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NHS: Maternity Care

Volume 759: debated on Thursday 5 February 2015

Question for Short Debate

Asked by

To ask Her Majesty’s Government what steps they are taking to improve maternity care and to ensure that maternity staff are trained and developed to meet future needs.

My Lords, today, we call the midwife. We do so in England and Wales, and I am particularly indebted to the National Federation of Women’s Institutes for bringing to my attention its excellent report, Support Overdue: Women’s Experiences of Maternity Services.

My adult children’s contemporaries are now growing families. In chatting to one new mother and friend of the family I learnt that her experience of childbirth was unsettling, to say the least, and her anxieties find all too ready an echo in the WI report. The report highlights that 700,000 women give birth each year in England and Wales. Indeed, that is the single biggest reason for admission to hospital. Midwives play the crucial role of setting families on the right path, from pregnancy through to birth itself, and then shape the first few weeks of family life. The report highlights shortcomings, which I will examine, while it readily acknowledges that mothers in England and Wales enjoy some of the highest quality maternity care in the world.

Choice of location of birth still remains an aspiration, not a reality, for many women. For too many women the choice of the four standard location options is a chimera. Thus the Government’s pledge to deliver choice in NHS maternity is defaulted on.

Secondly, maternity care is still fragmented; it is still a long and bumpy road that a woman treads from preconception through to pregnancy, birth and postnatal care. Thirdly, despite the best efforts of NICE, a postcode lottery for postnatal care remains, with wide variations in quality and standard of care across the country. Too often when we call the midwife, she is not there. Despite an increase in the birth rate of some 15% over the past decade, we still fail to provide the promised 1:28 midwife to birth ratio keenly advocated by the four royal colleges involved in midwifery. Despite the recent baby boom, some 50 trusts and boards even now employ fewer midwives than they did previously, which is astonishing. Call the midwife. Unfortunately, some 34% of women complained that they were not given the name or number of a dedicated midwife they could phone if worried or wanting advice. Surprisingly, some nine out of 10 women had not met any of the midwives who cared for them at the time of labour and birth before going into labour. Some 30% of mothers urgently wanted the designated midwife to,

“remain responsible for my care (not pass me on to someone else)”.

Call the midwife—but only one in 10 mothers had the full four choices of where to give birth, a promise unfulfilled in part because we have trained too few midwives. Matters are beginning to look up as more trusts and boards are promoting and expanding location options by building new, freestanding or colocated maternity units, or funding home birth services. Can the Minister update us on offering the full four locations, and give us figures on the provision of complementary services, such as birthing pools and partner accommodation? Can he give us up-to-date figures on the worrying incidence of temporarily closed units or suspended maternity services attributable to staff shortages and capacity problems due to unavailable bed space? Why do only one out of two women obtain the desired home birth?

Finally, three out of five mothers want more not less postnatal care, but a quarter of mothers were unable to call the midwife to fix up appointments convenient to themselves, as new mothers deal with the baby. Will the Minister ensure that CCGs develop transparent frameworks for postnatal care? We all know how crucial the transition to parenthood is for new mums and dads—and, please, do not forget the dads. Can the Minister respond to the Support Overdue report by the WI, and say which recommendations the Government might take up?

Furthermore, are maternity health planners taking into account the wider health needs of women during pregnancy? How is the midwife’s crucial role of influencing new mothers’ lifestyles being supported and expanded? Is the pivotal role of the supervisors of midwives being protected? Too often these valuable personnel are used to cover up midwife shortages, instead of supervising their charges. When will we fund and ensure one-to-one maternity care, surely the crucial relationship in any happy birth? Has the troubling and outmoded use of handheld notes and paper records to give vital information on risk status during birth been eliminated? I would be grateful if the Minister could update us and respond to the 2013 State of Maternity Services report published by the Royal College of Midwives.

The Government have funded the increase in midwives begun by the previous Labour Government, but it is worrying that the midwifery workforce has not kept pace with the rising number of births in the last decade, and worrying that the marked ageing profile of the current cohort of midwives threatens real instability to future maternity services as experienced midwives leave in droves. Student midwives’ recruitment stalled in 2014, and even though the baby boom has now paused, the RCW calculates that births still need to fall by some 130,000 before we can satisfactorily match midwife numbers to the current birth rate.

