Choice, policy and practice in maternity care since 1948

Angela Davis | 30 May 2013

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Executive Summary

• Changes to maternity care policies and practices since 1948 have resulted in a huge growth in the number of hospital deliveries and the wider medicalisation of birth.
• There was a dramatic shift from 1965 to 1975. Between the late-1940s and mid-1960s roughly two-thirds of births in England and Wales took place in hospital and one-third at home. By 1975, home births had fallen below five percent, remaining at, or below, this level ever since.
• Debates on maternity are often polarised between those who argue for minimal intervention and more homely birth environments, and those who celebrate modern technologies and see a hospital setting as essential to a safe delivery.
• This debate does not reflect how mothers have viewed their own birth experiences. Oral history interviews reveal that women recall the quality of their relationships with medical professionals as the most important aspect of their care, rather than place of birth or the level of medical intervention.
• Today, maternity care is seen to be in crisis; services with limited resources are struggling to cope with a rising birth rate and growing numbers of mothers deemed to be 'high risk'.
• Historical research indicates that government and hospital policies should ensure good interpersonal relationships between women and maternity/medical staff, as this is most likely to leave women feeling satisfied with their care.

Introduction

The question of how best to meet mothers' needs in their maternity care remains of utmost importance in today's climate of health service reorganisation and pressure on resources. How can women's expectations be satisfied at a time of increased demand and declining resources? Commenting on the 2012/13 Choice Framework, published by the Department of Health in December 2012, Cathy Warwick of the Royal College of Midwives, welcomed the Government's commitment to providing choice for women, but expressed concern that, 'at the moment there seem to be no real levers or mechanisms to ensure these important commitments are delivered. There is a danger that when resources are under pressure choices will be limited.' A few weeks earlier, Warwick claimed that the pressure of cutbacks combined with the highest birth rate in forty years had left maternity services on a 'knife-edge...we are at the limit of what maternity services can safely deliver.'

This paper explores the circumstances leading up to this crisis, tracing the history of maternity care in Britain since the introduction of the National Health Service (NHS) in 1948. It discusses how past experiences can inform our understanding of what women today want from their maternity care. It draws on oral history interviews with 160 women who lived in Berkshire and Oxfordshire and had their children between the 1940s and 1990s. The interviews covered their experiences of pregnancy, birth and the postnatal period, and encouraged them to compare their own stories with those of their mothers and daughters to assess generational change. The findings enable those involved in maternity policy today to see how women place their experiences of pregnancy, birth and postnatal care within a longer life trajectory, and compare the births of different children.

Changes in maternity policy, c.1948-1970

The foundation of the NHS in 1948 marked a turning point in the history of maternity services and sparked renewed interest in maternal health. Women and children were perhaps its greatest beneficiaries, having gained least from the pre-war health insurance schemes. Maternal mortality had risen in England and Wales between 1900 and 1937 (to over 40 deaths per 10,000 births), although infant mortality had been steadily declining (from nearly 170 deaths per 1,000 live births in 1900 to under 35 deaths per 1,000 by 1948). After 1948, both rates continued to fall and are now negligible in England and Wales.

Despite these improved outcomes for mothers and babies, there was never any clear, universally agreed vision for maternity care. Between 1948 and 1974 the maternity services reflected the tripartite system of the NHS with responsibility for maternal care divided between hospital services, General Practitioners (GPs), and local authority health services which ran public health services such as maternal clinics.

The 1956 report of the Guillebaud inquiry into the cost of the NHS identified a 'state of confusion' in maternity services and recommended a thorough review. The Earl of Cranbrook was appointed in April of that year by Anthony Eden's government to chair a committee of investigation, resulting in the 1959 Report of the Maternity Services Committee (the Cranbrook report). This set a target for 70 percent of all births to take place in hospital. Given correct selection for hospital or home confinement, the committee felt that the remaining 30 percent of mothers could safely give birth at home. However the medical community continued to debate this, as more pregnancies were being classified as 'high-risk' through new obstetric knowledge and methods.

