By Caroline Flint

Mothers-to-be often feel exasperated at the amount of time they spend waiting to be seen at antenatal clinics. Caroline Flint discusses how waiting times can be reduced by a sensible appointment system and how any time spent waiting can be filled constructively

Waiting times in hospital antenatal clinics have always been notoriously long, but is there any way to improve them? All the reports I have referred to previously have highlighted the horrors of the waiting times that women are subjected to. In The British Way of birth, 1,880 women (37 per cent) said that they had to wait between one and two hours to be seen in their antenatal clinics. One woman said `An absolutely appalling, unreasonable waiting time.'

Change in Antenatal Care, from the National Childbirth Trust working party, says `Waiting times are long, often two hours or more, and sometimes exceed three hours in surroundings which are often extremely uncomfortable and frequently depressing.'

Have you found any good ways to shorten your waiting times?

Last week I described a questionnaire that women coming to the clinic can be asked to fill in. This asks what time their appointment is, what time they actually arrived and what time they were actually seen. Of course the information obtained is valuable, but perhaps it is even more helpful to have a volunteer in the clinic for about three or four weeks whose sole function is to jot down the times when women are seen by a doctor or midwife and to tally the appointment times to those realistic times rather than to an imagined number of `how many we should be able to see in such and such a time'. This means that the appointment book will not look so neat.

A realistic system means that women coming to the clinic will not have to wait around until the doctors arrive. And women

Having achieved a realistic appointment system, you must anticipate that it will not last for ever. The system should be reviewed at least every six months and maybe more often. Every time a doctor changes it means a slight adjustment in the way the clinic works.

Last week I was shocked that the clinic which we had designated as `most impressive' in our minds as far as waiting times were concerned six months ago, has once again degenerated into an upturned anthill - so constant vigilance is needed!

Once midwives are used for seeing pregnant women the waiting time in a clinic is immediately reduced because of the full utilization of staff.

The Short report says `We have also recommended that more use should be made of experienced midwives who could relieve much of the load on obstetricians by providing part of the antenatal care for the "low risk" mother.'

It continues `Steps should be taken to make better use of the skills of the midwife in maternity care - particularly in the antenatal clinic and labour ward, where they should be given greater responsibility for antenatal care of women with uncomplicated pregnancies.'

In many clinics, midwives weigh women, take their blood pressures, give them certificates of expected confinement, test urine, act as chaperones or as the Royal College of Midwives said in their evidence to the Short committee `the midwife is there as his (the doctor's) handmaiden to support him'.

It is time the midwives did a full consultation with women in their clinics. Expertise is being lost and confidence in the midwifery profession is fairly low, but experience is only gained with practice. The way we have gained confidence in our midwifery skills is by the way we run our `midwives clinic' - but more about that next week.

As well as a `midwives clinic' we also have midwives seeing women in all our consultant's clinics. This gives the midwives confidence that the doctors are at hand if they have any worries. It also gives the consultants confidence because they feel that their patients are not disappearing from their care and that if the midwives detect anything worrying they will immediately call for help.

One of the first things we did at St George's was to look at how we were utilizing the available space. We listed the number of consultation rooms and the number of people using them. It might be worth taking a fresh look at how you are using the space in your own clinic. If you have eight consultation rooms, eight doctors or midwives are using them and seeing eight women at one

Having looked at reducing the overall waiting time in the antenatal clinic, it is still obvious that some women will have to wait sometimes. As the NCT's Change in Antenatal Care states `Few hospitals provide anything for women to do except wait'. What facilities can we provide with limited budgets and limited staff?

We have noticed a significant difference in the level of conversation in our clinic when we have the chairs arranged in rows (very little conversation) and when we arranged the chairs in small circles (much more conversation).

Sometimes we label each circle of chairs with the names of surrounding districts - Tooting, Streatham or Wimbledon, and we suggest that women sit in their own district in the hope that they will strike up a conversation with someone who lives near them.

Of course, this is much easier if a volunteer or staff member goes round to each circle in turn and attempts to introduce the women to each other. If a pregnant mother can leave her antenatal clinic having made a friend by the end of her pregnancy, the clinic will have given her something of enormous value - even if later research shows that her actual antenatal care is of limited value.

Refreshments while waiting, make a clinic feel much more homely and are needed by women who have travelled a long way to attend the clinic. Most hospitals have volunteers who give sterling service in the assorted clinics. At booking clinics it is very friendly if the midwife who takes the woman's history can sit down with her and have a cup of tea with her.

Any clinic can find a small space for children to play in, if ex-patients can be persuaded to come back and look after the children and donate toys, paints and so on the atmosphere in the clinic is immediately improved. The children's play area has more value than is immediately apparent.

Its primary function is, of course, to entertain the children while their mothers receive their antenatal care. This lowers the noise level in the clinic and makes the noises happy noises rather than bored noises. The presence of children being played with, is educational for `primips' who can learn much by seeing how the children are handled. At St George's we are blessed because we have someone who runs a nursery school to run our playroom.

With her expertise she is able to show how to stimulate and educate children - this is helpful to both the women waiting in the clinic and the volunteer helpers. The other benefit of the playroom is that it acts as a meeting place for the helpers who often have new babies and can be feeling quite lonely and isolated.

In hospitals, we often do not appreciate the importance of notices. In any hospital one can also see old signs that the staff no longer notice because they have been there so long. It is worth going round and checking that the lavatories are clearly labelled, that the public phone is indicated and that all the rooms with doctors and midwives in, are clearly labelled with their names.

This prevents women feeling that they are sitting in the wrong place and that they have been forgotten (a horrible and common feeling in out-patients clinics). If a woman has discussed with the sister/hostess, that she is going to see Dr Jones or Midwife Cooper she feels much more secure if she is waiting outside a room that is labelled Dr Jones or Midwife Cooper. This need not cost anything, we use yellow card - left over from X-rays which the X-ray department keep for us - written on with big letters in thick felt tip pen.

Many people are used to a television being on in a corner of their room. There are many excellent films and videos available for screening in a corner of the antenatal clinic. For no cost they can give women an enormous amount of pleasure and they can have great educational value as well. Usually a projector can be borrowed from the local health education department. We now have the luxury of a daylight screen, but originally we used to project our films inside a cupboard with women sitting outside it.

The antenatal clinic is the ideal place to do antenatal teaching Often subjects crop up with a question asked by one of the women waiting and this can lead to a discussion. If a midwife (with a fairly loud voice) can be spared to do antenatal teaching in the clinic this can transform the waiting time into a period of interest and usefulness.

Other departments also can be a source of teaching: dieticians may put on a display of iron rich foods, or fibre in food; physiotherapists can be encouraged to talk about and demonstrate posture during the clinic and the local library service can be asked to bring selections of books on pregnancy, childbirth, sex education for siblings, or on useful books for toddlers.

December 8 1982