I turn to the findings of the National Audit Office report of these services, and ask whether there is a reply from the Government to the concerns of the Commons’ Public Accounts Committee. Should the department not more rigorously assess whether it can afford to achieve its declared policy objectives? Indeed, are the current tariffs for maternity care set at the right level? What is the Government’s view on the finding that many efficiencies and savings in the service could be found and implemented if more midwife-led birth centres were established, as set out in the Birthplace in England study by NICE?

The PAC also points out that still too few women secure the birth location of their choice. Local maternity networks are an important route to share and spread best practice between and within networks, thereby improving quality and helping to eradicate unacceptable variations across the country. Does the Minister accept that current maternity networks are less well developed than other NHS networks? What can he do about it?

I am pleased that the noble Baroness, Lady Manzoor, will speak on mental health services for pregnant mothers. Indeed, I hope that other colleagues and maybe the Minister will pursue other aspects of maternity services that I do not have time to turn to, including maternal mortality rates and their breakdown into socioeconomic groups, perinatal deaths and the comforting of mothers suffering still births, the availability of hospital beds, the screening of babies for debilitating diseases, and data collection in maternity services, which is crucial in developing policies.

Will the Minister say more about pay, which has been frozen for midwives since 2011 and 2012, with just a 1% rise in 2013 and frozen again in 2014? This is an important recruiting angle that needs to be prized. Will the Minister confirm that in future the Government will listen to and implement the recommendations of the independent pay review body?

In my final minute, I turn to the European Union and ask the Minister whether there is sharing of practice across the EU. If it stands for anything, the European Union is the swap shop of ideas, which the National Health Service should be involved in—and nowhere more than in maternity services.

Finally, are we doing anything to recognise the wonderful nurses who go out to deal with the Ebola problems that have been experienced, and are we doing more to share the best practice with other parts of the globe, where improving maternity services is so crucial to getting a better world?

I look forward to the debate and hope that the Minister will be able to reply to some of those points and to write to me on those that he does not have time to cover.

My Lords, I am grateful to the noble Lord, Lord Harrison, for initiating this debate on steps to improve maternity care. One aspect of maternity care which shows marked variation across the country is staff willingness and ability to involve fathers. This depends to a very much larger extent on culture than on budgets. I wish to make a plea for the very many fathers across the country who have felt thwarted in their best efforts to support their wife or partner throughout pregnancy, during childbirth, and in the earliest days of their new family.

A poll carried out by Bounty found that 96% of mothers considered it to be very or quite important that midwives and health visitors include fathers as well as mothers, yet research reveals that fathers still feel excluded, frustrated at the helplessness this engenders, and fearful because of the risks and uncertainty of labour. Much of this is due to a lack of consideration by maternity staff contrary to guidance from the Royal College of Midwives. This is not so much about their rights as parents as the need for the great majority of new mothers to have their husbands and partners respected and considered part of the labour team. If they are calm and supportive, this can free up extremely pressurised maternity staff to look after any more pressing needs in the delivery suite, yet this requires fathers to have been well prepared from much earlier in the pregnancy.

Feeling needed and helpful rather than surplus to requirements can be a game-changing experience, especially for young fathers who have serious doubts about whether they should be involved at all in their new babies’ lives. The time of the birth and shortly afterwards can be a very special moment—the point when a young couple may decide to try to make co-parenting work, even if they sense that they are unlikely to survive as a couple. It can mean the difference between a child growing up knowing his father and that same child growing up thinking that his father did not care enough to be involved. A million children in this country have no contact with their fathers. Who knows, with a bit of relationship support, that child may even grow up living with a mother and a father.

I have never forgotten the first time I held each of my children while my wife was resting and recovering. The hard work starts immediately. Having the father 100% on board, helping with the practical aspects of baby care, such as walking inconsolable newborns around in the early hours, may protect untold numbers of new mothers against developing postnatal depression. Maternity services are uniquely positioned to help get things off to a good start.

Some noble Lords may be thinking about the recent headline which claimed that,

“it’s better for mothers coping with the pain of childbirth if their partner is not around”.

