To the NHS Maternity Review team: a message from a midwife

Photo: Midwiferyaction.org

It's incredibly encouraging that those interested in the future of maternity services in England, are continuing to engage with the NHS Maternity Review team. I've been collecting views via social media for my blog, and have sent links to Baroness Julia Cumberlege, and received a positive response. Ideas and opinions are still being sent to me, and this one is from Dr Tracey Cooper, who is an inspirational consultant midwife at Lancashire Teaching Hospitals NHS Trust. I was delighted that Tracey took the time to write this; she has a wealth of midwifery knowledge and tirelessly and passionately supports evidence-based woman centred care. 

Tracey (pictured above):

'We are so lucky to have superb professors and academics in the midwifery profession. Some of them have joined a wide range of experts from other disciplines to produce the Lancet Midwifery Series (Renfrew et al 2014), which provides maternity services with an evidence based framework to base care on, now and in the future. This framework is for low, middle and high income countries, therefore it is an ideal tool to use in the UK.

The framework for quality maternal and newborn care

The Lancet Midwifery Series is the most critical, wide-reaching examination of midwifery to date, and it includes a broad range of clinical, policy, and health system perspective (Renfrew et al 2014).

Within my own Trust we are going to use it to process benchmarking - where we are now and where we want our services to be in the future. We will use it as ‘our vision’ tool. As a group of north-west consultant midwives, we are also discussing it with Heads of Midwifery and the Strategic Clinical Network, to use as a vision tool across the whole of the north-west region. 

Key messages

- The findings support a system-level shift, from maternal and newborn care focused on identification and treatment of pathology, to a system of skilled care for all, with multidisciplinary teamwork and integration across hospital and community settings. 

- Midwifery is pivotal to this approachThe views and experiences of women themselves, and of their families and communities, are fundamental to the planning of health services.

- Midwifery is associated with more efficient use of resources and improved outcomes when provided by midwives. Midwives are only effective when integrated into the health system in the context of effective teamwork and referral mechanisms and sufficient resources.

- Promoting the health of babies through midwifery means supporting, respecting, and protecting the mother during the childbearing years through highest quality care; strengthening the mother’s capabilities is essential to longer term survival and wellbeing for the infant.

- Strengthening health systems, including building their workforce, makes the difference between success or reversal in maternal and newborn health. Since 1990, the 21 countries most successful in reducing maternal mortality rates—by at least 2·5% a year—have had substantial increases in facility-birthing, and many have done this by deploying midwives.

- Effective coverage of reproductive, maternal, and newborn health (RMNH) care requires three actions. These are:

• facilitating women’s use of midwifery services
• doing more to meet their needs and expectations
• improving the quality of care they and their newborn infants receive.

- Evidence so far shows that midwifery care provided by midwives is cost-effective, affordable, and sustainable. Around the world the return on investment from the education and deployment of community-based midwives is similar to the cost per death averted for vaccination.

- Quality improvements in RMNH care and increases in coverage are equally important for achieving better health outcomes for women and newborn infants. Investment in midwives, their work environment, education, regulation, and management can improve the quality of care in all countries.

- Efforts to scale up QMNC should address systemic barriers to high-quality midwifery— eg, lack of understanding of midwifery is and what it can do, the low status of women, interprofessional rivalries, and unregulated commercialisation of childbirth

For more information see the Executive Summary

Reference:

Mary J Renfrew, Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung, Deborah Rachel Audebert Delage Silva, Soo Downe, Holly Powell Kennedy, Address Malata, Felicia McCormick, Laura Wick, Eugene Declercq (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care The Lancet , Volume 384 , Issue 9948 , 1129 - 1145

Dr Tracey Cooper can be found on Twitter

What one group of mothers feels the National Maternity Review Team should know

I am delighted to introduce Helen Calvert, mother, play-group leader and campaigner, who positively supports parents and maternity services. Helen's post is number 5 of my #FlamingJune action for #MatExp, to inform the National Maternity Review team of key issues, and she actively sought out the views of parents using social media.  Thank you Helen! 

For the last 3½ years I have been running a Facebook group for mums.  What began as a way of talking privately to my “mum” friends has turned into a group of over 1,500 mothers across the country. 

 A desire to share some of the birth stories from my group was what first drew me to #MatExp and I have since become more involved in the campaign.  As one of her ACTIONS for #FlamingJune Sheena Byrom is publishing a series of blog posts about what the National Maternity Review Team should know, and she asked me to contribute.

