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Perinatal Care

Volume 932: debated on Tuesday 24 May 1977

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Motion made, and Question proposed, That this House do now adjourn.—[ Mr. Coleman.]

11.55 p.m.

I am grateful for the opportunity to raise the subject of the problems of perinatal care, an issue that the House has neglected for a long time.

I have no conflict with the Department of Health and Social Security. Over the past six months my Questions have proved that it is always most anxious to help, and I am grateful. It seems to me that I should be speaking to the Treasury rather than to my hon. Friend the Minister of State. He and I were close colleagues at university many years ago.

I am not attacking further research. More research needs to be done. Today I saw the preview of the film "Safe and Sound", a film which was financed by Action Research for the Crippled Child and sponsored by Duncan Guthrie, who is now retired. It showed a simple way of monitoring the foetus, with a woman being able to be examined without embarrassment and without difficulty.

The other person to whom I want to pay tribute is James Loring of the Spastics Society, which has financed a great deal of work on perinatal care. The MRC is financing work, and long may it continue.

I want more research to be done, but I am concerned that existing knowledge is not being fully applied. If we do not have good perinatal care, as the Swedes do, every year 4,000 children will unnecessarily be born dead in this country and 10,000 will be born with a handicap that they need not have.

This is a major issue which demands the attention of not only the DHSS but the Cabinet and my right hon. Friend the Prime Minister. I hope that my hon. Friend will tell his Department that the matter should end on the Cabinet table for consideration.

Let us continue research work and let the voluntary organisations and the Department do what they can, but let us also see that known methods and practices are adopted. The Treasury should be asked to give £10 million a year for the next five years. That may seem a substantial sum, but money given now will start to come back to my hon. Friend within nine months. This is one field of expenditure where returns show up virtually immediately.

Any severely handicapped child who lives for a normal period will cost the State about £250,000. Yet that child will not have had the opportunity of making a contribution to the wellbeing of this country. It will be a total dead loss in money terms. The expectation of life of a severely handicaped child nowadays is as great as that of the ordinary able-bodied. In fact, there are examples of severely handicapped children living longer than the normal expectation of life.

I should not advance my argument purely in terms of saying that we can save money. I merely say that, if we spend the money wisely, with good perinatal care we can make the family happier, relieve the disability of the child and save substantial sums of money.

It is difficult in this day and age to look at the Treasury and to say that it is enlightened. The fact is that it is not enlightened. The Treasury wields the big stick and says "You will cut this, you will cut that" without regard to what might be termed the cost benefit analysis. I feel strongly, as do many of my hon. Friends, that the Treasury has got its values wrong. We know full well that the Department of Health and Social Security is friendly disposed and wants to help.

I was asked to raise this subject about eight or nine months ago. I was approached by James Loring and Duncan Guthrie, who said "Lewis, we are happy with the work that you are doing with regard to disability, because it is important and vital. But why not do something about prevention?" At that time I did not realise that handicap could be prevented.

Here I must pay tribute to the all-party group and to the researcher Peter Mitchell and his assistant Kate who, through the good officers of professors and researchers all over the country, have supplied me with a vast amount of information. Indeed, I must keep my eye on the clock, because I should like to give the Minister time to give as full a reply as possible. It has been clearly brought home to me that it is possible not only to save life but to prevent substantial and deep disabilities.

When I was first approached, I thought "Oh, my God, they are asking me to save children and we shall have more disability". The answer is that, with good perinatal care, disability is reduced. I repeat the figures that I gave earlier. If our figures were reduced to match those of Sweden, 4,000 children each year would be saved from death and 10,000 children who are now disabled would not be disabled. It is not a case of trying to cause their survival and worse disabilities.

If we look at the distribution and compare the figures for some of the favourable areas, such as the Isle of Wight, with the worst areas, such as Wolverhampton, it is possible to find socio-economic divisions. It may be that these remarks should be directed to the Department of the Environment, because there are deprived areas which should be given more resources. I shall not pursue this point tonight, because I am debating an issue with the Department of Health and Social Security. However, I ask my hon. Friend to think carefully about making representations to the Department of the Environment to the effect "If you look at the perinatal death rate, you will find a pattern which indicates deprivation. It may be that additional funds should be found to supply aid to these areas".

My aim tonight is to draw attention to the needs within the medical field. I cannot help feeling that not enough has been done. I make the point loud and clear that the Department has recognised the need. I accept that it is in difficulty here. Local authorities and area health authorities must spend their money in any way they wish. It may well be that what I am asking for tonight will cause cutbacks in other areas. I am asking the Treasury to contribute £10 million a year for a five-year period in order to reduce disability at the perinatal stage.

At this point I should define "perinatal". It is the time after the 28th week of pregnancy up to the first week of life. There is absolutely irrefutable evidence that when a baby is born it requires more medical attention in the first three minutes of life than in the next 30, 40 or even 50 years. It is terribly sad that in 1933–d a great and proud record on infant mortality and that now we are only eleventh or twelth in the league.