Personal experience and much other research tells me that it is comforting and reassuring to have that other person present at the birth, and immediately afterwards, who is utterly invested in the well-being of the new member of the family.

When I looked more closely, it was clear that the University College London study was not primarily concerned with childbirth at all, but with how women cope more generally with pain and the effect of their relationship with their partner. Extrapolating this to their experience of childbirth and making any generalisations at all about the desirability of fathers being present is not at all justified and very misleading. There have always been women who, for whatever reason, have preferred not to have the baby’s father present at the birth. This might be because of strains in the relationship or safety concerns. However, the norm is for the father’s presence and support, before, during and after birth, to be very much welcomed because researchers have established that it tends to lead to less anxiety, lower rates of postnatal depression and less perceived pain, so surely this is what maternity staff should be fostering. Doing this as early as possible in pregnancy, without adding to existing high workloads, is not just about holding antenatal classes at convenient times for fathers. Communicating directly with fathers-to-be is now particularly easy through digital means such as Maternity Assist. Health and well-being-related advice and information is sent to both expectant parents on their phones and tablets, which they can both read, discuss and make joint decisions about. It is a world away from a letter addressed solely to the mother which the dad might feel awkward about reading.

To conclude, and to reiterate my plea, can the Department of Health add its voice to that of the Royal College of Midwives and many others to ensure that maternity services are in no doubt at all that they have a key role to play in drawing fathers in as early and effectively as possible?

My Lords, I, too, congratulate my noble friend Lord Harrison on securing this important debate about maternity services. Noble Lords have a range of interests to bring to debates and this is no exception. That is terrific. I wish to concentrate on the training and development of maternity staff to meet future needs.

We all know that, with advances in clinical techniques and technology, it is very possible that premature babies, even those who are 22 weeks old, can now, with careful, 24/7 care provided by skilled staff, live to be healthy babies to the joy of their parents. However, that outcome requires a skilled maternity team.

Our midwives and support staff require knowledge and experience to deliver babies who have gone to full term. However, something may still happen that should not, and their preparation for such events, and the skills they deploy, are hugely important in delivering babies safely, which brings a lot of love and joy for the mum, the midwife and the family.

I want to share with noble Lords some of the training and support mechanisms that Milton Keynes Foundation Trust, of which I am chairman, has developed, and continues to develop, to ensure that the skills of our maternity staff are constantly updated and refreshed. If you were to ask our head of midwifery at Milton Keynes—as I did—what the key issues are for her, she would say, “The key areas around the provision of great care are attracting the right people into the profession, standards of training and the ongoing development of staff to provide that care”. At Milton Keynes we train student midwives in partnership with Northampton University. Our clinical practitioners are involved at the very beginning with the recruitment of prospective students and use a value-based recruitment strategy which tries to ensure a caring and compassionate approach to the midwifery profession. Applicants need to have demonstrated that they have undertaken some care work prior to applying. This is hugely important as it illustrates their interest.

During training, the students work in all areas of the profession and we carefully monitor the time they spend with an appropriately trained midwifery mentor. Through discussion with our head of midwifery at Milton Keynes, I learnt that our consultant midwifes and senior lecturers run reflection sessions throughout the training to enable discussion and learning from experience to guide the students in providing safe, quality care. I was fortunate and honoured to take part in such a discussion last week in preparation for this debate. After students qualify at Milton Keynes, there is a very robust preceptorship competency programme. That programme is hugely important and is valued highly by students.

I would like to say a little more about what happens at Milton Keynes in terms of assessment and competency. However, in the short time that I have left, I will focus on the provision of quality evidence-based guidance, which is vital. However, it is useless if staff do not follow it. It is hugely important to encourage them to follow it, and that midwives monitor that. Good care is achieved only through good clinical practice and leadership, enabling staff to be involved in decision-making and supporting individual development and training. We do all this at Milton Keynes but many other trusts do not necessarily have such a robust programme for staff. We have heard accounts from my noble friend about what happens in some instances of community midwifery as well as in some hospitals.

