births, can be provided close to home and by midwives. For these ‘in area’ women, intrapartum transfer was 9%, episiotomy 2%, and pharmacological pain relief 8%.

Q2: Can such units impact on Scotland’s instrumental delivery rates?
A: Yes, significantly…
We recorded delivery outcomes for all ‘in area’ women, wherever they gave birth. In 2002 the operative vaginal delivery (forceps + ventouse) rate for all women coming through the care of Montrose midwives was 21%. In 2005, for ‘in area’ women it was 6% (national average 12%). (NB National averages for Scotland for 2005 are not yet available, but our comparisons here are with the ISD website figures for 2004 for ‘live singletons by mode of delivery’. ) The caesarean section rate was 20% (national average 23%). We understand from leading midwifery researcher Denis Walsh that it is harder to make an impact on the caesarean rate, so this figure is a very good start. The normal birth rate for ‘in area’ women was 74% (national average 64%).

The number of first time mothers giving birth at Montrose (44% of ‘in area’ births at Montrose) seems to be a crucial factor in reducing intervention rates. A post-dates induction rate for the unit of only 4% also reduces the risk. Nationally, induction rates are recorded for all inductions whatever the clinical reason, but we understand a significant proportion of this 25% is for post-dates. It is also worth mentioning that women understand they do not need to see a GP or obstetrician if they are well, and that the midwives will only suggest involving a doctor if there is a clinical need.

Active birth and birth without medical intervention is promoted and explained antenatally at Montrose, whatever the chosen birth location. Also of significance is that 53% of the ‘in area’ women giving birth at Montrose had a waterbirth. Waterbirth statistics for Scotland are not held centrally, but we are in the process of gathering that information. Although it is clear from responses so far that it is extremely rare, the Montrose figure is comparable with birth centres in England where women have a real choice of waterbirth (Jubilee Birth Centre near Hull; Edgware Birth Centre, London).

Outcomes are summarised in Table 1.

Table 1 Summary of 2005 outcomes

Analyses in NHS Board Variations in Maternity Care and Outcomes (SPECRH, 2005) support our finding that the improved outcomes are a result of the midwifery-run model of care available to women in north Angus and not some special population characteristic. For example:
1. “Data presented in this report show NHS Board variations in rates of both elective and emergency Caesarean section. These differences persist following adjustment for key factors (such as morbidity and socio-economic deprivation). This suggests that differences reflect geographical variation in professional practice, rather than the population.” (p.10)
2. “The percentage of live singleton births which end in spontaneous vertex delivery is steadily declining across all NHS Boards between 1990-1992 and 2000-2002. The Scottish rate has fallen from 72.8% in 1990-1992 to 65.5% in 2000-2002. Differences among NHS Board areas are relatively small; and standardisation for age and deprivation has little impact on the pattern seen.” (p.21)
3. “There are significant variations among NHS Boards in rates of induction. Among mainland Boards, in 2000-2002, Dumfries and Galloway had the highest rate (37.7%) and Ayrshire and Arran the lowest (22.0%).” (p.27)

Q3: What next?
A: “Community Maternity Units, where deliveries are midwife-led, should be developed, either standalone or co-terminous with a Consultant-led unit.” (SEHD, 2005, p.206)
Changing the culture of childbirth across Scotland will take time and commitment, particularly from midwives. Montrose midwives have set the standard; we know now it can be done, and that it makes a real difference to women. Midwives are the lead professionals for women who are pregnant and well. While they need to take responsibility for changing public perceptions, they also need to know they have the trust and support of policy makers, managers and other healthcare professionals.

Every new mother deserves the best possible start in life with her baby. When they are given a genuine choice by midwives, women know what they need. As analysis of the Montrose outcome-focused statistics shows, community maternity units can play a central part in making ‘normal birth’ the norm.

Phyllis Winters is midwifery team leader at Montrose Community Maternity Unit, tel. 01674 832175 . Avril Nicoll is a member of the Association for Improvements in the Maternity Services.  

References
Leatherbarrow, B., Winters, P., Macleod, L., Nicoll, A., McNicol, K. & Hoggins, K. (2004) ‘From vision to reality: the development of a community maternity unit’, RCM Midwives 7(5), pp. 212-215.
Scottish Committee of RCOG (2005) The Future of Obstetrics and Gynaecology in Scotland. Edinburgh: RCOG.
Scottish Executive Health Department (2005) Our National Health: A plan for action, a plan for change. Edinburgh: Scottish Executive.
Scottish Programme for Clinical Effectiveness in Reproductive Health (2005) NHS Board Variations in Maternity Care and Outcomes. Edinburgh: Information Services NHSScotland. Available here  (Accessed: 23 January 2006).