In 1967 the Maternity and Midwifery Advisory Committee was asked to consider the future of the maternity services. The resulting report, named after the committee chair, consultant obstetrician John Peel, recommended 100 per cent hospital deliveries with medical and midwifery care provided by consultants, GPs and midwives working as teams. The report implied that hospital birth was safest, though it was criticised for a lack of evidence to support this and for a lack of consultation with women about their needs and experiences. The Peel report contributed to the dramatic shift from home to hospital birth over the following decade. Before the Second World War, most women had given birth at home, with hospital births only becoming a majority during the war. From 1954 to 1960, the proportion of hospital deliveries in England and Wales increased only slightly, but between 1963 and 1972 the rate rose from 68.2 percent to 91.4 percent, and from 1975 onwards, it never fell below 95 percent.

Technological changes

The introduction of new technologies during the 1970s led to further changes in maternity care. New antenatal testing and monitoring was available, notably ultrasound, which transformed the nature of antenatal care. By the 1980s ultrasound was routinely used to view the foetus and estimate gestational age. Originally used as a diagnostic aid in high-risk pregnancies, the ultrasound scan now became a crucial rite of passage in all pregnancies. During the 1970s intervention also became a routine feature of labour and birth. In British Births, a national study of all deliveries that took place during one week in 1970, the National Birthday Trust Fund revealed increased use of caesarean sections, oxytocic drugs to induce labour and episiotomy (a surgical incision to enlarge the vaginal opening), since their last survey in 1958. Until the 1960s, British clinicians had viewed episiotomy as an emergency procedure, but by the 1970s it was routine in many consultant units.

Induction and acceleration of labour, either through artificial rupture of the membranes and/or the use of an oxytocin drip, was the most controversial aspect of childbirth in the 1970s, when its use peaked. In 1965 only an estimated 15 per cent of labours were induced; in 1974 it was around 41 per cent. Induction was favoured by some, although not all, obstetricians who argued that it reduced perinatal deaths (deaths of babies in the first seven days of life) by preventing pregnancies going beyond full-term. Opponents, including natural birth campaigners, argued it was being overused, caused more painful labours, and led to the increased use of pain relief (such as epidural anaesthesia), instrumental deliveries and caesarean sections. The mid-1970s witnessed a vigorous public debate about obstetric practices in medical journals, the press, television and, ultimately, in Parliament. By the time Reducing the Risk, a report by the Department of Health and Social Security, was published in 1977, its authors could reflect how, 'The value and increased use of induction has been a source of discussion and controversy for some time among doctors and midwives and the general public.'

Maternity pressure groups

The complaints of the 1970s were not without precedent. The obstetrician and natural childbirth advocate Grantly Dick-Read had argued as early as the 1930s that most women did not need medical intervention to give birth safely. Opposition to the medicalisation of childbirth continued to grow after the foundation of the NHS. Prunella Briance, whose baby had died following conventional obstetric care, launched the Natural Childbirth Association of Great Britain in 1957 to promote Dick-Read's teaching. After a period of internal conflict it became a charitable trust, changing its name to the National Childbirth Trust or NCT in 1961. The NCT aimed to teach pregnant women skills for relaxation and breathing in labour, but also tried to persuade medical authorities to facilitate home births and provide a more homely environment for institutional births, including allowing fathers or other birth companions to attend. Initially the organisation tried to work with the medical profession, but increasingly found itself in opposition to it.

Other organisations campaigning for a new approach to maternity care were also formed at this time. In 1958, after a distressing stay in hospital for the birth of her child, Sally Willington aimed to publish a letter in a newspaper, asking if other women had shared her unhappy experience. She wrote that, 'In hospital, as a matter of course presumably, mothers put up with loneliness, lack of sympathy, lack of privacy, lack of consideration, poor food, unlikely visiting hours, callousness, regimentation, lack of instruction, lack of rest, deprivation of the new baby, stupidly rigid routines, rudeness, a complete disregard of mental care or the personality of the mother.' Childbirth was still taboo in the 1950s and it was more than a year later, on 1 April 1960, that her letter was eventually published in The Observer. The response, once it did appear, gave rise to a new voluntary organisation, the Society for the Prevention of Cruelty to Pregnant Women, renamed in 1960 the Association for Improvements in the Maternity Services (AIMS). Unlike the NCT, AIMS did not, at least initially, argue for fewer medical intervention or against hospital birth, but campaigned for women to receive better care within hospitals. The work of these organisations led to changes in hospital care, such as fathers being allowed into the labour room and an end to routine procedures such as pubic shaves and enemas to purge the bowel. While deference to medical staff remained common, at least until the 1970s, hospitals became less regimented and more attuned to patients' needs.