This is completely indefensible, both morally and economically. Above all, it is indefensible in terms of family suffering. No Department should stand aside. I realise that there are limitations imposed by financial restrictions, but if my hon. Friend wants a bit of muscle power or assistance, he should know that there are a substantial number of Back Benchers who will give him that power and support if he starts getting rough with the Cabinet. At the end of the day I believe that this is an issue that the Prime Minister must face.

My hon. Friend may well say that this is a strange attitude and that there is no precedent for it. The supreme example lies in France. In 1971. the French Finance Minister said that if there were to be priorities, the top priority must be in perinatal care. I believe very strongly that it is right to save 10 babies a day from dying and to prevent 25 children from being born handicapped tomorrow and tomorrow and tomorrow and so on.

The French plan was that, taking half the money allocated to be spent on improvements in antenatal care, 10 per cent. each would go on inoculations against rubella, and on an increase in staff and equipment of obstetric departments; and 5 per cent each would go on medical education, research, minimum standards of resuscitation and intensive care units.

In this country where we have the best practice, it is superb. But the Minister must accept that if he cannot get his priorities right he and his colleagues will be responsible, directly or indirectly for death and disability among substantial numbers of babies. I was astounded when the facts were brought to me, and I thought at first that there was nothing I could do about it. I was ashamed to find that our country has fallen so far behind.

I shall not lay down priorities. I am a layman. I have been privileged to work with a substantial number of experts at professorial and consultant level and I find it terribly sad that these people feel that the research work which has been done in this country has not been implemented.

What my hon. Friend the Minister has said to me has revealed the anxiety of his Department. There have been 43 or 44 reports on perinatal care in the last 25 years. They have all said much the same thing. There has been one committee after another on the subject. Chapter 8 in the Court report on perinatal care merely says what the Oppé Report said seven years back. The Department has got the message, but the trouble is that the Cabinet and the Treasury have not.

There is a precedent. The French decided that, and they dealt with it. Briefly, I want more screening of mothers who are at risk, and that presents no problems. I want better ante-natal care. I want training and equipment for resuscitation. This can be done cheaply and it can prevent a substantial number of deaths and disabilities. Finally, I want specialised ambulances. These will be the means by which the child who is born at risk can be cared for, resuscitated in many ways, and handicaps reversed.

My hon. Friend is a good Minister. He would go down well in the country if he accepted responsibility for providing better, more expensive and more intensive perinatal care.

12.12 a.m.

I am genuinely grateful to my hon. Friend the Member for Eccles (Mr. Carter-Jones) for bringing this important question to the attention of the House. I know that he has a deep and abiding interest in perinatal care. Last year, more than 10,000 babies were stillborn or died in the first week of life in England and Wales. That is a perinatal mortality rate of 17·5 per thousand births. A great many more children were rendered handicapped although we are not sure how many.

Without going into detail on my hon. Friend's figures, which he derived from Sweden, I can tell him that the Government agree that there is much to be done. There has been a steady reduction in perinatal mortality through the years. It has not been as rapid in this country as in some European countries or as rapid as I would wish. I concede that there is a wide variation, geographically, between rates of perinatal mortality, and that there are high rates among certain disadvantaged groups, such as unsupported mothers. My hon. Friend quoted the Isle of Wight and Wolverhampton, and I would broadly accept that, except to say that we must not look too closely at figures in individual years. For example, in the Isle of Wight the 1975 figures show that there were 12 deaths per thousand births in the perinatal period. That was based on 13 deaths in the Isle of Wight. The figures prove that there is a wide regional variation.

The point that worries me is that although the figures have fallen throughout the country, it is sad to read that they may have fallen for any one of three reasons. The first is better care. The second two reasons are not good reasons. They are that it was a good winter and a hot summer.

The point I was going to derive from this was, first, that if only the best practices were spread across the country I am sure that substantial improvements could be made. There are also social reasons for these variations. I accept the basis of my hon. Friend's case. Since I have made that provision, I hope that my hon. Friend will forgive me if I go on to say what we have been doing to combat the problem.

The Government are firmly committed to policies that are aimed at reducing perinatal mortality and have two major objectives in the area of care of mother and baby during pregnancy. The first objective is to provide a uniformly high standard of obstetric and paediatric services and to make use of the latest available knowledge, not only to save life but to promote its quality for the vast majority who survive. The second objective is to ensure that those in need of these services are helped in every way to make use of them.

Perinatal care cannot be considered separately from antenatal and obstetric care. My hon. Friend will know that the whole area of reducing risks to both mothers and babies is one to which the Government attach great importance. That is why, for example, the United Kingdom health Departments are on the verge of issuing a paper devoted to safer pregnancy and childbirth as the first in the series of follow-ups to "Prevention and Health: Everybody's Business." This paper is in an advanced stage of preparation and it is the first that will be issued under the series that was promised in that document.