Following the tragic and unacceptable situation at Morecambe Bay and then at Guernsey Hospital, a review was carried out by the King’s Fund. Sadly, this review, which was contributed to by the Nursing and Midwifery Council, took place in a closed meeting. There was no discussion with any of its members or with experienced midwives. The NMC accepted all the recommendations, including on the loss of statutory supervision of midwives in the near future. That is concerning as this has been a gatekeeper for safe midwifery practice since the Midwives Act 1902. Removing it from local maternity units to a centralised system removes this important responsibility, which is key to safe local practices. Everyone understands the horror of those two hospitals and the necessity for the report to look at them. I ask the noble Earl to look at this carefully before it reaches the stage of legislation. Many midwives, including my head of midwifery, believe that—excuse the pun—this is throwing the baby out with the bathwater.

My Lords, I also congratulate the noble Lord, Lord Harrison, on securing the debate. Today is Time to Talk Day, a national day where everyone across the country is encouraged to take five minutes to talk about mental health. That is what I intend to do today.

Women in around half of the UK have no access to specialist prenatal mental health services. Up to 20% of women develop a mental health problem during pregnancy or within a year of giving birth. Suicide is also a leading cause of death for women during pregnancy and within the first year of giving birth. More than one in four women have c-sections. Evidence suggests this rate is well in excess of the number of c-sections necessary to create health benefits for women and babies, as has already been alluded to by the noble Lord, Lord Harrison. Perhaps the Minister can see whether this financial tariff is to be re-evaluated and reviewed again.

The Centre for Mental Health and the LSE examined the economic and social costs of perinatal mental health programmes and problems, and the cost of effective interventions to manage them. They looked at three of the most common mental health problems—depression, anxiety and psychosis—which affect women during both pregnancy and the first year after they have given birth. Those organisations found that these perinatal mental health problems carry a total cost to society of about £8.1 billion across the UK each year. This is equivalent to a cost of just under £10,000 for every single birth in the country. Some £1.7 billion of this cost is borne by the public sector, of which the greatest costs of around £1.2 billion accrue to health and social care services. They also found that nearly three-quarters of the costs of perinatal mental ill health relate to the poorer health and prospects of the mother’s child. This is based on growing evidence that mental health problems during and after pregnancy have a significant impact on children’s health, many of which can last a lifetime.

There is clear guidance from NICE about what services need to be in place for women. This includes: training midwives and GPs to spot the early signs of distress; speedy access to talking therapies; specialist community services for women needing more intensive support; and mother and baby hospital beds for women who need in-patient care once their baby is born. However, the NHS offers just a fraction of the treatment and support required to meet this level of need. It is estimated that only 40% of women with perinatal depression have their needs identified. Of those recognised, just 60% receive any treatment, of whom only 40% get effective care—that is, care according to national guidelines. This means that just one woman in 10 is getting good quality care for prenatal or postnatal depression.

The Centre for Mental Health and the LSE calculated that the cost of improving perinatal mental health support to include all the interventions recommended by NICE would be about £300 million nationally. This would imply an additional spend of £1.3 million for an average CCG—about a third of the cost to the same CCG of not providing the right care. In other words, investing in better care could actually save the NHS money, as well as bringing about both immediate and longer-term benefits in communities.

The Government have recognised a major deficit in support for women with postnatal depression. The most significant area of progress so far is investment in greater numbers of midwives and health visitors. It is crucial that these are trained adequately in recognising and responding well to distress in women they see. However, there has been no “big push” relating to maternal mental health; little reliable data about outcomes and coverage; and no one is accountable for achieving improvements. Hence, NICE guidance on perinatal mental health is not being adhered to in most areas seven years after its publication.

What needs to be done? First and foremost, we need government to make it clear to the NHS that improving mental health in maternity services is a top priority for reinvestment, and that progress will be monitored actively to improve identification of needs and speed of access to psychological support. Identification of mental illness is key. This could be improved by better training of GPs, midwives and health visitors in perinatal mental health. It is not the quickest of wins, but could be achieved within a reasonable timescale if given priority. The other major change would be to prioritise women in the perinatal period for access to psychological therapy, so that there is a clear process for getting women in to these services quickly. It is estimated that it would be possible to develop a fully functioning service at all levels—including specialist mother and baby units—within five years. It would be helpful to hear the Minister’s views on this.

