By Caroline Flint

Caroline Flint was overwhelmed by the response to this series, which looked at ways of improving antenatal care for mothers-to-be, midwives and consultants. The comments were varied: some critical; some enthusiastic; but all were constructive

It was rewarding to receive so many letters and phone calls in response to this series. My overwhelming impression is that antenatal clinic staff nationwide are trying out new ideas in order to make their clinics more attractive to mothers. Everywhere midwives are talking about how to change, how to streamline, how to `humanize' their service. Many of the letters were from women who had recently experienced the `system' and were extremely happy with the efforts being made on their behalf. Several women mentioned specific hospitals, midwives and consultants by name.

Shared care with GPs was extremely popular and several women mentioned with pleasure the care they had received from their doctors and community midwives. They felt that they could talk with the GPs or midwives for as long as they needed, and that the GPs and midwives were interested in them as a person.

In an interesting letter from Heavitrees Hospital in Exeter I read about a proposal that booking histories may be taken in the privacy of a women's own home by the community midwife. I think this is a lovely humane idea. In conjunction with this are plans for the further integration of hospital and community midwives. Surely the next step from this idea is that the community midwife attends the clinic when the client she had booked in comes for her first visit.

From the letters it was apparent that community midwives help at several hospital antenatal clinics, but sadly it seemed that this happened when the community midwives had not many community clinics.

Not only does the manager's attitude matter enormously; so does the consultant obstetrician's attitude. Some consultants can be very involved and encouraging. At St George's we are fortunate to have consultants who are willing to come to a monthly meeting with me to discuss ways to improve the antenatal clinic. With this support we have been able to increase the midwife involvement and to try many different ideas.

Sadly, some obstetricians feel the need to monopolise the patients which leads to the situation I saw recently. I met a consultant obstetrician who reckoned that out of a clinic containing 100 patients he had to see at least 50 of them. I pointed out that the clinic only lasted three hours, which meant that on average he was spending under four minutes with each women, not counting him answering the phone, stopping for a cup of tea, talking with colleagues.

As the National Childbirth Trust's report Change in Antenatal Care says: `It is not surprising that women feel disappointed when they are in and out of the examination room in a matter of minutes and have no opportunity for discussion or for voicing anxieties.'

Another paragraph from Change in Antenatal Care says: `The convergence of 100 or more expectant mothers on an overcrowded antenatal clinic within a period of two hours is bound to produce stress however well organized the clinic and well intentioned each single member of staff. It is an unsatisfactory experience for all concerned, in some ways as much for the doctors, nurses, midwives and clerks working in the clinic as it is for the women required to attend it. Women feel that they are on a conveyor belt which must be kept moving at all costs; doctors are under intolerable pressure to keep the flow through, and feel guilty because under such circumstances it is impossible to give adequate care; and midwives, deprived of the opportunity to exercise their professional skills, experience dissatisfaction and frustration in their role.'

I received some suggestions that consultant obstetricians might find great satisfaction in being `real' consultants, that is that their role might become peripatetic, looking in on midwives and doctors seeing patients, or to be available for referrals or lead a 'teaching round' on the different rooms in the antenatal clinic.

I received some exciting ideas from the nursing officer and sisters of Queen Charlotte's antenatal clinic. They have files containing articles of interest for the patients to read and they encourage the women to bring in articles for inclusion in their library.

At Queen Charlotte's they are also thinking of having a `suggestions box' for patients to put ideas into and they are making a video about what their hospital offers from pregnancy right through to the postnatal ward. This tape will then be shown at evening sessions.

A few weeks ago, a student nurse came to our clinic and criticized our booking clinics as being far too clinical. He suggested that we should invite a group of women and their partners to see a film about antenatal care, introduce them to each other, and that a midwife should take their histories then. He felt that the emphasis would be of a social nature rather than a medical one at that session.

This feeling also has come through when I have talked with others involved with delivering antenatal care - that is, our emphasis is on the medical aspects of pregnancy. For the mothers-to-be it would be much better to stress the more social and emotional aspects with the need to take blood pressures and palpate abdomens still there but not the main reason for coming.

At Queen Charlotte's, the staff also have plans for on-going evaluation by both staff and clients, demonstrations in the waiting area, evening booking appointments with plenty of time being allocated to each women, discussion groups for postnatal parents and a book list for prospective parents.

Many letters stressed the enormous value of having somewhere where the children could play. At Heavitrees Hospital they use volunteer helpers and at King's they use nursery nurses.

In a letter from King's College Hospital, and in several other letters, midwife allocation is described. At the booking clinic each midwife is allocated an equal number of patients. She then puts a sticker on the front of the notes with her name on. Each time the woman attends the antenatal clinic, the same midwife sees her and only refers her to a doctor when necessary. Many hospitals have specific times when women see the consultant - we always send women at 36 weeks to see the consultant, and earlier if the baby is presenting by the breech.

