The Amalgamation of Maternity Units.

Caroline Nichols.

I have been following the consequences of maternity unit reorganisations closely since 1993 when, coincident with the birth of my first child, I became actively involved with the Community Health Council movement. My intimate knowledge is of the reconfiguration of services in West Surrey and West London where four reconfigurations (Frimley/ Cambridge Military; Heatherwood/ Wexham Park; Ashford / St Peter's /West Middlesex; Kingston/ Roehampton) have taken place since 1992.

The results of these amalgamations have not been quite as local health authorities had imagined.

Although "safety" as measured by perinatal mortality rate (PMR) has improved, the intervention rates have soared; women have not chosen to attend units in the numbers predicted, leading to a significant increase in daily emergency closures at oversubscribed units, with stress for mothers and staff alike; midwives have left in response to changing terms and conditions of service, exacerbating vacancy levels; and the number of serious complaints, including requests for independent reviews has increased fourfold. I believe that the amalgamation of maternity units is a significant factor contributing to the dramatic increase in caesarean section rates.

Faced with these consequences health authorities (HAs) have fallen back on measuring success solely in terms of PMR improvements which they attribute, wrongly in my view, to reconfiguration. They have acted not out of a clear philosophical view as to what represents the best quality service for women. Instead the action has been one of reaction: HAs have been overawed by the crisis surrounding junior doctors' hours and training, consultants' inflexibility in altering their working practices, and the diktats of Royal Colleges over their preferred configurations. The HAs, unsupported by the Department of Health, itself under pressure to release money from the capital invested in the smaller acute hospitals, have capitulated to those most powerful, and have ignored the views of the largest group of professionals involved in childbirth, namely midwives; as they have ignored consumers' needs for local services.

The expedient solution has been offered with two sweeteners: a supposedly safer service because there will be more investment in higher level neonatal units - and more choice, because in units of 4000 births there will be a dedicated anaesthetist for epidural anaesthesia. That is all. That the reality has proved to be different should come as no surprise.

Health authorities have a duty to examine whether a medicalised model of care for childbirth meets their duties to deliver health. It is perfectly possible for example to create a high level neonatal unit without requiring 4000 or more women to pass through a hospital's doors. If HAs looked more closely at the behaviour of the largest interest groups - women (and their families) and midwives - they might realise that the most effective maternity service, in terms of safety and choice, is one based on distributing expertise as evenly and widely through local communities as possible, rather than concentrating it in remote ivory towers.