 Last week I asked the group “what would you like the National Maternity Review Team to know so that they can improve maternity care for UK families?”  The group has no particular emphasis when it comes to birth plans or feeding choices – the only things we have in common are that we are mothers and we have Facebook accounts.

 What is important to us?  What makes a difference?

• Continuity of Care
• Individualised Care
• Presentation and Provision of Information
• Listening, Respect, Control
• Compassion and Communication
• Collaborative Working
• Postnatal Care
• Breastfeeding Support

 Continuity of Care

This theme was probably the strongest.  Women want to know the people who are delivering their babies, they are unhappy with having to explain their story over and over again and with receiving conflicting advice and opinions from a number of different birth professionals.  Group members talked about building relationships with their midwives, knowing the professionals helping them to give birth and getting to know a small team.  This is currently not the reality, with one mum commenting “I didn't recognise anyone at the birth”.  Some families are choosing homebirth precisely because the homebirth team available is a smaller team and it is more likely that they will know the community midwife who attends their labour.

 Continuity throughout pregnancy, birth and the postnatal period is what women are so keen to experience, but even continuity and consistency whilst in hospital would be a step forward.  One group member explained:

“I feel continuity is a major factor too!  I was on a lot of strong painkillers postnatally and every time there was a new shift they questioned why & wouldn't give them to me until they checked (I was in agony by the time they came around again crying in pain!). Then they’d realise a consultant had ok'd it. I felt like they didn't read notes well & looked at me like I was a druggy! So knowing your patient prior to seeing them could be a good one / better handovers?”

With birth being such a personal and individual experience, and with very few women feeling comfortable discussing their mental and gynaecological health with a stranger, continuity of care can only improve outcomes.  As one woman commented:

“Without continuity it's so hard to build a decent relationship with your midwife, and therefore it's just not easy to be open with them and they with you. I think it's vital for mums.”

 Individualised Care  

As a partner to continuity is the idea of care being provided with the individual in mind.  The current feeling is that there a “boxes” pregnant women are forced into, and once you are in a “box” your care is structured accordingly, with little thought to your individual circumstances, personality, fears and wishes.  An understanding of what is important to that particular family can make a huge difference to their maternity experience.

 “...the midwives there (Ashford Hospital) knew that I was gutted I'd not got my home birth and so they basically recreated a home birth atmosphere for us (dimmed lighting, blankets, left us alone together) it was an altogether lovely experience and didn't feel high risk at all.”

Individualised care is even more important when a family have been told that their baby is seriously ill:

“I didn't fit into any box with my first born due to his antenatally diagnosed exomphalos (and postnatally diagnosed diaphragmatic hernia). Antenatal classes were all relevant but I felt so aloof. Who is giving birth at x? Who is giving birth at y? If complications arise you'll go from x to y so if you want to have a look around y then book that in (then we were shown round hospital x). But poor old me couldn't put my hand up as I was being induced at hospital z. Also in the breastfeeding class, no consideration was given to breastfeeding a baby in NICU. I had to speak to them at the end. And they didn't know much. We didn't fit in. Maybe specific antenatal classes for people in our boat at specialist centres would be better than the ordinary ones?”

Presentation and Provision of Information

Mothers talked about having to seek out information for themselves, and having to ask “am I allowed...?”  Antenatal classes were discussed and it was suggested that they focus more on birth as a normal bodily function and how hormones and environment play their part.

One message that came through strongly was that families would like to be given their birth notes as standard.  It is so important that parents can understand what has happened to them and to their baby.  Finding out that baby was back-to-back, that you had a PPH, that there were complications that made physiological birth unlikely – all of this is important for women and surely it is their right to know these details?

“For me the one thing I'd like to see change is for everyone to be given the option of having a copy of their notes when they are discharged from hospital. In hindsight, I felt like a bit of a failure after the birth and I was so fearful of giving birth again. If I'd known more about what had actually happened I'd have realised that I did blooming well under the circumstances. It was only after support from others on this group that I pushed to get access to my notes and I finally gained a bit more confidence.”

Listening, Respect, Control

Many women discussed feeling as though the midwives had not listened to them – had dismissed their pain, had questioned their stage of labour, even questioning whether their waters had really broken or whether they had wet themselves.  These women felt patronised, belittled and ignored.  There were also examples of women's concerns being dismissed leading to serious health complications for them and their babies.  Feeling as though they are listened to and are in control of their own birth experiences is very important to women. 

“I know both my pregnancies and births were full of complications, but there were still opportunities that I feel were missed, that could have given me more control and allowed me to lead my labours more effectively.”

