MIDIRS Midwifery Digest, Vol 23, no 4.
Dr Tania McIntosh, Lecturer in Midwifery, University of Nottingham
This year marked the 20th anniversary of the Changing childbirth document (DH 1993a), which drew the attention of members of the De Partu, History of Childbirth Group. To celebrate this landmark occasion, members of the group led by the well-known midwifery historian Dr Tania McIntosh arranged a ‘witness’ seminar in the Council Chamber of the RCOG (Royal College of Obstetricians and Gynaecologists) supported by a grant from the Wellcome Trust. The aim of the seminar was to explore the genesis, implementation and legacy of Changing childbirth in terms of its practical and philosophical impact.
Whilst still remaining one of the most prominent pieces of work upon which many other reports and studies have been developed, the original premise was that once the work of the report was done it would be consigned to history! However, as Dr McIntosh demonstrates in her Hot Topic article in the December issue of MIDIRS Midwifery Digest, the work of Changing childbirth still continues today.
Changing childbirth: consigned to the ‘shelf of history’?
Dr Tania McIntosh
2013 has seen the 20th anniversary of the publication of the Changing childbirth report (DH 1993a) which explored the landscape of maternity in England and made recommendations for the future direction of the service. Far from being consigned to ‘the shelf of history’ the language and ideas of Changing childbirth, and its precursor, the ‘Winterton Report’ (House of Commons Health Committee 1992), continue to resonate in the maternity services.
Maternity care provision is once again under national discussion following the passing of the Health and Social Care Act (DH 2012) and debate continues about how to provide the most cost effective and meaningful care to women and their families. The genesis, development and legacy of Changing childbirth were explored at a seminar held in London in October entitled ‘Changing childbirth twenty years on: genesis, implementation and legacy’. The meeting was attended by some of the key players involved in developing the original work, including Baroness Cumberlege, and Sir Nicholas Winterton, together with representatives from midwifery, obstetrics, general practice and consumer groups. The overall consensus was that the report represents unfinished business and as such its recommendations and conclusions still matter today. This paper will explore what Changing childbirth said at the time, and why it was, and remains, so influential.
It is also worth remembering that although it was an English report, Changing childbirth impacted nationally on the language used to describe maternity care and the debate about how care should be provided and by whom (Welsh and Scottish reports made similar arguments: Welsh Health Planning Forum 1991, Scottish Office, Home and Health Department, Health Policy and Public Health Directorate 1993). The language and philosophy of care which Changing childbirth espoused have continued to resonate in policy documents, for example Maternity matters (DH 2007) and Midwifery 2020 (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales 2010) and in the language of stakeholders such as the Royal College of Midwives (RCM), the Royal College of Obstetricians and Gynaecologists (RCOG), NCT (formerly known as the National Childbirth Trust) and the Association for Improvements in Maternity Services (AIMS).
Where did the report come from?
The Changing childbirth report was produced in 1993 by the Expert Maternity Group, convened by the Conservative government and chaired by Baroness Cumberlege. It followed the publication in 1992 of the Winterton Report (House of Commons Health Committee 1992) and built on its recommendations. It therefore had its genesis, not among professionals or consumers, although they were both vital in setting the agenda, but among politicians.
Maternity care in Britain had changed significantly in the 1960s and 1970s. In 1960 just over 60% of births took place in a hospital setting, and this figure had risen to 85% by 1970 and 96% by 1990 (Macfarlane et al 2000:523). The reasons for this were multifaceted, driven by a mixture of consumer demand, professionals’ beliefs about risk and safety, and the growing power of the acute hospital sector in managing health care (McIntosh 2012).
In 1959 the ‘Cranbrook Report’ (Ministry of Health 1959) had recommended that beds be available for 75% of births to take place in hospital, and by 1970 the ‘Peel Report’ (DHSS 1970) had widened this to offer beds to all women, regardless of health risk, parity or social need. These reports were seen as both influential and ground breaking in setting the agenda for the development of the maternity services. Maternity care was about more than just where a birth took place, however; it was also about how it took place.
In 1962 the vast majority of labours had begun and developed spontaneously, with an induction rate of around 8%. By 1974 the landscape had changed beyond recognition and 39% of labours were induced or augmented (Macfarlane et al 200:529). This was coupled with an episiotomy rate which reached a high point of 53% of births by 1979 (Macfarlane et al 2000:532). Of course patterns of care were always more diverse and complex than these overall figures suggest. Women did still birth at home or in low-tech GP units, some midwives retained agency and autonomy in their work. Generally, however, maternity was characterised as a high-risk activity, with success or failure dependent entirely on the production of a live mother and live baby at the end of the process. By 1980 concerns about perinatal mortality in particular seemed to be driving the agenda. The ‘Short Report’ (Social Services Committee 1980), yet another official production, commented that:
‘…mounting babies were unnecessarily dying or suffering permanent damage during the latter part of pregnancy and the earliest part of infancy.’ (Social Services Committee 1980:1).
The full article and references can be found in the December 2013 issue of MIDIRS Midwifery Digest.
Other original articles in this issue include:
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