To conclude, the cost to the public sector of perinatal mental health problems is five times the cost of improving these services. That is why we, as Liberal Democrats, have committed to invest at least £500 million extra in mental health each year in the next Parliament, building on the waiting time standards that we have already introduced and improving support for new mothers, children and adolescents.

My Lords, my interests are in the Lords’ register. In addition, I am a vice-president of the Royal College of Midwives, and patron of the NCT and of Independent Midwives UK. Like others, I thank the noble Lord, Lord Harrison, for initiating this debate and for the briefing that I have had from other bodies, not least the Women’s Institute, of which I used to be a very active member.

The NHS Five Year Forward View states:

“Having a baby is the most common reason for hospital admission in England”.

For women with low-risk pregnancies, research shows that,

“babies born at midwife-led units or at home did as well as babies born in obstetric units, with fewer interventions. Four out of five women live within a 30 minute drive of both an obstetric unit and a midwife-led unit, but research by the Women’s Institute and the National Childbirth Trust suggests that while only a quarter of women want to give birth in a hospital obstetrics unit, over 85% actually do so”.

That document goes on to say that the NHS will commit to a commission to review future models for maternity units to report next summer—I will be watching that—and to recommend how best to sustain and develop maternity units across the NHS. It will ensure that tariff-based NHS funding will support the choices women make, rather than constraining them. It will make it easier for groups of midwives to set up their own NHS-funded midwifery services.

I really cannot tell noble Lords how delighted I was when I read that. This is such fresh thinking. It rides the wave of what women and midwives want: giving choice to women as to how they want their care provided, and to midwives as to how they want to work. Of course, this is just the beginning. The noble Lord, Lord Harrison, and other noble Lords clearly set out the immediate problems facing maternity services. The first concerns workforce issues and the shortage of midwives. One solution is to attract back into the service those thousands of midwives already qualified—some with a great deal of experience—who have chosen not to work in the current system, often because it is too dysfunctional, fragmented and rigid. The second is to stop the loss of newly trained midwives, who characteristically leave in their first two years after qualifying.

How are we going to achieve that? The NHS needs to enable midwives to offer a service to women that supplies genuine continuity throughout pregnancy, birth and antenatal care. Midwives who work with a caseload and who really get to know their women and their families—and especially the fathers of the babies—find the work rewarding, particularly when they have some control over their work/life balance. Then they stay in the service.

As the Five Year Forward View states, different models are needed. We already have some but they are very fragile and nascent and they need support. These different midwives want to work for the NHS. I should like to cite two models. One is Neighbourhood Midwives—a social enterprise, employee-owned and not-for-profit organisation based in the community. Midwives follow the women and work flexibly over 24 hours. This is possible because they are not needed to staff labour wards and clinics on 12-hour shifts. Likewise, Independent Midwives UK is a membership organisation that represents and supports 70 self-employed midwives, with a further 60 associate members. IMUK is a public benefit registered company with a very high-powered board. It has come a long way in its struggle to secure clinical indemnity, which it now has, and as a consequence I think it is destined to grow.

Both those organisations—and there are other, similar models—are pioneers, but they are up against the deep reluctance of the NHS to award them contracts. However, this coming year’s planning guidance, signed off by NHS England’s board in December, states that for 2015-16 commissioners should review the choices that are locally available for women. This may include choice about how women access maternity care, the type of care they receive, where they give birth and where they receive their antenatal and postnatal care.

Many of us may think that we have heard similar rhetoric in the past, but I think that this goes beyond rhetoric. For the first time, this spells action. I believe that many CCGs will want to implement this guidance, but can my noble friend tell me what will happen if they do not? If they do commission these services, that will enable groups of midwives to set up their own NHS-funded service based in the community and funded directly from a tariff or, in the future, from personal budgets. They will work in partnership with the trusts to offer a complete care pathway, but it will mean that both sectors can plan and manage their own staffing levels, and this will dramatically increase the offer and provision of a very reliable home birth service. It will also increase the use of free-standing birth centres. Working in group practices in the community will increase midwives’ autonomy, improve their clinical skills, and enhance their experience and confidence across the whole care pathway.

