Place of Birth not a Choice anymore?

Below is the AIMS response to the shocking statements made midwives and barristers at the RCM conference regarding women’s right to choose where they give birth.  http://www.rcm.org.uk/midwives/news/choice-not-an-option-for-some/

AIMS response:

“At the Royal College of Midwives Annual Legal conference midwives were told ‘that women can’t insist on a home birth if the NHS doesn’t have the capacity to provide it’ (Barbara Hewson, a leading barrister) and that ‘A woman’s right to choose must be constrained by the art of the possible,’ (Lorna Muirhead, past President of the RCM).

The following is AIMS response:

‘Choice not an option for some’

If the argument is that ‘Choice of birth is not an option for some’ then perhaps we should be arguing that choice of hospital birth is not an option for fit and healthy women who want to be delivered in an expensive obstetric bed.  The research is quite clear.  Obstetric units are less safe for low risk women and babies.  The women run an increased risk of avoidable interventions and surgery and the babies are, for example, more likely to be exposed to drugs that seriously affect their ability to breastfeed .  Sadly, comparative studies of home/hospital outcomes do not include mental health; if they did, we suspect the advantages of home would be even greater.

While the law in this country restricts supervision of birth to midwives or doctors there has to be, therefore, a balancing responsibility of the profession to provide a midwife when asked.  If the profession wishes to change this law by giving itself the right to refuse attendance then it should be open to anyone to provide midwifery services at the birth – roll on lay midwifery; the alternative is abandoning women who birth at home to birth alone without any professional attendant.

It is irresponsible to suggest that hospitals should be able to withdraw home birth provision, it puts women at risk unnecessarily.

Furthermore, Laura Muirhead also reveals her lack of understanding of normal birth.  ‘Students are only exposed to normality. When qualified and they need to interpret CTGs or cope with a PPH, they can’t.’ Students are not ‘only exposed to normality’ indeed, they rarely see it.  What they see is a continuous stream of women subjected to a wide variety of interventions that pervert the normal progression of labour and it is no wonder that 30% of them end up with a caesarean section.  Suggesting that ‘if continuous monitoring is right for a woman, then we can’t give her the choice not to have it’ reveals Lorna Muirhead’s worrying and erroneous assumption that interventions can be imposed on women .  To do so is an assault, and it is illegal see http://www.aims.org.uk/?Journal/Vol24No3/editorial.htm
Beverley A Lawrence Beech

http://www.rcm.org.uk/midwives/news/choice-not-an-option-for-some/

Infant Loss, Inequality and why things should change

I went to a workshop  a couple of weeks ago about ‘Inequality and Infant Loss: Identifying the gaps in women’s networks’.

I learnt that the UK rate for infant mortality is 4.1 per thousand. But for Caribbean Women it is 9.7 per thousand, for Pakistani women it is 7.4 per thousand, for African women 7.4 per thousand and for teen mothers 5.4 per thousand births.

I also learnt that in Bradford and Airedale the only risk group that get caseloaded midwifery are the teen parents.  Their normal birth rate is 94%.

The highest risk groups in our city do not get caseloaded midwifery and we know this is affecting outcomes.  And outcomes are not just statistics but human beings lost and unnecessary grief and suffering.

One to One Midwifery came to Bradford and Airedale offering women caseloading care on the NHS with evidence of great outcomes elsewhere. They are being prevented from operating in our area because our local CCGs are both refusing to commission them or pay the invoices on non contracted activity.

At the same time local Trusts tell us that they cannot at this time deliver one to one midwifery care even to the most vulnerable and at risk groups in our city – except teen parents – who need it most.

These UK infant mortality rates reflect our experience in Bradford district over several years and I am saddened and disappointed that the people who have the power to make a difference – without paying extra  – are currently choosing not to do so.

Is there any one there who will answer?  Who will do something that will make a difference?

One to One Midwifery: How things can change

Belinda Phipps CEO of the biggest UK wide charity for parents NCT sets out the barriers to achieving one to one midwifery care on the NHS and how it can change to enable the maternity care we all want.

The question is:  why is it proving so difficult for CCGs and Providers to deliver one to one care, and why is there so much opposition to commissioning other providers to deliver the care?

