If we can increase the proportion of births supported by midwifery care, we will be able to reduce the cost of medical interventions  

The 2016 review of maternity services is especially interesting, coming at a time when the NHS is under huge financial pressure, there is concern about the safety of services stretched to capacity, and questions about how out of hours services compare with services during working hours. We need expansion of midwifery-led care to enable NICE guidance on intrapartum care, postnatal care and antenatal care to be delivered.  Furthermore, Julia Cumberlege, who chaired the review, has the rare and valuable perspective of having carried out a detailed review of maternity services 25 years ago. She knows a lot of the issues and challenges in improving maternity care, such as getting the right kinds of monitoring and interventions to women with a more complex pregnancy or significant risk factors while making real strides to keep pregnancy and birth as normal and straightforward as possible, with a focus on prevention of illness, and provision of good social and psychological support.

If here is one key message from the new report it is about the need for personalised care and care plans, centred on the woman, her baby and her family:

‘Every woman, every pregnancy, every baby and every family is different. Therefore, quality services (by which we mean safe, clinically effective and providing a good experience) must be personalised.’

The report says in the introduction:

‘We found almost total unanimity from mothers that they want their midwife to be with them from the start, through pregnancy, birth and then after birth. Time and again mothers said that they hardly ever saw the same professional twice, they found themselves repeating the same story because their notes had not been read. That is unacceptable, inefficient and must change.’

The report is strong on women’s autonomy and right to make decisions about their care:

‘Safe care is personalised care. Women have made it abundantly clear to us that they want to be in control of their care, in partnership with their healthcare professionals. With this control comes a responsibility which mothers must accept and professionals must support – that personal health and fitness are integral to safe and fulfilling childbearing.’

The report makes reference to the Morecambe Bay maternity services enquiry, one of whose recommendations was that there should be an active MSLC (maternity services liaison committee) for local maternity services, to enable concerns and complaints expressed by parents to be responded to promptly by managers, commissioners and service user advocates. This report also highlights the role of MSLCs:

‘Maternity Service Liaison Committees (MSLCs) provide a means of ensuring the needs of women and professionals are listened to and we saw how effective they could be when properly supported and led.’

What we need now is detailed guidance for commissioners on and local health economies on how to bring that about. As MSLCs are an unusual multi-disciplinary independent advisory body, structures for creating a budget and paying honoraria to those who do the work week-in week-out are not always clear-cut. Yet it is possible to share good practice and to learn from the solutions that some CCGs have found.  The current guidance has been refreshed. Now that the Review Report has been published, NHS England should be able to finalise the guidance and publish it.

Midwifery care and continuity models of care

The report calls for more continuity of midwifery carer, with teams of 4 to 6 midwives, working with obstetric and neonatal specialists. On midwifery staffing and the move to a continuity of carer model of midwifery staffing, the report says:

‘Once rollout begins the NHS should achieve an annual increase of 20% of births having continuity of carer each year. In line with the NHS funding settlement, we have assumed that national rollout will begin in in 2018/19. Continuity of carer will be delivered by a caseload model of midwives working in small teams of 4-6. International literature on caseloads per midwife generally implies a range from 30- 40 births per midwife.’ It goes on to add ‘However, there may be opportunities to test more flexible models.’

There will, the report says, also be an average of 10 minutes more time allocated to each antenatal and postnatal appointment, allowing more discussion and support time. This will be allocated as needed, so some women will get longer visits and others less of an increase.

On the transition to continuity, the report recognises that moving to a different model of care – a continuity model of midwifery care – involves a big change, something that wasn’t costed for roll-out after publication of Changing Childbirth in the early 1990s. The authors state:

‘To fundamentally shift the model of maternity care, each local maternity system requires local leadership and support to manage the transition for a time limited period. This has been costed on the basis of project management and clinical resource to support change locally and training for all staff that will be moving to a continuity of carer model.’

The team address at high level what is needed when there are problems: a national standardised investigation process is needed for when things go wrong. Cultural values of kindness, honesty and openness should be further supported by a system of rapid resolution and redress, encouraging learning and ensuring that families quickly receive the help they need.