Caseload midwifery is seen as the gold standard of care, yet providing women with a midwife whom they can get to know and trust is still the exception rather than the rule. However, we know that this model of care improves outcomes, reduces interventions, saves money, improves women’s experience of birth and improves midwives’ job satisfaction, skills and commitment. What is now needed are commissioners who are brave enough to enable this model of care to be provided in a sustainable and innovative way. Does my noble friend agree? Does he see this as a way forward, and has he suggestions as to how the Government could encourage commissioners to commission such services?

My Lords, I, too, very much welcome the initiative of my noble friend Lord Harrison in allowing us to debate these very interesting issues. I agree with many of the points that he made about the risk of fragmentation of services and the need for more prenatal and postnatal care. The noble Baroness, Lady Manzoor, made a very good point about mental health, and indeed it was raised at Oral Questions this morning by my noble friend Lady Royall in relation to postnatal depression. The role of fathers was given a great deal of emphasis by my noble friend and the noble Lord, Lord Farmer. Also recognised was the excellence of many maternity services. I agree with my noble friend that one of the roles of maternity services in this country is to share good practice globally.

On the question of choice, it is very clear that we have a problem at the moment. The Public Accounts Committee made some very important recommendations about choice in its report of January 2014. In particular, the National Federation of Women’s Institutes suggested that although many women wish to take advantage of midwifery-led units, not enough are given the choice. It is not always my experience that these units are used sufficiently once they are set up, and certainly, looking at the numbers in a lot of them, it is clear that they are bordering on viability. Despite the view that has come across from opinion polling, confidence in using those units needs to be built up among parents and mothers. That is something that the NHS may need to think about in the future. Often, the units are set up because the service has been downgraded. Services are now centralised and I am sure that that is appropriate, but it can lead to a loss of confidence among many members of the public about what is left of those midwifery-led units.

I want to ask the noble Earl, Lord Howe, something else that was raised by the PAC. It says that the NHS has persistently failed to deal with inequalities in maternity care. It adds that the latest data on women’s experiences show that black and minority ethic mothers are less positive than white mothers about the care they receive during labour and birth. What is the NHS doing about that? I also refer the noble Earl to Oxford University’s National Perinatal Epidemiology Unit, which found that the most deprived women in England were 38% less likely to be seen by a professional prior to 12 weeks’ gestation and 40% less likely to report being able to see one as early as they would have desired. Presumably they are the people who most ought to take advantage of those services. What can we do about that?

Can the noble Earl respond to the point raised by the PAC concerning confusion around the department’s policy on maternity services, what it wants to achieve and who is accountable for its delivery? Of course, this is partly a product of the arrangements resulting from the 2012 Act, but clearly it is very unsatisfactory in terms of having a cohesive policy at local level and then ensuring that it delivers. I point out to the Minister that, prior to the PAC report, the NAO inquiry found that the department did not fully consider the implications of delivering the ambitions that it had set out in its strategy for maternity services. It went on to say that it was unclear how local commissioners were monitoring the performance of the providers of maternity services and holding them to account. The noble Baroness, Lady Cumberlege, pointed to the ability of mothers to take advantage of home births. How can we make sure that the enunciated policy is implemented unless there is proper monitoring? I very much agree with what she had to say about that.

My noble friends Lady Wall and Lord Harrison referred to training commissions and training in general. There is a concern that with a huge increase in the number of births in recent years, the number of training commissions is not keeping pace with need and demand. That is one reason why so many midwives have left the profession and why it is such a challenge to bring them back into the service. I should just like the noble Earl to say a little more about how convinced he is that we have got the number of training commissions correct.

Is the noble Earl prepared to say something about the relationship between midwives and consultant obstetricians? My noble friend referred to Morecambe Bay, where I think one of the issues was a very poor relationship. We know that there are tensions up and down the country. I wonder whether there is a leadership role within the department to try to bring the professions together at a national level and to resolve some of those tensions. They cannot be good for the safety and quality of care within midwifery units. Yet this issue is being raised in a number of areas.

Finally, on midwifery leadership, it is essential that we have visible, strong leaders locally and nationally. Is the noble Earl satisfied that at his department’s level and at NHS England there are sufficient midwifery-led professionals and a visible head of profession, perhaps a chief midwifery officer? Often, midwives are subsumed within the nursing profession. They are a separate profession but they often come under the management and leadership of a chief nurse. Sometimes midwifery does not get a fair shot when it comes to issues about arguing for resources and priorities. I wonder whether the noble Earl is able to comment on how we can enhance leadership nationally and locally.