The pressure groups of the 1970s built upon these campaigns, but also became more vocal and overtly political as the social climate changed and there was growing public, media and parliamentary willingness to discuss childbirth. The NCT reacted against the increasingly interventionist obstetric practices of the 1970s, and by the 1980s, explicitly espoused the 'right to choose' in a way it had never done before. New groups were founded representing specific interest groups, such as the Foundation for the Study of Infant Deaths, the Stillbirth and Neonatal Death Society (SANDS), Baby Life Support Systems (BLISS), and the Pre-eclamptic Toxaemia Society. These reflected recent technological changes, particularly improvements in neonatal care, and belief in the power of such specialised pressure groups to achieve change.

Policy responses c.1970-2000

Policy responses to these campaigns were often slow. The 1977 report Reducing the Risk asserted that: 'Even if a woman is 'low risk' and likely to have a normal birth, one cannot be sure it is normal until it is over. Hospitals are better able to cope with emergencies and to provide the special care some babies need at birth. It is not possible to provide such facilities at home and the travel and delay in getting a baby from home to hospital in an emergency may be harmful.' This remained the view of the Department of Health in the 1980s. In 1982, the government set up the Maternity Services Advisory Committee to the Secretary of State for Social Services, in response to continued criticism of maternity care from consumer and feminist groups. While the Committee accepted there were problems, it continued to assert that all births carried medical risk and consequently hospital was the safest place to be. After the 1974 reorganisation of the health services, all maternity services came under the responsibility and management of 14 Regional Health Authorities, replacing the previous tripartite system and translating the Department of Health's faith in the superiority of hospital births into regional practice. In England and Wales the years between 1985 and 1988 saw the lowest ever recorded rate of home births, an average of 0.9 per cent.

The most public and dramatic moment in the debates over maternity care came in 1985 when the obstetrician Wendy Savage was suspended from her post as Honorary Consultant in Obstetrics and Gynaecology to the Tower Hamlets Health Authority. In 1977 Savage had become the first woman to hold this post at the London Hospital and Medical College. Savage believed in minimal surgical intervention during labour and birth, asserting that every pregnancy should be treated as 'normal' unless there were clear contra-indications. She argued that women should not be labelled 'high-risk' on the basis of statistical rather than individual information. Her anti-interventionist views and practice made her a controversial figure in the male-dominated field of obstetrics. On 24 April 1985 Savage was suspended for alleged incompetence in five cases, accused of having delayed performing caesarean sections; in two of the cases the babies died. However in February 1986 she was exonerated by a public inquiry and was reinstated five months later. The inquiry panel disagreed with most, though not all, of the criticisms in the cases against her. Her case had an enormous effect on obstetrics, the medical profession in general, and on women as health care consumers. Savage herself believed it had led women 'throughout the country' to realise 'they have the right and the power to see that the health services they get are the ones they want.' The campaign attracted widespread media attention and the Wendy Savage Support Campaign raised around £45,000, helping to bring women's reproductive rights to the fore.

By the early-1990s there had been a significant change in policy rhetoric even if in reality women's ability to choose where and how to give birth often remained restricted by limited resources, conservative medical attitudes and the widely-held view that home birth was eccentric or old-fashioned. Nonetheless, choice of place of birth was now on the policy agenda, thanks partly to the work of pressure groups, campaigners, and patient advocate groups. Furthermore, the statistician Marjorie Tew had challenged the evidence base for claims that hospital birth was safer than home birth, attributing post-war improvements in perinatal mortality to healthier mothers. National policy, although not always implemented in local practice, was altered in response to these campaigns. The report Changing Childbirth (Department of Health 1993) resulted from the work of the Expert Maternity Group established in October 1992, under the chairmanship of Lady Cumberlege, Parliamentary Under Secretary of State for Health. The committee included women using NHS services, professionals providing maternity services (including a midwife, GP, obstetrician and paediatrician), as well as an NCT representative, a journalist, and a management consultant. The report explicitly criticised unsympathetic doctors and midwives who used 'safety' to impose unwanted interventions on mothers.

In recent years the Department of Health has reiterated the need to promote choice and respectful relationships, most recently through Maternity Matters, which committed to offer women a choice in type of care and place of delivery (at home, in a birth centre or in an obstetric unit), by the end of 2009. These policy aims have not been realised. Research by the NCT at the end of 2009 found that only four per cent of women were given the full range of choices about where to give birth. Current coalition government policy also purports to support choice and continuity of care. However a 2011 NCT report showed that women's choices remain severely limited, with only a small minority of births taking place in midwife-led units (MLUs) or at home, despite these options being both safe (for most women) and more cost effective than births in consultant-run units.