Other suggestions included a 'problems room' where a senior midwife sits throughout the clinic so that she is available to answer questions that have not been answered during their consultations. Another idea is to place a midwife at the exit of the clinic saying goodbye to women as they leave and asking `Everything all right?' or `Are you happy about everything?' In this way, the women are encouraged to voice any queries or worries they have.

Some clinics have an open invitation to women to come and have a 'cuppa' with sister to talk about their worries, or questions they have about what goes on at that particular hospital. Women are more likely to come if there is a specific time each week when a sister is available. I have found that women who are not even booked at St George's will come to have a cup of coffee with me on a Friday at 11.OOh. This can cause some embarrassment when one's opinion is asked on treatment being given at other hospitals, but relieves quite a bit of anxiety in women who want to compare what each hospital in the area has to offer.

I picked up a useful tip on a visit to King's College Hospital. This was to have a selection of commonly prescribed drugs on hand in the antenatal clinic, so that our patients do not have to queue for ages in the pharmacy. We have a selection of different iron preparations, treatments for thrush, simple antibiotics, antacids and folic acid tablets. This cuts down the total length of the visit for women needing extra drugs, rather than just our usual iron tablets.

The student nurse who was unhappy about our booking clinic, was also concerned about how little we involve fathers. This needs considerable thought, because he was right in his observation that, despite the fact that husbands are always welcomed to our clinics and, indeed, often come, husbands are still somehow left sitting there like a `spare part'. We need to ask them and their wives how we can involve them more.

Some letters emphasized the poor communication between hospital and GP: blood results and culture results taking two to three weeks to arrive at the doctor's; ultrasound results not being notified to the GP or haemoglobin results at 28 weeks. Much appreciation was expressed for the letter of welcome we send to all our pregnant women before the booking clinic.

I was fascinated by the large number of women who have small children and are working in the health service. I was gratified that they were able to make time to read Nursing Mirror and write to me. I was over whelmed with admiration for these women, remembering how demanding it was bringing up tiny children. But it also made me realize that there is a huge untapped source of knowledge and experience about working mothers in the NHS. It also made me wonder if I was supporting working mothers on my staff enough. How many hospitals run nurseries for their shift workers? How many have a list of registered child minders in the immediate vicinity?

Since I started to write this series, two reports have come out that are worth reading. Maternity Care in Action, the first report of the Maternity Services Advisory Committee, has checklists for helping clinic staff to review what they need to do; this costs 55 pence and is available from HMSO. And the Report of the RCOG Working Party on Antenatal and Intrapartum Care, which is available from the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, London NW 1 4RG.

Thanks go to all those readers who sent me their comments and suggestions. To Mrs Murray, director of maternity services, Mrs Afari and Miss Rawana, nursing officers, Professor Chamberlain, Mr Amias and Mrs Varma, consultant obstetricians. To the staff midwives, staff nurse and auxiliary nurse with whom I work in the clinic. To the staff in the labour, antenatal and postnatal wards and to our clerical staff and volunteers.

Boddy, K., Parboosingh, J., Shepherd, C. A Schematic Approach to Prenatal Care. Department of Obstetrics and Gynaecology, Edinburgh University.

Boyd, C., Sellers, L. (1982). The British Way of Birth. Pan Books.

Chamberlain, G. (1978). 'A re-examination of antenatal care.' Journal of the Royal Society of Medicine, 71, September.

Cling, P, MacGillivray, I. (1980). `An audit of antenatal care: The value of the first antenatal visit.' British Medical Journal, 281, November 1.

DHSS (1980). Perinatal and Neonatal Mortality. Second report from the Social Services Committee. HMSO.

Hall, M., Chug, P, MacGillivray, 1. (1980). `Is routine antenatal care worthwhile?' The Lancet, July 12.

Kitzinger, S. (1978). Women as Mothers. Fontana Books.

Mac[ntyre, S. (1980). `Interaction in antenatal clinics.' Paper given at Research and the Midwife conference, Glasgow.

National Childbirth Trust (1981). Change in Antenatal Care. Report from working party set up for the NCT by Sheila Kitzinger.

Oakley, A. (1979). From Hereto Maternity. Becoming a Mother. Penguin Books. Oakley, A. (1980). Women Confined. Towards a Sociology of Childbirth. Martin Robertson and Co. Ltd.

Spastics Society (1981). Who's Holding the Baby Now?

Spastics Society. Feeling Special. A film about care before birth, produced by Randel Evans Productions Ltd, directed by Nigel Evans.

January 26 1983