New year – new NICE quality standards for care during labour and birth

Mary Newburn (left), midwife Dr Sara Kenyon and Professor Richard Lilford, Director of Centre for Applied Health Research & Delivery at University of Birmingham for a conference on Midwifery-led care and choice of place of birth: Facilitating change through sharing research and good practice 2nd July 2015.

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  ( ) 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 : )

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 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!

Letter to the Guardian on Jeremy Hunt and how to address stillbirths and neonatal deaths

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.

Midwives of the fells – lessons from a Herdwick sheep farmer

Maybe we need to be woken up to our cultural ignorance and our compliance with a medical model of birth. Following my earlier blog ‘A midwife for Kate: The silence that demands a roar’, this is a look at maternity issues from a different perspective…

I’m heading for Cumbria. I’ve been reading The Shepherd’s Life: A tale of the Lake District. So I’m even more excited than usual. I’m a Cumbrian by childhood and went to school with sheep farmer’s daughters and sons.

James Rebanks is author of The Shepherd’s Life and @herdyshepherd1. At this time of year, he’s posting wonderful photographs of lambing sheep, as well as images of sunrise over the fells and sheepdog pups. He’s followed by over 60 thousand people. The story and images of ‘our shepherding year’ have captured the imagination of people who know nothing about the harsh realities of a Lakeland winter or Herdwick sheep. What’s more his book is currently the number one best-selling hardback. With that many followers, you can tell it’s not just a small clique of aficionados who are keeping company with Rebanks.

I’ve retweeted some of the lambing images. Just as I’ve shared on Facebook amazing photographs of human births in domestic or ‘social’ rather than ‘medicalised’ settings, and ordinary instinctive – rather than ‘stranded beetle’ – birthing postures. I feel there is much that we can learn from reflecting on humans as mammals, and thinking about long-standing ways of living and working that have evolved through the evidence of experience.

I’m struck by so many messages from Rebanks’s book. The birth of healthy lambs each year is fundamental to the success of the farm and the wellbeing of the flock. So birth really matters. Birth in human society has been side-lined as a core activity that we all respect. Instead of being seen as fundamental to our society’s success and to community wellbeing, culturally we do not prioritise quality of birth, either for women or for babies. In societies with less access to drugs and surgery – medical aid – better attention tends to be paid to nurturing women during and after birth, to making them feel protected and enabled to birth and to mother. Medicalisation of birth often swiftly follows on from industrialisation and privatisation of healthcare. But the drugs and surgery seem an odd way to go about a healthy, normal process and there is growing evidence that the unintentional consequences are stacking up.

Societal success is often reduced to growth in GDP. Keeping up with the neighbours is about acquisition of material goods and marketed experiences. More stuff rather than better stuff. Throughput. Commerce is a trump card. The Herdwick farmer knows he or she will never become wealthy through shepherding and will work long hours in tough conditions for what they earn. But the way of life is full of riches of a different kind. The Shepherds’s Life narrative and the tweeted photographs are inspiring because they demonstrate values and a way of life that is different from the modern mainstream. A different culture that needs to be lived out in order to be known, and preserved. A culture – or way of thinking, feeling, behaving and doing things – that needs to be explained. Outsiders just do not ‘get it’ otherwise. Normal midwifery is threatened by the modern values of being risk-averse, ‘outcome’-focused and preoccupied by cost and cost-saving. Less tangible but nevertheless important values and experiences get overlooked.

I don’t want to overdo the analogy between fell-side shepherding and midwifery. But there are some parallels. I find this Lakeland shepherd’s story inspiring because it is a challenge to received thinking. Rebanks communicates the excitement and reward of working in a more traditional way. By presenting mountain-farming as a distinctive culture with a nobility of its own, he opens our eyes to the possibility of seeing the world differently. Rebanks invites the reader to see, to appreciate, then to come to respect and to value ways of living and being that have evolved and been practiced over thousands of years. The fact that he had to struggle against the teaching at school and attitudes of the teenage girls he fancied, and then decline other opportunities after graduating, makes his commitment all the more powerful.

Another message with a strong parallel is that it’s not all or nothing. Like a resourceful midwife or a clued up pregnant woman, Rebanks adapts to and takes advantage of modern technologies. But he does so on his own terms and without disturbing too much of the equilibrium. The quad bike enables him to get around the ewes efficiently. Antibiotics are used when there is infection. Sick sheep and freezing lambs are brought inside the barn – ‘like the maternity ward and A&E rolled into one’ (p245). But his aim is to enhance shepherding and the fortunes of the flock without losing the knowledge of the old ways. The resourcefulness and endurance of sheep and farmer bring rewards and pleasures. After a long, bitter winter comes a glorious summer with new lambs, sheep free on the fell tops, and the valley bottoms alive with swallows and hay-time flowers.

Do we need a shepherd’s story to inspire? Maybe not. Growing numbers of women and midwives convey the wonder and majesty of human birth. Working with our physiology rather than against it, birth can be simple and joyful, even ecstatic. Photography and film add to the message. Check out the wisdom and fabulous images at Normal birth for lone nuts, Apple Blossom Families photographer, and also at Birth without fear.

