By Caroline Flint

Health care for pregnant women has been much criticized recently, although midwives have been doing their best to provide a satisfactory service. Caroline Flint begins a nine-part series on antenatal clinics with an investigation into why this situation has arisen

For the past two years antenatal clinics have been under attack. The Spastics Society started with their film Feeling Special and they were followed by the Short report, Esther Rantzen in That's Life, the National Childbirth Trust in Change in Antenatal Care, the Spastics Society in Who's Holding the Baby Now? and countless local newspapers and consumers.

Many of those working in antenatal clinics are doing their best to provide an adequate service for too many women in overcrowded buildings with two few staff. Many of us are aware of the criticisms and indeed often feel that they are justified - but what can we do to improve our service given the present cuts in NHS spending?

This series is for you and your ideas - suggestions from those working in the field with ideas that have worked for them - ideas to be floated that have never yet been tried, ideas from women going through the system and women who have already been through it. So whoever you are, student nurse to district nursing officer, please get your pad and pen and start sending your ideas to Caroline Flint c/o Nursing Mirror.

The aim of this series is to improve delivery of antenatal care by looking at ideas and practices, thinking through new ideas and suggestions, thinking about the care we are giving a `shake up'. We may decide afterwards that what we are doing is best in the circumstances or we may decide to try something different. Let us try to define the most common problems.

The impersonality of the experience at a time when women are feeling especially emotionally vulnerable. The Short report talks about the `cattle truck atmosphere of antenatal clinics where there is little privacy, little dignity'. A woman in The British Way of Birth says: `I felt I was wasting everyone's time ... theirs and mine. I was kept waiting for up to two and a half hours to have less than two minutes with a doctor who talked to me with his back to me'.

Change in Antenatal Care says: `The expectant mother is treated as the passive object of management, who is fed into the system and whose progress through it from point to point is controlled as if she had no wishes or preferences of her own.'

Long waiting times

Change in Antenatal Care 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. Few hospitals provide anything for women to do except wait.'

A woman in The British Way of Birth says: `I never waited less than one and a half hours and on two occasions I left after two hours without being examined, to catch transport.'

Short consultation times with obstetricians

Change in Antenatal Care says: 'Contact with an obstetrician is restricted to one or two minutes. To many women this seems the whole point of the visit, and all the planning and waiting are directed towards this moment. But for the most the visit culminates in only a brief laying on of hands by a member of the obstetric team who may have no more idea of who the person is he is examining than she does of him. It is not surprising that women feel disappointed when they are in and out of the examination room in a matter in minutes and have no opportunity for discussion or voicing anxieties.'

A woman in The British Way of Birth says: `The clinic is very overcrowded, you can be waiting for up to two and a half hours just to see the doctor for two minutes.'

Evidence from the Spastics Society quoted in the Short report says: `I think this is what women complain about most: they do not have continuity of care, which they want very much during their antenatal visits but certainty during labour and delivery.'

This leads on to a recommendation in the Short report: `We recognize the difficulties of providing continuity of care throughout pregnancy and labour but consider that a measure of it can be obtained by better organization.'

A woman in The British Way of Birth says: `I never saw the same doctor twice, they were examining you as if you were part of a car.'

Change in Antenatal Care says: `There is almost a complete absence of continuity of care and each time she attends a woman may see different, anonymous faces and also be given conflicting information and advice which leads to anxiety and confusion.'

If these are the problems, we could define our aims as:

* to help women to feel special when they come to the clinic, so that they feel that they

* to cut down the waiting time in clinics and to make any waiting that cannot be avoided into a positive experience;

* to enable the actual consultation to be longer, more meaningful for the woman, and for her to feel that she is being seen as a person not as a `pregnant-shaped container'

* to attempt to provide the same staff each time the woman visits the clinic.

First let us look at the antenatal clinics in most hospitals and see the great variety of antenatal care that exists, even in the same town.

The first antenatal visit a woman makes to the hospital varies enormously from clinic to clinic. Some women `book' their bed over the phone, some send their doctors letter to the hospital, some women have to appear in person and some hospitals `book' beds according to a co-operation card sent in by the woman's GP, some hospitals have a 'documentation clinic' when women can arrive any time between 13.00 and 15.00h on Tuesday and Thursday afternoon

Some antenatal clinics hold a booking clinic at a different time from the ordinary 'follow on' clinic sessions. Other clinics incorporate new patients in with the ordinary follow-on patients. Some booking clinics consist of midwives taking medical and obstetric histories from the women and then the women return a week or fortnight later to see one of the doctors.