My Lords, first, I join other noble Lords in thanking the noble Lord, Lord Harrison, for securing this debate. In doing so, I thank all noble Lords who have spoken for their excellent contributions. We cannot overstate the importance of good health and well-being for women before, during and after pregnancy. It is an absolutely critical factor in giving children the best possible start in life and in building the foundations for good health and well-being as they get older. That is why providing high-quality maternity care is a key priority for the Government. In their mandate to NHS England, the Government set out an expectation to see significant progress, by March 2015, in improving the standards of care and experience for women and families during pregnancy, and in the early years for their children.

The noble Lord, Lord Hunt, emphasised the importance of choice for women and we agree. Women should have as much choice and control as possible over decisions about their care while they are pregnant. The mandate is clear that women should be offered the greatest possible choice of providers and that they should have a named midwife who is responsible for ensuring she has personalised, one-to-one care throughout pregnancy and childbirth, and during the postnatal period, including additional support for those who have a maternal health concern. I quite agree with the noble Lord, Lord Harrison, about the importance of continuity. NHS England is working to deliver these commitments through the Maternity & Children Programme Board.

Part of that delivery must lie in increasing the number of midwives. The Government have taken steps to improve the size and capacity of the maternity workforce. There are now more than 22,000 qualified midwives, which is an increase of nearly 2,000 midwives since 2010. Another 5,000 midwives are currently in training, which is a record number, and we expect that this level of midwifery training commissions will be maintained in 2015-16. The number of midwifery-led units has increased from 87 units in 2007 to 152 units in 2013, giving most women a choice of place of birth, and 79 per cent of women of childbearing age in England now live within a 30 minute drive of both a midwifery-led unit and an obstetric unit, which is up from 59 per cent in 2007. We have also taken steps to improve the quality of the environments in which women give birth and are cared for. In 2013 and 2014, we provided a total of £35 million capital funding for the NHS to improve birthing environments.

The Government’s investment represents the single biggest capital investment in maternity care for decades, with more than 100 maternity services benefitting. Across the country, many local maternity services have been transformed. Improvements delivered by our maternity investment fund include almost 40 new birthing pools, which can help to make labour less stressful and painful; nine new midwife-led units, which are less clinical and can be more relaxing places to give birth; more en-suite bathroom facilities in more than 40 maternity units, providing more dignity and privacy for women; more equipment, such as beds and family rooms, in almost 50 birthing units that allow dads and families to stay overnight and support women while in labour or if their baby needs neonatal care; complex needs suites for women who need a more constant care environment due to maternal mental health or substance abuse problems; and better bereavement rooms and quiet area spaces at nearly 20 hospitals to support bereaved families after late pregnancy loss, a stillbirth or an early neonatal death.

The noble Lord, Lord Harrison, spoke of the bumpy road faced by women and the wide variation in quality of service. I recognise that there is variation but we are making progress. According to December’s friends and families test, 96% of women said that they would recommend their maternity service for antenatal care; 97% for their labour and birth care; and 98% for their postnatal community care. However, we are keenly aware that we must not be complacent. Although the birth rate in England fell by 3.6% in 2013-14, we know that complexity of maternity care is increasing with increases in average maternal age, obesity rates and awareness of other physical and mental health concerns.

To meet those challenges, it is important that the maternity workforce continues to develop. This Government established Health Education England, which is responsible for promoting high-quality education and training that is responsive to the changing needs of patients and local communities. For maternity services, this means ensuring that the NHS has access to the right numbers and mix of staff with the right skills, and the right values and behaviours to provide every woman with personalised one-to-one care throughout pregnancy and childbirth, and during the postnatal period

As set out in its mandate, HEE is working with NHS England to establish a vision of personalised maternity care by 2022 across geographical and service settings; to describe the workforce needed to deliver it; and to work with key stakeholders, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health and the Royal College of Midwives to deliver it.