More emphasis is needed to deliver better postnatal and perinatal mental health care, to address ‘the historic underfunding and provision in these two vital areas’. Number one in the list of needed developments:

‘There should be significant investment in perinatal mental health services in the community and in specialist care, as recommended by NHS England’s independent Mental Health Taskforce.’

Multi-professional training should become the norm, both before qualifying and as part of continuing professional development, to build-in fundamental understanding and respect for each other’s skills and perspectives.

Community hubs – a one-stop shop for women and families – are recommended. A spin on children’s centres, perhaps?

‘Community hubs should be established, where maternity services, particularly ante- and postnatally, are provided alongside other family-orientated health and social services provided by statutory and voluntary agencies.’

Commissioning and clinical networks

There is a focus on monitoring quality and safety in maternity services and taking action at all levels, including a ‘champion for maternity services’ on the provider trust board. The report recognises the need to refer rapidly when additional services are needed and to be able to work across organisational boundaries.

The role for commissioners and clinical networks is re-emphasised (though apparently the ‘strategic’ aspect of clinical networks is being dropped. They will , having ‘responsibility for improving outcomes and reducing health inequalities’.   It is suggested that by ‘commissioning against clear outcome measures’ thy will be ‘empowering providers’ to make service improvements:

‘Professionals, providers and commissioners should come together on a larger geographical area through Clinical Networks, coterminous for both maternity and neonatal services. They should share information, best practice and learning, provide support and advise about the commissioning of specialist services to support local maternity systems.’

In my limited experience, this is very useful, but it takes skilled and motivated staff from both commissioning and the provider services, huge commitment my network members and well-prepared papers to make systems effective in moving quality and safety forwards. Many aspects of the system are outside the control of the maternity and neonatal staff, such as IT systems and data management and reporting.  Service user advocates must be involved, and ways must be created for there to be time for more relaxed discussion as well as short agenda items and formal reports. At their best, these clinical networks, could potentially function like a mega- or superstructure-MSLC.

Funding implementation

The payment system for maternity services ‘should be reformed’.  Some of the objectives identified include:

• The need to ensure that the money follows the woman and her baby as far as possible, so as to ensure women’s choices drive the flow of money, whilst supporting organisations to work together.
• The need to incentivise the delivery of high quality of care for all women, regardless of where they live or their health needs.
• The challenges of providing sustainable services in certain remote and rural areas.

Implementation of the review will work on a two phase basis: first, ‘establishing proof of concept’ via up to four maternity early adopter sites, followed by a national rollout phase. This phase would enable some detailed costing to be done (MN comments: postpone the expense (!) and prevent any very expensive developments form being attempted wholesale.)

’ In the first phase the NHS should trial the conclusions of the review with a number of volunteer health economies in order to establish the barriers, work out the potential solutions and share the learning widely. We are expecting that there will be up to four sites, they will run from September 2016 to September 2018 and that NHS England will make available to them a total of £8m over three financial years.’

NHS Personal Maternity Care Budget will be piloted. The report says ‘NHS England with selected CCGs should pilot the NHS Personal Maternity Care Budget scheme before national rollout. We estimate this starting by 2017 and approximately 4 CCGs or groups of CCGs will act as pioneer sites testing this model, for which £0.6m should be allocated. Following successful testing, national rollout would begin in 2018/19. The proven model to be rolled out nationally will need to be delivered within existing funding allocations by NHS England and CCGs.’ 

In addition, ‘Providers available for selection by women using their NHS Personal Maternity Care Budget might be an existing NHS trust, or a midwifery practice operating in a similar way to a GP practice.’ Midwifery practices would need to be accredited and meet standards for quality and governance arrangements. They would need to be fully integrated into community hubs, multi-disciplinary training and the clinical network for their area.  They would have ‘access to NHS facilities, including the community hub and diagnostics either in the community hub or at the hospital.’  This could include independent midwifery practices, ‘who already provide NHS services in some parts of the country. These midwifery practices will provide services to women in a similar way to other long-standing contracted providers, such as General Practitioners.’