Compassion and Communication 

The experiences where compassion was lacking were, for me, the hardest to read.  The language used, the way that some women are spoken to, the way that some are treated – at this vulnerable and important time – never ceases to shock me. 

“When I threw up I got told off for not using the sick bowl which was in the bathroom. To clean it up she took the sheet from the bed and swirled it round with her foot and left it all on the floor.”

All women deserve compassion and understanding, but this is never more true than when a woman's notes include the information that she has been a victim of abuse

“The matron I had post-delivery was very damaging - especially as I've been abused and find physical contact difficult. She would literally pinch my nipple into my baby's mouth and leave me not caring when I said it hurt.”

When care HAS been compassionate and communication effective, this is what the family remembers.  Women spoke about their midwife putting them at their ease, being someone they could talk to about anything, being patient and giving hugs and reassurance.

 “I know it’s a day-to-day thing for midwives to see women in labour but it isn't a day-to-day experience being in labour.”

Collaborative Working

There was some discussion of how midwives and consultants work together, and how this can be improved.  Women want to see the knowledge of these two groups combined, rather than used as a tug of war between professions.  What is most concerning is those women who appear to be caught in the middle of professional disagreement:

“My midwife and consultant openly disagreed on my treatment, to the point where the midwife told me she didn't agree with him and he was wrong and she refused to carry out the treatment plan he had recorded on my notes.”

Postnatal Care

Very few women had poor experiences antenatally, but postnatal care is the area most cited as being problematic.  The lack of time that midwives have to help with feeding and to give advice, especially to first time mums who will be anxious about things the midwives might see as “minor”, e.g. how to cope with the cord stub whilst changing nappies.  Many mums felt abandoned postnatally – after all of the preparation for birth, classes and discussions, once baby arrived they were alone. 

Two issues came through strongly:

 ·       The problem of fathers and partners being sent home from postnatal wards

·       The handover between midwives and health visitors

 “On the first night of OUR baby being in the world he had to miss it coz he wasn't allowed to stay.”

“I was solely responsible for baby after going through labour and I needed his support.”

“The handover to health visitors needs to be much slower and more gradual. With my first, I felt I'd barely given birth before I was shunted over to some other service that I had barely heard of and certainly didn't understand. I didn't have any faith in myself and was in no condition to form a trusting relationship with some new random professional.”

Mental health was also discussed, with one mother explaining that the noise on the postnatal ward made it impossible for her to sleep, and this sleep deprivation coupled with anxiety led to postpartum psychosis.  “Someone should have noticed my deterioration and tears.”

Breastfeeding Support

As always, breastfeeding support was said to be lacking.  Families are sent home too soon without a full feed being observed, and are then often readmitted or switch to formula feeding due to weight loss, nipple pain or a lack of understanding of what are normal breastfeeding patterns.

“All I wanted was for someone to just stop and really talk to me and address the issues, someone who ACTUALLY knew what they were talking about in terms of breastfeeding, not someone who was just going to come in to try and patch over the issues and tick me off as job done.”

I hope that these views from a range of geographical areas and different types of women are of use to the National Maternity Review Team.  I hope that ordinary, extraordinary and everyday maternity experiences can help to change childbirth in the UK.

Helen Calvert 2015

Follow me on Twitter! @heartmummy

What the national maternity review team should know: a mother's opinion

This is the second post in my #FlamingJune #MatExp action.

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Women want to be given unbiased evidence-based information to enable them to make informed choices about their care.

Women want to be treated as individuals.

 Women want to be at the centre of all decisions made about their care.

Women want to be listened to.

My name is Michelle Quashie, and I'm a mother. I'd like to share my views.

We all know that any pregnancy may present with 'risks', but it's important that these risks are not the main focus, and that the women's feelings are considered. The label "high risk" can makes women feel like a disaster waiting to happen. It can create a mindset filled with trepidation, fear and anxiety. This can have a negative effect on women’s emotional wellbeing and that of her baby. Risk is associated with many factors during pregnancy, i.e. previous caesarean, age, gestational diabetes, high blood pressure, multiple pregnancy, previous miscarriage, previous pre term labour, foetal presentation, post dates, growth of baby, infection, BMI, the list goes on and it can be quite daunting. When a woman has this label her care is often consultant led ensuring that medical support is in place as a precaution.  This is great, but it is so important that every woman has equal midwifery input into her care to balance the woman's needs. The word ‘midwife’ means ‘with woman’ we must not forget this and its importance. Even though there may be need for medical assistance we must not forget that the women is at some point going to give birth and will need the support of a midwife, her knowledge of childbirth and her care. This combined expertise of midwife and doctor, if needed, ensures that the risk and benefits of choices are considered, but it also helps to maximise safety and a positive birth experience. 