It is always difficult when dealing with subjects such as the one that is under discussion tonight to attribute improvements and developments with certainty to particular causes. However, enormous strides have been made over the years. There were 23·5 deaths per thousand births in 1970 but the figure was 17·5 per thousand last year. The improvements in obstetric skills and techniques are not unconnected with the steady and significant falls in the perinanal mortality rate, including the stillbirth rate, that have consistently accompanied them. We have a number of sophisticated techniques that enable obstetric staff to check the baby's progress right through pregnancy and labour and to identify early signs of distress or trouble. The fact that problems can be identified sooner and that prompt action can be taken to meet them has played an obvious part in reducing the chances of a baby being born impaired or dying during labour.

Our aim is to make birth as safe as possible for the mother and her baby. The techniques used to identify problems are only part of the whole story. It is often said that there is no normal safe labour or delivery. They cannot be classified as normal until they are all over. It is because problems can arise at any time that we advocate that women should have their babies in hospitals, where there is the full range of facilities to deal with any problems that may occur. When a baby needs special care it is important that it should have to travel only along a corridor between one hospital ward and another rather than be put into an ambulance and taken on a journey to another hospital—although in certain circumstances, however well organised our pregnancy and obstetric services, that cannot be avoided.

We realise that this is an area where there is no room for compromise and that nothing but the best standards are worth striving for. That is why we are rationalising maternity provision, because this means that we concentrate beds in well-used, well-equipped hospitals which can offer mothers and babies the kind of facilities—and so the kind of safeguards—that I have described.

By reducing the numbers of beds, we are not reducing the availability of hospital delivery but rather aiming at a higher general standard of care. That is why our emphasis on rationalisation of maternity facilities in "Priorities for Health and Personal Social Services" went hand in hand with a stress on the need for higher standards of special and intensive care for babies.

Small babies are particularly vulnerable. That is vividly illustrated by mortality rates. Babies weighing under 2·5 kilograms account for 7 per cent. of all live births, yet, in 1974, 76 per cent. of first-day deaths and 58 per cent. of deaths in the first month occurred in small babies. Their prospects have improved in recent years, but we must ensure the highest standards of neo-natal care for them.

The consultative document on priorities for health and social services which we published in March 1976 drew attention to the urgent need to improve the level of special care for low birth-weight and sick newborn babies. In August last year we issued a circular accompanying the Oppé Report asking health authorities to review their facilities, including resuscitation, for the newly born and the special care services for sick and low birth-weight babies. All regional health authorities are carrying out this review. This will include transport facilities covering those cases where an extremely sick and weak baby has to be transported to the regional intensive care unit. The centres will have special equipment that can be put into those ambulances travelling between the maternity wards and the regional centre. I think that covers the point made by my hon. Friend about the provision of special ambulances.

Care during labour and delivery and for the newborn baby is only part of the continuum of care. It is impossible to overstress the importance of proper antenatal care, health education and preventive measures that the mother can take to protect herself and her unborn baby, including the avoidance of smoking and non-prescribed drugs in pregnancy. She must take the first step to see her doctor when she thinks she is pregnant, and the earlier she does so the better, because she will then have the full range of professional services available to monitor the progress of her and the baby.

This alerts obstetric staff to any needs, identifiable in advance, that may need to be met during labour, delivery or afterwards. And this leads on to another vital point—the continuity of care and the importance of communication between community facilities and the hospital and between the professional staff and the parents. My hon. Friend will know from my reply to his Question on 16th May that this is a subject on which I am taking fresh advice from professional bodies and hope to commend to the professions concerned. We have made a point of developing human relations in obstetrics to ensure that the anxiety of parents is eased during the antenatal and perinatal periods. If we can apply the best practice throughout the country, things will gradually improve, but there is room for research.

The Court Committee on Child Health Services made a number of recommendations for further research in its chapter on the newborn, and a working party under the chairmanship of Professor Morris of the London School of Hygiene and Tropical Medicine is currently considering research priorities in perinatal and infant mortality and morbidity. If more resources are put into perinatal care, the chances of producing important results are improved. We hope that our discussion paper will reinforce my hon. Friend's efforts and stimulate public debate of the subject.

Last year the perinatal mortality rate in England and Wales fell dramatically from 19.3 per 1,000 live and stillbirths in 1975 to 17.5 in 1976. This was the biggest reduction in a single year for almost 30 years. This shows, when compared with the French practice, what can be done. Much effort has been put into this field, and I welcome my hon. Friend's support of the improvements. Although the French practice has been improving in recent years, the difference is not dramatically marked. Until 1974, our two countries ran more or less, side by side. It is difficult to give the present position because we do not have the French figures for 1975 and 1976. They will be interesting. They have a different way of approaching these matters. They have cost benefit analyses in particularly narrow fields—

The Question having been proposed after Ten o'clock on Tuesday evening, and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put pursuant to the Standing Order.

Adjourned at twenty-five minutes past Twelve o'clock.