Choice of place of birth – there is some suggestion of additional funding for new capital costs to extend choice. More fundamentally, the report says that in line with NICE recommendations, ‘meeting women’s choices more clearly’ and reducing costs to ‘meet the coming efficiency challenge’ there will be a significant increase in the proportion of births at home, in freestanding midwifery units and in alongside midwifery units.

‘As well as reflecting what some women want, care in these settings costs less when accompanied by service transformation across the local health economy. This would need to be carefully managed by local maternity systems but is essential.’

Rapid resolution and redress

The report makes recommendations about a proposed new insurance based system that the Department of Health will decide whether and when to implement. DH are ‘undertaking further modelling and research into the proposed scheme’.  The National Review team say the system should fulfil three criteria: i) provide rapid, compassionate support to parents, ii) effective learning for staff and iii) improved outcomes and reduced incidences of harm (and therefore costs).   The new insurance based system where families whose babies who had suffered harm could claim redress without the need to go through the courts. The scheme would be limited to harm occurring in term babies (37 weeks or more gestation) who were considered healthy when labour commenced, and to harm resulting in serious injury to the baby. The nature of the rapid resolution and redress scheme is that it would not be necessary to establish negligence in order to secure financial redress. The test would be one of causation: whether the harm was the probable consequence of the treatment provided or not provided during birth. An insurance assessor, working with appropriate professional and legal advice would settle claims.

I hope this summary of the key messages will encourage others to read the report in full. It will give colleagues on MSLCs an immediate handle on key themes and indicate some of the words and phrases that can be searched for in the report. No doubt there will be many column inches devoted to the recommendations and many hours of debate about the implications over following weeks and months.  The three C’s of Changing Childbirth: Choice, Control and Continuity of care and carer are revisited here. In 2016 there is more high quality evidence of effectiveness available regarding choice of place of birth, midwifery-led care and continuity models of midwifery, so there is good reason to feel that commissioners will get behind the calls. There is also more of a plan for implementation, albeit a staged plan. So much more could and should have been said about public involvement in shaping local services and identifying priorities for change based on the experiences of local women and their families. However, the role of MSLCs is acknowledged, and we must build on this. Let’s hope we will see real changes, with more truly woman-centred care becoming accessible in every area, and improved outcomes for those mothers and babies with most to benefit from improved maternity services.

What’s new in the world of maternity in the UK? In England? New for those of us who got involved in family and Christmas preparations in December are the Quality Standards for care during labour and birth – or Intrapartum Care NICE Quality Standard [QS105] – for healthy women with a straightforward pregnancy.

These are based on the NICE Intrapartum Care ‘clinical guideline’ that was published a year ago.

Seven key ‘quality statements’ are highlighted

Seven key ‘quality statements’ are highlighted. These are auditable. Commissioners, managers, and advisory forums where service users get to have a say in what goes on in local services, can use these to audit how services are being run.

If you are are a midwife or a student, on a maternity group, such as an MSLC  (https://www.nct.org.uk/professional/mslcs ) or a labour ward forum, these statements might just help you in your work.  Are local services complying with these quality statements? If not why not? Is the reason a good one? What are the consequences? Do management know? Do local people in the community know? How does your local service compare with neighbouring services, or services 200 miles away?

The statements are roughly split between positive approaches to care that need to be promoted as they are not mainstream yet (things that should be done), and practices that are commonplace but are not supported by evidence (things that should not be done). In effect, things that need to be undone.   Read on (or you can go to : http://www.chimat.org.uk/resource/view.aspx?RID=269485&src=KU )

The do’s

There are four positive activities to do:

Do  – Women receiving care who are unlikely to have complications during labour or birth should be given the choice of planning their birth in any one of four places: in a midwifery unit (birth centre) freestanding in the local community or alongside a hospital, at home, or in a hospital unit run by obstetricians and midwives.

Statement 1. Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.