The label 'high-risk' can make women feel like a disaster waiting to happen....

Society needs to trust a woman's ability to give birth, to acknowledge and respect her intuition and instinctive ability to understand her body, and to feel confident about its capabilities. We should encourage women to use their voice and question or discuss any concerns they may have.  The focus of maternity care needs to ensure it is truly women centred. At booking, a woman should have the opportunity to discuss her plans for her pregnancy and birth. Opportunities to discuss fear or trauma in the past, whether it was result of previous pregnancy or a life event that could affect her ability to give birth should be identified, and appropriate support offered.  A doula or ‘one to one’ care could be offered, as continuity of care is linked to better birth outcomes.

Birth should not be approached with trepidation, but with knowledge, understanding and support. .

Every pregnancy should be treated as a new journey addressing problems if and when they arise, whilst carefully considering previous history. By identifying women’s needs and wishes early on, care can then be tailored to her needs. A woman who feels in control is better at digesting information and is more able to have open discussions, and build trust and respect for those caring for her.  Birth should not be approached with trepidation but with knowledge, understanding and support.

Birth has become very medicalised and Caesarean section rates are continually rising. It is often discussed in the tabloids, and by organisations such as the World Health Organisation. So what is being done to resolve this? I believe that perinatal metal health disorders, particulary postnatal depression, has increased in line with the over medicalisation of birth. Whilst no one disputes that a healthy mother and baby are a primary outcome, a mentally traumatised mother is not a healthy mother, and physical well-being is not the only parameter to be measured. 

It would be great if the maternity review could address this and put some real action in place to reduce Caesarean rates, and ensure interventions are offered only when medically necessary, and after  full, unbiased consultation with the woman.

My opinions are based on my own experience, but are similar to that of many women I liaise with on a daily basis. I hear stories from women across the country, who have very similar themes to my own maternity experience.  My story can be found here. 

In brief, here are the elements of my care that left me feeling disempowered, vulnerable, and sceptical about the birth ideology and what it represented.

- At booking in I was labelled high risk, trepidation set in and from that moment I felt like I was a disaster waiting to happen.

- My care was consultant led so I didn't have any midwifery input into my care plan.

- My birth wishes were denied due to 2 previous c sections even though reasons for these sections would not necessarily occur in third pregnancy and there was no robust evidence to deny my request.

- Care was given based on carers personal perception of risk, no discussions regarding my own considerations regarding risk perception took place.

- My previous surgical notes were not accessed or considered when decisions about mode of birth were being discussed instead the mode of birth was made on a systematic belief.

- Access to services like the ‘VBAC’ clinic was denied due to care givers personal views and labels accorded to me.

- Information given to me was biased focusing only on the risks of birth. The risks of third and fourth surgery were never spoken of even when I raised this as a personal concern.

- Birth discussions did not happen until 36 weeks leaving very little time for planning to take place and for any questions that I had to be explored. This proved to be very stressful and pressurising.

- I was booked for surgery without my consent even though I had expressed I did not want surgery.

- I had called ahead and tried to discuss this with the midwife on the phone but was told that it was my consultant who would make that decision. (Feedback that I have received in response to telling my story at midwifery training events  is that sometimes midwives feel they are not supported by their peers when wanting to support women and her wishes when they are outside of the norm? “On your head be it” is a phrase that has been used.)

- No consideration was given to my emotional well being during discussions that focused on risk.

- I was told I could die leaving my children motherless, which was very upsetting, and made me question my mental health.

- No one responded to my request for help and support, and I was told that they had never experienced anyone give birth after 2 C sections.

- Fear based practice was evident, as a result my individual needs and wants were neglected.

- Interventions were offered to reduce risks without any discussion regarding alternative options. Information should have been given to enable me to make informed choices.

- My ability to birth was constantly questioned and doubted. This made me feel inadequate and less of a woman.

- No consideration was given to my future life plans; I was ridiculed for mentioning them and reminded to focus on here and now.

- Risk of uterine rupture was constantly focussed on and described as a major catastrophe, yet women are being offered induction daily with this possible risk not being highlighted in such a way?