But maybe we do need to be woken up to our cultural ignorance and our compliance with a medical model… first thing this morning, Kensington Palace announced that Kate and William were off to hospital for the birth of their second child. While the names of obstetricians (surgeons) were provided and duly reported by the media, there has so far been complete silence about Kate’s midwifery care. (See my earlier blog ‘A midwife for Kate: The silence that demands a roar’).

End note

Here are some quotes from The Shepherd’s Life which I particularly enjoyed. They may sound strangely familiar…

‘I find myself talking to the ewe, telling her she has done well’ (p242)

‘I always marvel at how gentle some of the men (shepherds) are at this time of year…’(p244)

‘Mountain sheep like ours are healthiest and most settled lambing outside, but that means a lot of ground to cover each day in the valley bottom fields.’ (p246)

‘My grandfather and father taught me that we have a range of options and the trick is to know which one to resort to, depending on the situation. …you can do more harm than good, they say, unsettling the ewes. My grandfather had incredible patience with the lambing ewes, and would leave them and leave them as long as all seemed well. He’s stand and watch, leaning on his crook, seeming to know when it was better to act, or when to leave well alone.’ (p251)

‘I… leave [the lambs] to their mother’s attention… she is an old experienced ewe and knows the game’. (p248)

There are ‘well-mothered and healthy lambs that don’t need my help’ but also sheep who become separated from their lambs and uncertain how to behave ‘like the thread between them has broken.’ (p248)

Rebanks quotes William Wordsworth on ‘an ideal society or an organised community, whose constitution had been imposed and regulated by the mountains which protected it. Neither high-born nobleman, knight nor squire was here; but many of these humble sons of the hills had a consciousness that the land, which they walked over and tilled, had for more than five hundred years been possessed by men of their name and blood…’ (1810)

This sense of history, and our lives being connected to those who went before us, reminds me of my midwife.

When I was in labour and felt I couldn’t go on, Caroline Flint said to me ‘Yes, you can, Mary. Women have been doing this for thousands of years.’

Her sense of calm and confidence soothed me, and soon my baby was born.

A midwife for Kate? The silence that demands a roar

Like much of the world, Kensington Palace just doesn’t get it. Every women needs a midwife and some need a doctor, too!

Kate, The Duchess of Cambridge, has been having care from a midwife for months, like every other pregnant woman in the UK, yet there is a white-out obscuring this important reality. This royal birth could do so much to share important messages about quality maternal and newborn care.

At 6.37 this morning LBC announced:

‘Kate will be looked after by a similar team of doctors and nurses to the one that helped her through Prince George’s birth in July 2013.

Guy Thorpe-Beeston, who holds the role of Surgeon Gynaecologist to the Royal Household, will be leading the medical team.

Alan Farthing, a consultant gynaecological surgeon, will also be present, as he was for the birth of her first son. He is also Surgeon Gynaecologist to the Queen.’

Guy Thorpe-Beeston ‘leading the medical team’, perhaps!

Alan Farthing ‘present’, quite possibly!

A ‘team of …nurses’, Oh please!

Who will provide the care throughout the labour? Who will encourage and support? Who will stage Kate through the undramatic hours?

A midwife, that’s who. A real person, a skilled and experienced professional. A person with a holistic approach, who thinks about the mind as well as the body, who knows that labour is demanding but that a women can do it.

A midwife with a name who should be celebrated for her part and for the sake of her profession. For the sake of other women in the UK and the world-over.

This roll-call  of the key personnel with the big hole at its centre must come directly from a Kensington Palace news release. Shame on their advisors.

Don’t they know that ‘Every woman needs a midwife and some need a doctor, too’? A midwife who is well educated, kind and reliable.

Of course it’s only one birth, but the coverage will be vast. What the royals do and value can influence a generation. We know that Kate is receiving midwifery-led care (no doubt with consultations with an obstetrician from time to time). When Lesley Page received her CBE William made it clear that he knew about the role and the value of a midwife.

The Lancet Midwifery series provides a framework for quality maternal and newborn care that firmly places the needs of women and their newborn infants at its centre. The framework is for midwifery care that includes ‘preventive and supportive care that works to strengthen women’s capabilities’.

In the UK we have some of the best maternity and midwifery services in the world, yet they still need to be developed and extended.

  • More women need to be advised that a midwifery-led birthing unit or a planned home birth is a really positive option.
  • Each and every NHS trust should be providing women with can care from the same midwife in pregnancy, for the birth and for care afterwards, as those who get this kind of relationship value it highly and we know that there are health benefits when continuity of midwifery is provided.
  • More midwifery and community support is needed in the days and weeks after birth to help women and their partners adjust to new parenthood and to help them establish feeding their baby.

In countries where a medical model of care prevails, women are subject to far more invasive interventions and are frequently not respected, as Milli Hill reported yesterday.

The royals will have all the options, all the clinical care and all the support they need. What a good opportunity to promote midwifery care for all.

We have progressive maternity policy in England; hard fought for over many years. Making it happen in practice is the continuing challenge. Come on, Kate. Join us in sharing what you know matters.

And congratulations on the birth of your daughter!

Important further reading

All that matters: Women’s rights in childbirth

The roar behind the silence

NICE guideline on Intrapartum CareAll women should be supported in their choice of setting wherever they choose to give birth. Women who are healthy with a straightforward pregnancy (low-risk) should be advised that ‘planning to give birth in a midwifery‑led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit’. For multiparous women the same positive message applies to home birth.