Perinatal mental health has not previously been given the attention that it deserves. I was grateful to my noble friend Lady Manzoor for emphasising that. That is why we have made creating a maternity service that meets the individual needs of women and supports the prevention, diagnosis and treatment of maternal mental health issues a priority. HEE is continuing to work with the Nursing and Midwifery Council and the Royal College of Midwives to ensure that midwives in training have a core training module focusing on perinatal mental health, which should be in place for those entering midwifery training in 2015. It is also developing a continuing professional education framework for the existing maternity and early years workforce, which will include identifying the care and treatment required by women with perinatal mental illness. It is also continuing to work with the medical royal colleges to support specific perinatal mental health training being incorporated into the syllabus for doctors in postgraduate training.

The noble Lord, Lord Harrison, referred to the midwife to birth ratio, which is an interesting subject. The ratio set by the Birthrate Plus tool of 29.5 births per midwife is not a mandatory ratio. The Department of Health does not recommend a midwife to birth ratio. The midwife to birth ratio is an indication of throughput only and does not indicate the safety, quality or outcome of the service provided. Nevertheless, the National Institute for Health and Care Excellence published draft guidance on safe staffing in maternity settings in October 2014. That guidance proposes that the number and skill mix of midwives needs to be determined by the midwife in charge at the start of every shift or service and sets out the process that midwives should use to determine whether there is sufficient staff to provide for the needs of women and babies. NICE is planning to publish the final guidance this month.

The noble Lord also referred to the importance of maternity networks. I entirely agree with him. NHS England has set up 10 women and children maternity strategic clinical networks which are working with NHS England area teams to support clinical commissioning groups to commission maternity services. These networks can develop action plans and collaborative working to drive improvements in access, quality of care and inter-service communication to enhance the experience of women and families generally and, more specifically, of the large numbers of women who are at risk of poor mental health during pregnancy and following childbirth.

As I have mentioned, my noble friend Lady Manzoor referred to the costs of perinatal mental health problems. She is right to do so. Two fundamental principles articulated in our mandate to NHS England are relevant. The first is equal access for equal need; the second is parity of esteem for mental health. There is no doubt that offering better support to new mothers to minimise the risks and impacts of postnatal depression is a priority. Indeed, NHS England has announced that perinatal mental health will be a priority for it in 2015-16.

To support CCGs, NHS England has just updated its maternity services commissioning guidance, which will be published soon, and include information on commissioning for parity of care for a woman’s mental health as well as her physical health, and there will be more detailed guidance on the development and delivery of perinatal mental health services across a range of geographies and demographics for all commissioners and service providers.

My noble friend bemoaned the lack of maternal mental health outcome data. The Department of Health has commissioned the National Perinatal Epidemiology Unit at Oxford University to develop a maternal mental health outcome indicator to monitor mental health outcomes for women across the maternity pathway. We expect to include this in future NHS and public health outcome frameworks.

My noble friend also referred to the incidence of suicide, about which we are extremely concerned. However, again, this is a focus for both NICE and midwives in training.

My noble friend Lord Farmer referred, rightly, to the importance of fathers in perinatal care. There is no doubt that involving new fathers and partners in a child’s life is extremely important for maximising the lifelong well-being of a child. It is absolutely central to that and our policies are quite clear that pregnancy and birth are the first major opportunities to engage fathers in the appropriate care and upbringing of their children. This is explicitly mentioned in the healthy child programme, which every health visitor has to implement. I referred earlier today to the Start 4 Life information service, the material on NHS Choices, the baby guide and on the online birth-to-five guide. All these signpost parents to wider information about parenting and relationship support. The NICE guidance for health professionals on antenatal and postnatal mental health explicitly mentions the role of the partner, family or carer in providing support.

My noble friend Lady Cumberlege referred to the Five Year Forward View and the need to reconfigure maternity services. NHS England, in that forward view, said that it would look at new models of maternity care. It has set up a programme board, co-chaired by NHS England and Cathy Warwick, the external secretary of the Royal College of Midwives, and the first meeting for this is tomorrow.

Time prevents me, unfortunately, from addressing all the other questions that noble Lords have put to me. I undertake to write as soon as possible to every noble Lord who has spoken. In the mean time, this debate has drawn out some extremely important threads and themes that both the Government and NHS England would do well to follow up and implement.

Sitting suspended.