Do – Women need practical and psychological support in labour, not just task-oriented clinical care. NICE says midwives should provide both care and support, enabled by  being allocated on a one-to-one ratio, rather than caring for several women at once or focusing on record keeping at the expense of women’s needs.

Statement 2. Women in established labour have one‑to‑one care and support from an assigned midwife.

Do – Get the woman off the electronic fetal heartrate monitor when the trace is reassuring, if it is used at any stage because of uncertainty about wellbeing. This is important because leaving women on this kind of monitoring equipment can cause harm, e.g. by reducing comfort and mobility and increasing use of other interventions, unnecessarily.

Statement 4. Women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

Do – Make it easy, and gently encourage women, to hold their baby next to their skin without clothing in between them, so they have intimate loving contact in the hours and days after birth. This is great for forging loving bonds, helping the baby to feel secure, regulation of baby’s temperature, colonisation of the baby’s skin with mother’s microbiome (healthy bacteria), and establishing breastfeeding.

Statement 7. Women have skin‑to‑skin contact with their babies after the birth.

 

And the don’ts

Some developments that have become common practice aren’t necessary, and may do harm.  Three of these kinds of practices are highlighted as indicators for quality:

Don’t do – Avoid continuous electronic fetal monitoring in women who are healthy and have no known complications of labour. In practice this can lead to false positives (concern when the baby’s heartbeat is normal), and continuous monitoring being continued which can restrict movement, the opportunity to use a birth pool, more need for pain relief and the impact of epidural /opioid drugs for the labour and the baby.

Statement 3. Women at low risk of complications do not have cardiotocography as part of the initial assessment of labour.

Don’t do – Cutting the umbilical cord immediately after birth does more harm than good. It  deprives the baby of blood that will circulate from the placenta if the cord is left intact until it stops pulsating.

Statement 6. Women do not have the cord clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.

Don’t do – Avoid intervening in the biopsychosocial symphony of labour and birth when labour is progressing within the normal range. Surgical interventions, including ‘breaking the waters’ can have an unwelcome impact, including more pain for the woman, leading to other interventions. Giving synthetic hormones interrupts the flow of hormones produced by the women and the development of her labour. Unless there is a reason to intervene, leave well alone.

Statement 5. Women at low risk of complications are not offered amniotomy or oxytocin if labour is progressing normally.

Already well known in the UK

The NICE Intrapartum Care Guideline was made public knowledge when it was distributed for consultation, before the final version was published. There were press and TV stories and social media discussions.So the  recommendations are already widely discussed and familiar to many midwives, doctors and women.  In the UK, in England, Wales and Northern Ireland NICE the recommendations are generally considered seriously by commissioners and managers. Scotland makes its own clinical recommendations.

Are these standards a reality in your area?

The development of quality standards is designed to promote implementation across NHS services and enable monitoring of practice to improve care and make it more consistent.

Are these standards a reality in your local service  – or in your country?  If you are doing anything to improve these aspects of care, share your successes. We want to hear all your good news stories.

What can you do to make a difference?

Last July, I organised a conference with NCT and Dr Sara Kenyon of Birmingham University and the West Midland CLARHC to share evidence and good practice on midwifery-led care and choice of place of birth. Sara, Richard and I (see above) contributed to the chairing and discussion. Speakers included:

• Tracey Johnston, Consultant Obstetrician, Birmingham Women’s NHS Foundation Trust
• Tracey Cooper, Consultant Midwife, Normal Midwifery at Lancashire Teaching Hospitals NHS Trust and member of the NICE Intrapartum care guideline development group
• Cathy Shneerson, Reasearch Fellow, University of Birmingham
• Paula Clarke, Consultant Midwife, Birmingham Women’s Hospital
• Sarah Noble, Consultant Midwife, Birmingham Women’s Hospital
• Kirstie Coxon, Senior Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, Kings College, London
• Diane Reeves,Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group
• Kathryn Gutteridge,Consultant Midwife, Serenity and Halcyon Birth Centres
• Soo Downe,  Professor in Midwifery Studies, University of Central Lancashire

To be informed and inspired on this topic, see the speakers’ presentations  available at https://www.nct.org.uk/professional/events Just scroll down the page and look for the PDFs in ‘related documents’.