In some clinics the midwives also weigh the women at this first visit, take their blood pressure, test their urine, take their blood and palpate them - even though nothing is palpable before 12 weeks, this gets the woman used to having her abdomen felt. In this way the woman is introduced to the midwife's role and it gives the midwife the opportunity to pick up anyone who is booking late or is very large for dates. Some booking clinics consist of a three-and-half hour marathon where the patient has a medical and obstetric history taken by a midwife. Then the prospective mother is weighed, measured, produces a midstream specimen of urine, sees a dietician, physiotherapist, social worker and health visitor. She has a blood sample taken, has a full medical examination (including vaginal examination and cervical smear) from a doctor and then goes on tour of the obstetric unit.

Some antenatal clinics expect all the women to undress and sit in rows in identical hospital dressing gowns.

Some antenatal clinics do not ask the women to undress. Others ensure that the woman has talked to the doctor who is going to examine her, with her clothes on and sitting up in a chair, before she is asked to undress for her physical examination.

At some clinics vaginal examinations are performed at booking (to detect pelvic abnormalities or growths, to determine the size of the pregnancy and to perform a cervical smear). Sometimes clinics do not perform a vaginal examination because the policy is that the fetal head is the best indicator of pelvic adequacy. Other clinics do the examination at 36 weeks when the action of circulating progesterone makes it a far more comfortable procedure for the pregnant woman.

The fascinating aspect of this huge variety is that each clinic considers its procedures to be the `right way', even though a sister hospital in the next street carries out a completely different regime with apparently similar obstetric outcomes in an apparently similar population.

Sheila Kitzinger in her Wornen as Mothers suggests that these are rituals that we subject the woman to: `The organization of many antenatal clinics incorporates procedures which many patients find humiliating . . . Patients wait, with their specimens, in rows and dressed in white hospital smocks, as they are slowly processed through the clinic system. . . Naked from the waist down, she lies flat while a group of men form round her lower end and her abdomen and her vagina is uncomfortably and sometimes painfully prodded and explored ... her private parts are referred to as `the vulva', `the bladder ', `the perineum', `the uterus', thus depersonalizing them ... In the modern hospital this is our own ceremonial rite de passage into motherhood. It involves separation from `normal' people going about their everyday lives; taking over by agencies outside the woman's control; investigation and assessment involving exposure of the most intimate parts of the body to men and strangers; and subjection to alarming and sometimes painful procedures at which she must not flinch because `it is for the sake of the baby'. Only after these rites of separation and humiliation does society remake her as a mother.

Kitzinger is not the only person to question what antenatal care is really about. In a paper questioning the efficacy of conventional antenatal care given by Sally MacIntyre at the 1980 research and the midwife conference in Glasgow entitled `Interaction in antenatal clinics' , MacIntyre quoted from her questioning of pregnant and postnatal women and found that 50 per cent of women were neutral about the supposed benefits of antenatal care and a further 25 per cent thought that their antenatal care had been useless - leaving only 25 per cent who had ben able to detect any positive benefits from their antenatal clinic visits. Her study also showed that more than half the patients seeing their consultant obstetrician had consultations of 2.9 minutes only.

In The British Way of Birth a woman says: `Hospital examinations were sometimes so basic that they could have been done at the GPs with less all round expense, time and bother to all parties'.

In the Journal of the Royal Society of Medicine, Chamberlain says: `It is still worth trying to re-examine current ideas and not to accept blindly that every procedure is bound to be helpful. Everything should be assessed

In The Lancet, Marion Hall questioned the productivity of routine antenatal care in a paper entitled `Is routine antenatal care worthwhile?' and outlined a scheme in which women without special problems are seen in the antenatal clinic only five times, at 12 weeks for booking, at 22 weeks to detect multiple pregnancy, at 30 weeks, 36 weeks and again at term.

Whether antenatal clinic visits are sometimes beneficial, always beneficial, or rarely beneficial is a different debate but those of us who work in antenatal clinics need to make clinic visits something that women enjoy and look forward to, so that if in the future the clinic visit is shown not to be as beneficial as we have always accepted, at least the women will feel that they have spent happy times with us.

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

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

Cling, P., MacGillivray, 1. (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., Chng,P, MacGillivray, 1. (1980). 'Is routine antenatal care worthwhile?'. The Lancet, July 12.

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

MacIntyre, 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. (1981). From here to Maternity. Becoming a Mother. Pelican Books. Spastics Society (1981). Who's Holding the Baby now? July.

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

November 24 1982.