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Specialist lawyer blames budgets and numbers for disparity in maternity care
A specialist in legal cases involving maternity issues, birth injuries and infant deaths has said many of the problems identified in a new report into maternity care are caused by managers concentrating on budgets instead of patients.
Janet Johnson, a medical negligence specialist with Fentons Solicitors LLP, said that the first report of its kind by The Royal College of Obstetricians and Gynaecologists (RCOG) showed the enormous disparity in the quality of care patients received across the country. The report, which analysed the performance of maternity units in England during 2011/12, found that rates of inductions, emergency caesareans and assisted deliveries were twice as high in some hospitals as others.
“This does not come as any surprise to us,” said Janet, an Associate with the firm who for more than 15 years has specialised in pursuing cases relating to birth injuries, gynaecology and obstetrics. “Different Trusts across the country set different targets for the number of caesarean sections they allow their obstetricians to perform,” she said. “The straightforward rationale is that it is significantly cheaper if a woman is able to deliver naturally. A c-section requires a larger number of specialist staff, an operating theatre, and simply costs more to perform. Therefore some of those setting and monitoring budgets will try to manage and limit the practice.”
The new report was based on research carried out with the London School of Hygiene and Tropical Medicine. It focussed on 11 ‘indicators’ of the quality of maternity care, using data routinely collected by hospitals, including the number of induced labours, emergency caesareans after induction, deliveries involving instruments such as forceps, severe tears during labour and emergency readmissions of mothers after delivery.
The report led RCOG vice president Dr David Richmond to suggest that not all women are receiving the best level of care. He told the BBC: "The initial set of indicators suggests wide variation in both practice and outcomes between maternity units which is a source of concern for the specialty as we cannot be sure that every woman is getting the best possible care.”
Janet said that although the disparity was clearly a cause for concern, there could be other reasons that some frontline staff appeared to be not giving the best possible care. “We have seen an increasing number of maternity-related medical negligence cases from across the country, where the common theme is a lack of numbers of midwives,” she said.
“We know that midwives are working very hard, but there are just not enough of them.There appears to be a trend in which more experienced midwives are being asked to undertake more administrative duties, leaving less midwives on the ward,” she said. “For example, there are midwives who are given the dedicated role of discussing the issue of breastfeeding with new and expectant mothers, while the delivery ward itself can be left understaffed,” she said. “That just doesn’t make any sense.”
Some of the variations highlighted by the RCOG report include a two-fold difference between hospitals with the highest and lowest rates of induction of labour among women giving birth for the first time (17% compared to 38%), emergency caesarean section after induction of labour (20% to 40%) and instrumental delivery (16% to 32%).
“There can be many reasons for these differences,” said Janet. “A patient’s age, health background or even their size and weight can be a determining factor in how their child is delivered, and that’s before even considering individual trust targets,” she said. “But the fact is we are being contacted by more and more injured people who tell us the main factor in their own case is an obvious lack of midwives on the ward at any given time.
“I know of one delivery ward where two midwives were looking after 27 beds. It only takes one of the women on that ward to encounter difficulty during her labour and suddenly there are a lot of other woman who will not be receiving the care and attention that they expect, deserve and need. In some hospitals, there simply just aren’t enough midwives.”
Her claim was supported by the findings of a separate report from the National Childbirth Trust and National Federation of Women's Institute into women's experiences of maternity care, which was released on 2 May. It found that 67 out of 84 trusts (79%) did not meet the recommended staffing ratio of midwives in 2011.
“We are seeing a growing number of cases being referred to us, where women are saying there is an alarming lack of midwives to look after them,” said Janet. “I have spoken with women who said they have gone several hours without literally even seeing a midwife. In one particularly tragic case, an expectant mum actually lost her baby as a result of being unable to find a midwife when her baby’s heart monitor showed something was wrong.
“Midwives by and large do a fantastic, difficult job, but the findings of this report show that there appears to be a lack of resources which is hampering their ability to consistently provide the best level of care,” said Janet. “The government has said it hopes the report will help frontline staff raise standards, but I think it would more appropriate to use the data to underline the need for greater numbers of trained midwives being allowed to do the job they have trained for, rather than being tasked with administrative duties and having their decisions influenced by budgets and bean-counters.”
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