I consider that ignoring my wishes, scare mongering and the emotional blackmail that I suffered were all breaches of the health professional codes of conduct, and guidance on interacting with patients. Regulatory organisations state that a patient’s informed choices must be respected, even if the individual professional is not in agreement. Some health professionals feel they can simply ignore the requirements of their regulating organisations and violate legal and human rights. Are there any plans in place to address this as part of the Maternity Review?


Here are the elements of my care that made me feel empowered, happy and confident:

- Previous pregnancies and complications were not considered a threat to this pregnancy.

- I was told that 2 previous c sections did increase my risk but even though the risk was there, it was small and put into perspective alongside risks to surgery and future pregnancies.

- Midwifery support. This was absolutely key to restoring my strength and emotional well being.

- I was able to openly discuss the risk and the benefits of a vaginal birth with the main focus being on me as the individual and my own perception of risk. Consideration was constantly given to my feelings and my wishes. I felt respected and empowered and in control of my body and fully supported.

- A consultant obstetrician who discussed risks and benefits to both surgery and VBAC. The conversations were very balanced and open,  and I felt that I was supported either way.

- Impact on my future pregnancies were also discussed and recognised as an important factor to consider.

- The consultant midwife attended the consultant appointment with me, supported and contributed to the discussions. I was at the centre of these discussions facilitating real 'woman centred' care. Our unity was my maternity experience.

- I left these appointments feeling informed, supported, happy and empowered as I was able to make educated choices about my care.

- Faith in my body and my ability to birth were never doubted. I was given some great advice on active birthing, what to expect and the physiological changes that would happen to my body were fully explained so I really felt that I understood birth.

- My midwife discussed oxytocin, and its important role in birth so in turn encouraged me to be happy.

Just sitting having these lovely, very womanly discussions were so important. I felt excited to about giving birth and grateful that I was being given the opportunity to experience it.

All women should feel empowered, in control and supported during pregnancy and birth.

It is a very vulnerable time for women and there is no way out. Consideration should be given to the woman’s emotional well being as well as her physical needs. It is not about 'allowing' or 'not allowing'; it's about considering, facilitating and supporting.

Experiencing birth has truly been life changing for me. The positive effects I am experiencing have been overwhelming and surface in some way on a daily basis. I want all women to have the best possible chance of having a positive birth experience and I hope the National Maternity Review does too.

You can follow Michelle on Twitter @QuashieMichelle 

What the national maternity review team should know: action for June

Baroness Julia Cumberlege

The news that a national review of maternity services in England was going to take place, led by Baroness Julia Cumberlege, was more than welcomed. The process is now underway, and information of the progress is filtering through, and more is eagerly awaited. 

I am hopeful for the future, given the growing body of evidence, data from surveys, national policy documents, and feedback from those who use and deliver maternity services. Being an avid user of social media, I am regularly in the centre of discussions about childbirth, and most importantly, I find myself reading blog posts of detailed stories and accounts of childbirth written usually by women who feel compelled to share their experiences. I also read about wonderful maternity care celebrated by staff working in nurturing environments, and other less positive revelations of over-worked demoralised maternity workers, usually midwives. I’ve written before about the ever-increasing opportunities of social media, and the virtuous circles that can emerge when childbearing women and their families, and all those involved in providing maternity services come together to enable change. But action is needed, and those members of the maternity review team, tasked with collating evidence and opinion, will be looking for ways to enable this to happen with efficiency.  There are processes in place for individuals and organisations to provide feedback to inform the review process, and the team are planning more ways of engaging with interested parties. 

So, in the month of June, I invited guest posts for my blog from individuals who felt they have information or ideas to offer the team. The first post was by the dynamic duo Gill Philips CEO of Whose Shoes?, and obstetrician Florence Wilcock, who together have developed an ever expanding and inclusive #MatExp dialogue via workshops and social media. Gill and Flo are working so hard to try to influence the way maternity care is delivered....here is a reflection of their first year! 

 

WHAT ARE FOLKS SAYING?

Then came the rest... one post by mother Michelle Quashie, who had a vaginal birth after Caesarean section, inspirational student midwife Hannah Tizzard's views of evidence and practice, Victoria Morgan, who is developing the 'Every Birth a Safe Birth' methodology,  Helen Calvert asked lots of mothers what there views were, mother and campaigner Leigh Kendall, who tragically lost her baby boy Hugo aged 35 days, and Natalie Meddings, doula, has given us an insight into her antenatal group choices for place of birth! 

If you would like to write a post too, please contact me here and I'll get back to you....