Women's experiences of birth

What did women think about these post-war changes? I interviewed 160 women about their experiences of childbirth during the second half of the twentieth century. The oldest interviewee was born in 1912 and the youngest in 1962. The first child was born to an interviewee in 1938 and the youngest in 1996. Of the total 435 children, 329 were in born in institutions (the vast majority in hospital) and 106 at home. My research reveals that women's criticisms of their care centred on the quality of their inter-personal relationships with health professionals (doctors, nurses and midwives), rather than the precise nature of their medical care. Consistently, throughout the period, many women felt that despite receiving good medical care, emotional care was lacking.

Jackie, who had twin girls in the early 1960s at the Radcliffe Infirmary (RI) in Oxford, remembered women waiting in rows in trolleys along the corridors before being taken into the delivery room; she was, 'just one in a sort of sausage machine'. Georgie also had her first baby at the RI in 1961: 'Of course I hadn't a clue... they decided the [contractions]...were not close enough together to put me into a delivery room, so they stuck me in the corridor ... nobody came, they left me there for hours on end.' In the mid-1960s, Gloria haemorrhaged while on the bus to work and was rushed to the RI. She felt the care she received before the birth was excellent, but 'the birth wasn't exactly brilliant'. On arriving at the hospital Gloria had been told she would need to have a caesarean section, but 'then the consultant marches in with his entourage and examines me [saying]... 'Oh there's no need for a caesarean, she'll be able to give birth herself.'' It was the lack of communication that upset Gloria most, compounded by her reluctance to ask questions: 'I hadn't got a clue what was going on ... And in the end, I think I took so much gas and air that I knocked myself out.'

Women who felt they had established a relationship with their attendants in labour recalled having a better birth experience, irrespective of the circumstances of the birth. It was easier for women who had home births to have a close relationship with their midwife, because they usually got to know her during their antenatal care. While the overwhelming response from women who had home births was that it was a fulfilling experience, a small number experienced difficulties, such as Tina who recalled haemorrhaging after her daughter was born at home in 1971. By the 1970s technological advances meant that hospitals now had equipment that was not available at home, particularly for neonatal care, strengthening the medical rationale for hospital births.

Women's experience of hospital delivery was also changing during the 1970s and 1980s as induction and acceleration of labour became routine in many hospitals. There was great variation between individual hospitals, and a woman's experience was highly dependent on local hospital policies. A survey of consultant obstetric units in 1989-90 reported the overall induction rate was 17 per cent, but rates for individual units varied from four to thirty-seven per cent. Some of the women I interviewed resented their care being determined by hospital policies and practices, rather than individual medical need. Kaye discussed the different hospital policies she encountered as a midwife:

At St Thomas' [London]... the consultants would routinely induce people when it suited them ... and I thought that was all wrong ... I thought it was ... more natural the way they did things at the smaller hospitals [where] the midwives were ... skilled in normal deliveries without using episiotomies routinely. At the Royal Bucks [Buckinghamshire] it wasn't very good. The doctors sort of interfered unnecessarily and if a labour wasn't going as fast as they'd like they'd stick a drip [in] ... to speed things along.'

Kaye said she turned down a job at Oxford's John Radcliffe Hospital (JRH) because, 'their induction rate was so high at the time which I thought was terrible. It was something like 37 per cent... in the mid-1970s'.

Interviewees were more critical of the manner in which medical interventions were carried out than of the interventions themselves. Katherine's first child was born in 1983 by caesarean. She described the birth as, 'very traumatic. Yes, they decided, he was a big baby ... that they would induce me ... then suddenly the distress [call] went out... and it was an emergency caesarean by the evening.' However, she did not regret having a caesarean: 'I was glad because he was a big baby.'

By the late twentieth century hospitals were making some effort to improve the quality of maternity care, including through the establishment of smaller, GP or midwife-led units. In 1966 the first GP Unit in Oxford was opened, attached to the Churchill Hospital. It provided a more relaxed style of care than consultant-led labour wards, giving women continuity of care from known GPs and midwives without a long stay in hospital after the birth. The unit transferred to the newly opened JRH in the early 1970s. April had her first baby in Oxford in 1978 under this system of care, recalling: 'It was just great... you went to your GP and ... they had some midwives attached to the surgery and you bonded with [them] ... And they were the people who were there at the birth.'