Why not hold your own local event on one or all aspects of the quality standards?  Get local women involved to tell their stories. Get midwives, obstetricians, a local commissioner and public health lead to present. good luck!

Dear Editor and Jeremy Hunt,

‘Stillbirth and deaths in newborn babies are devastating for parents. Every thinking person wants pregnancies to end with a happy outcome. Having that ambition and doing evidence-informed things to address the issue are, however, two very different things. Jeremy Hunt (Jeremy Hunt aims to cut number of stillbirths and neonatal deaths, 13 Nov) is strong on rhetoric but weak on detail. Evidence that ‘digital equipment’ saves lives is limited, so let’s not kid ourselves and get caught up in a technology race. MBRRACE (Mothers and Babies: reducing risk through audit and confidential enquiries across the UK) shows there is wide variation between the performance of different maternity services (‘commissioning organisations’) across the UK. Those that need help show perinatal mortality rates up to 10%, or more than 10%, above the average. Clinical leadership from doctors and midwives; effective multi-disciplinary team working, including joint training; effective communication – both between staff and staff with service users; plus psycho-social support for women provided by continuity of midwifery care are all important, but not a quick fix. Look up the evidence (including the Cochrane review on ‘midwife-led-continuity-models’, by Sandall et al) and use it!’

Yours, etc

I’ve just submitted that letter. Here I explain why.

My blog site has been quiet all summer. I have had a cancer diagnosis and have been off my usual form and away from my laptop having chemo-radiation therapy. That’s a wholly different health story. It takes a long while to get back to full energy and I’m not there yet. But I’m enjoying taking life at a more leisurely pace. Next week, I have my three-month follow-up CT and MRI scans and the meeting with my oncologist.

I could step back and leave user representation on maternity services to the many other, younger, maternity advocates and parent leaders out there. I know there are women of all ages influencing maternity services for the better across the UK, week-in and week-out, as I have a large network of contacts, partly through ‘MSLC leaders’ on Facebook, partly through 27 years of employment at NCT, through my social media work, and as a result of two of my sons’ partners being pregnant this year, and my friends’ children also becoming parents, for the first time or subsequently. But, I know that many people don’t speak up because they are not sure how best to express what they feel; they fear ‘going public’, making a mistake, or being ridiculed. For those who have a young family, a job, busy lives… there just isn’t time.

And very few feel confident to challenge or join in the debate using high-quality evidence. It’s difficult to keep up to date, to interpret findings and conclusions, to know when the methodology is reliable, to put it all together and makes sense of the whole, etc, etc. So many service users, women especially (?), stay mum.

That’s why I’ve sent a letter today. Because I can and others who might, won’t.

There’s lots more that could be said. I’m attending the MBRRACE conference at RCOG on Thursday in London, the focus of which is ‘Perinatal Confidential Enquiry into: Term, singleton, normally-formed, antepartum stillbirth’. In fact its the ‘report launch meeting’. One of the sessions is on ‘Diagnosis and intrapartum care’ , though I note there is nothing on prevention. There are sessions on ‘Communication issues’ and ‘Lessons to be learned and key recommendations from the 2015 Perinatal Confidential Enquiry’.  Maybe I will write more later.

Very sadly, this month the pregnancy of Leigh and my son Robin was one of those with a sad ending. In Australia, pregnancies that end after 20 weeks are counted as a stillbirth, even if they end just hours or days after that time, unlike in the UK where the threshold is 24 completed weeks of pregnancy. Leigh and Rob were caught up in that, needing to register a stillbirth. So, I dedicate this blog to them, their love and their courage, and to little Jesse James who didn’t make it to enjoy the Sydney sunshine or grow up in our family.

Source: Evidence, Experience and Safety: Letters to Editor

Source: Evidence, Experience and Safety: Letters to Editor

Source: Evidence, Experience and Safety: Letters to Editor

Source: Mental Health – and Money

Source: Mental Health – and Money

welcome baby jake. A great and important birth story