In addition to the answer given below she has offered to work with CCG commissioners here and in other parts of the country because she says there are ways and means of working within the NHS rules, inappropriate as they are at the moment, to give acute hospital providers the flexibility they need to deliver one to one/personalised, continuity of CARER.

Belinda Phipps, CEO of NCT over to you:

I think you know that it is proving difficult for the NHS itself to offer or to buy in proper one to one care with a midwife you know and trust because

1)      The health service including commissioners don’t accept/understand how important continuity of carer is to women and what health benefit/cost reductions this can bring over all to the NHS. If you want to help them understand add your voice to this campaign   http://www.m4m.org.uk/

2)      The heath service cannot, with in its current system rules accommodate case-loading in a sustainable way that is acceptable to most midwives

3)      Fairness is an important NHS value and a service that is “unfairly” better and reaches only a minority of women is difficult for commissioners to take on.

I think first we need to change NHS rules:-

In England the new risk based PbR (Payment by Results) will not work any better than the old activity based one.  We need a system that is truly based  on results ie outcomes for the woman and her baby.  We need to pay when women are satisfied with their care and when babies and mothers come through pregnancy and labour whole and healthy with the mother feeling ready to start her role as mother.

The old PbR (Payment by Results) system paid by activity.  The more activity you did as a hospital, the more you got paid, the more complex activity you did the more you got paid. It was based on the principle that C-Section costs more than a normal birth so the payment for this would be higher, using the principle that the price of an activity is the same as costs, because the NHS is non profit making.  However the actual cost of a C-section for instance is not known and the payment for it does not necessarily bear any resemblance to what the procedure actually costs in reality.

However, in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost as above does not work because the building, equipment and staff need to be available even if the C-Section is not done.  So there maybe little difference in cost for a Trust between a 15% C Section rate and 25% C- Section rate in terms of costs to them.  But they rely on the income often to fund the fixed costs for other services and so any fall in the election rate means they cannot cut costs because so much of it is fixed so start to have financial problems

This means a ratchet mechanism operates which drives the C-section rate up irrespective of clinical need.

The new PbR system allocates women at booking to a risk category ( low medium and high) of course there is now an incentive in monetary terms to allocate women to a higher risk category to  raise income levels delivering more women into the Consultant led system.

What would work is a payment of x per birth ( where x is total cost of maternity in UK minus necessary admin costs not borne by providers divided by number of births) with a deprivation payment per woman for those from the most deprived postcodes ( bit like the pupil premium).  This should be paid per birth and the provider take the risk.  Effective providers  would benefit by making sure they did all the preventative work they could to keep births simple.  There would have to be a rule that says the woman chooses the midwife and then irrespective the provider cannot refuse care (they would have to pay for others to provide complex care if that became necessary).  However this would require the NHS to break its mental rule of cost=price at a treatment level.

This would also work better than the block contract approach.

Another option is to give the woman the budget – and I like that option too.

In concert with this, the capital changes have to be changed from a charge on space (as now) to a charge on people (a capitation charge) so the payment has to be made irrespective of treatment location which would remove the drive to treat people inside buildings in acute trusts unless this was clinically necessary.

You know I think CNST (the NHS litigation insurance payment system) and its equivalents in other countries needs to change so that prevention and watchful waiting is rewarded with lower fees and that the focus is not only on being safe during intervention however necessary or unnecessary they are.

Then there is the whole business of care being carried out in organizations where the governance and the building is aligned. They don’t need to be and a system set up across trusts with the service and governance alighted rather like clinical networks with teeth would probably work better, certainly for maternity.

Case-loading without the rule changes above is only a  partial solution to this dilemma and is difficult to sustain because of the above.

NCT ONE TO MDIWFERY HOW THINGS can change 1

It starts to address this problem of women being left alone in labour and stressed midwives caring for may women because the rostering pattern almost never matches the number of women in labour.  It can’t be done like this, so the system needs changing.

NCT 121 midwifey blog 2

I am happy to offer whatever support I can though I think NCTs optimum skill is getting attention paid to these rules so they change for the better and make it possible for women to have a midwife they can get to know and trust who is there fore the pregnancy, labour and birth and afterwards.   if you want to help join us http://www.nct.org.uk/get-involved/become-nct-member

Best wishes

Belinda

Belinda Phipps

Chief Executive

Thankyou Belinda!

And don’t forget the Airedale Mums Petition for One to One Midwifery http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/