There were also changes within consultant-led units. Husbands were allowed to attend births, less deference was expected by hospital staff, women were better-informed about, and included in, the decisions made about their care. Carol's first baby was born in 1979 and her last in 1996, both in the JRH in Oxford. Her first birth included many of the features of maternity care criticised by campaign groups, giving birth on her back with legs raised and a routine episiotomy. She explained:

I was about a week late ... So they started me off. And that was horrendous. ... I had to have a gown, lay on the bed, have my socks on and legs in stirrups and you weren't to move and just lay there ... it was routine as well, to give you an episiotomy on your first. And ... because he was being born so quick I had no injection, to numb the pain. And they said, 'just a little snip'... it... felt like a pair of shears, just cutting into you. It was the only time out of all five children that I let out a scream. Coz that was just really painful. And shocking as well, coz they didn't tell you. And, of course, he was born and they took him straight out of the room.

Dramatic improvements had occurred by the time Carol's fifth baby was born:

the most relaxed birth was [my last] because my Mum came in ... and [my partner]... holding my hand and talking to me...I could walk around. I chose what music I wanted to play. I chose that I wanted soft lighting. I chose that I wanted [my partner] to tell me the sex of the baby and to cut the cord... you felt much more empowered and in control at the birth. And it was just so much nicer... You know when I think back to how my first one was... I'm surprised I ever had any more after that... So big changes from 1979 to 1996. All for the better.

Conclusions

During the second half of the twentieth century, maternity provision changed dramatically. Both midwife- and GP-supervised births at home or in hospital were in decline; delivery at consultant-led obstetric units became the norm and medical intervention in pregnancy and childbirth increased. However the women I interviewed provided an ambivalent account of these changes. They were primarily critical of a lack of information, lack of choice in their care, and dissatisfaction with their care-givers (doctors, midwives and nurses), rather than with the procedures themselves. Throughout the period, some women felt they received excellent medical care, but criticised their treatment by hospital staff: medical professionals they perceived as self-important, who believed that they, rather than their 'patients', knew best. They felt inadequately informed about the procedures being carried out and that their emotional needs were not being met. Good communication and durable relationships between women and their birth attendants led mothers to feel better equipped to deal with their antenatal, birth and postnatal experiences and to improved outcomes for them and their babies.

Maternity care remains a contested policy arena. New groups such as Birthrights, launched in January 2013 to promote human rights in pregnancy and childbirth, have strikingly similar aims to older organisations such as AIMS, and demonstrate the continued need to promote dignity and choice in birth. While chiefly framed as a debate about reconciling women's choice over how and where to give birth on the one hand, with the safety of their babies on the other, implicit - and often explicit - in this discussion remain the issues of cost and control. Women's choice is characterised as an expensive, and possibly dangerous, luxury. A Daily Mail article from 31 January 2013 quoted Dr Gedis Grudzinskas, a former Professor of obstetrics and gynaecology at St Barts Hospital, London: 'The fact is, because of budget issues, there's much less flexibility and likelihood of a happy outcome to an agreed birth plan.' Women being assertive about their desires also challenge the belief of medical professionals that they are the experts. Grudzinskas continued: 'The advice that professionals give is based on many years of experience', while 'many women think they're well-read because they've done research on the internet'.

Empowering women, maintaining safety and pursuing cost effectiveness need not be seen in opposition to one another. The history of post-war maternity care and mothers' own past experiences indicate that investing in the maternity services in the short-term, and directing resources to provide genuinely personal care will ensure the long-term wellbeing of mothers and babies, ultimately a cost effective strategy. While current, controversial moves to reconfigure maternity services, closing smaller units and consolidating provision into a smaller number of large centres, is unlikely either to meet mothers' needs, promote safety or prove cost effective.

• Tags:
• Davis, Angela
• Families and children
• Medicine and public health

About the author

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Angela Davis is a British Academy Postdoctoral Fellow in the Centre for the History of Medicine at the University of Warwick. She is currently researching the history of pre-school childcare in England, c. 1939-1979 and her latest book is Modern Motherhood: Women and Family in England, c. 1945-2012 (Manchester: Manchester University Press, 2012). angela.davis@warwick.ac.uk

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