Freestanding Midwifery Led Units in Shropshire: at the sharp end of the debate

Notes from ‘Questions at the Shropshire CCG Board meeting’ 13th December 2016

Those who know me well will understand the commitment of turning out before 8am to drive somewhere (and back) on my own for the first time – I got lost with the help of two SATNAVs today but just managed to slip in on time to the Public Board Meeting of the Shropshire CCG.  I was there because the brilliant Gill George campaigner for the Ludlow Maternity Unit and small hospital had encouraged mothers and others to attend and ask questions:  she wanted a commitment from the CCGs to ensure their contract with the Shropshire and Telford Hospital Trust (SaTH) maintained the freestanding midwifery units (FMU) and all the maternity care they provide to local women in a large county.

The front row was taken by a cluster of Mums with their babes and toddlers – giving a dour meeting a lightness of touch and sense of humour that was much needed.

The first part of the meeting was questions from the public, and the first part of this (clearly planned) were questions from the Mums.  The first Mum stood up saying she represented a small fundraising charity for local midwifery units and all the Mums in the area as there were concerns that the maternity services at the Midwifery Led Units (MLUs) were going to be cut and indeed threatened.  They wanted the Midwifery units to be open 24/7 and offer the postnatal care and breastfeeding support they currently do.  SaTH have announced they will close the MLUs – of which there are three – Ludlow, Bridgnorth and Oswestry – at night, this will also end Postnatal stays and 24 hour breastfeeding support.

Her actual words were that the Units were going to be turned into Birthcentres – clearly implying this was a bad thing.  It is a shame that such a term in this area has become synonymous with cuts to the very services that Birthcentres represent to many of us in other parts of the country.

She described her own ordeal of being transferred by ambulance across Shropshire to hospital but not making it and having to give birth in a layby en route.  She believed that this would happen more often if the services of local MLUs were reduced so women had to travel significantly further during labour.  We know that the least safe place to birth is at the road side.

She described how in just a few days her Save Ludlow Maternity Unit Facebook page had got 1100 members and that there was a successful march in Ludlow on 3 rd December.

She gave 4 reasons for keeping the MLUs:

  • Research shows that most women labour during the night (Thank you Alison for that painstaking work over decades!)
  • Most Midwives live a significant distance from the MLUs, so there could be delays if women arrive in full labour at the unit before the on-call midwife can make an appearance.  And what if more than one woman births on the same night?
  • What would be the impact on breastfeeding rates if the units reduce their care?
  • Finally, she described how constant threats to the service and lack of investment in it reduced midwives’ morale.  Good midwives will leave the service was her message.

A second Mum stood and spoke.  She quoted the NICE  Intrapartum Care Guideline reminding the CCG board that planned birth for low risk women in an obstetric unit raised the rate of C-Sections in this group. That MLUs reduced instrumental delivery, raised normal birth rates and so on.

She also described the important role in breastfeeding the MLU in Bridgnorth had provided.  She described how they supported her breastfeeding and she only went home once she was confident.  She had found this invaluable.

Gill George then stood up and asked some incisive questions demonstrating she knew the politics and financial situation in detail.  She along with the Mums asked the board for the same thing:

We want the CCG to commit to funding for continuation of the current rural maternity service and units (Bridgnorth, Ludlow and Oswestry) and to get this written into their contract with the hospital trust – due to be signed by 23rd December. (We also want them to guarantee consultation before they allow any change to the service – but mostly we oppose the cuts!).

I always say that asking the question is more important than the answer you receive.  On this occasion it really was not the case.  The CCG iterated its position that safe good quality maternity services were a priority.  The dire financial position of the Hospital Trust and the CCG was stated but we were told that SaTH had not approached the CCG about reducing or changing its maternity structures. This was a significant point because SaTH have already announced that they are closing the MLUs at night in effect changing the service provision.

The speaker pointed out that there was an issue that women were choosing to birth at Hereford and have their postnatal care at Ludlow – but the tarrif money for the postnatal care had not been retrieved.  I recalled a similar difficulty between Calderdale and Bradford and decade or two ago!

Gill George pressed for rural maternity services to be in the contract signed on 23rd December and that there would be public consultation before any changes were made.  And what would be the chances of this being signed off on 23rd?  ‘Optimistic’ came the sad faced reply.

Here I am inserting Gill George’s notes of the answers to her questions at this point which she kindly sent to me on reading this blog:

Q: Will rural maternity services be in next year’s contract with SaTH (the hospital trust)?
A: Yes.
Q: At the current level of service?
A: We’re in discussions with SaTH.
Q: Are you expecting this to be possible?
A: I’m very optimistic.

This was from the Head Honcho of Shropshire Clinical Commissioning Group, in a meeting this morning. It’s possible that we’re getting there. We also got something that came very close to a clear commitment that would be consultation on any ‘substantive change’ to maternity services.

The floor was opened to further public questions – most of which were about cuts to services.  This is clearly a well rehearsed session with the players all knowing each other and their roles.  There is a sense of frustration from the public side as they fight to keep valued health services and exasperation on the board side desperately trying to balance books with one of the lowest budgets per head of population in the country.  There is a massive deficit and the prognosis is £15 million pounds worth of cuts to be found in 2017/18 by the CCG.  There was a short stunned silence at that point: there is no choice was the message we will have to cut valued services – there is no money.

The chair of the board said at one point to the public – you are the electorate you need to elect a Government that provides money for the NHS you want.  This said in a county that returns Conservative MPs and has the lowest financial settlement per head of population.

Finally I stood up and as light relief invited the board and everyone present to the SaTH supported conference – Implementing the National Review in Rural Areas:  Better Births in Shropshire and beyond #SaTHFMU

I mentioned its impressive speaker line up (including Baroness Cumberlege, Prof Dennis Walsh, Cathy Warick and Kathryn Gutteridge).  I left programmes on the table and the response was that someone from the board would probably be there.  Listening to the discussion it could be a good thing.  Here is the link if you want to join us:  https://www.facebook.com/photo.php?fbid=1372545286097059&set=gm.151748551970104&type=3&theater

Meanwhile in the foyer the local reporter was interviewing the Mums about what they said.  No opportunity wasted by these Mums to ensure the survival of their community maternity care.

A CCG with no money, with services costing more than their budget, a Hospital Trust with no money and running at a deficit (as are the majority of hospital trusts in England): the quality of all health services are threatened – A&E waiting times grow, dementia and other care is not getting the investment needed, Maternity care in rural areas threatened.  There are no easy choices here for the CCG Board and I would not be in their shoes for half of all England with no power but to dispense the national Government agenda of cutting heath service costs to this population – dressing it as efficiency does not wash.

In this context it can feel easier to cut low tech low cost services to protect the high cost, high tech, highly qualified services.  But as Alan Brace points out in my blog : Why is it so Difficult to Implement Continuity of Carer, it maybe the low cost services people actually need and it won’t save money to funnel more people into high cost services who only needed a low cost service.  This is the case with Maternity care in special degree – why send healthy young women across a vast county to birth in a high cost obstetric unit when they can more cheaply and safely birth at home or in a midwifery led unit? But if you have made a capital investment in a new Obstetric unit as SaTH has done – it has to be paid for by a higher throughput of women.  Read Belinda Phipps analysis in my blog: One to One Midwifery: How things can Change, of why Trusts may not save money by promoting midwifery led care.  In Austerity NHS, medical-based evidence may come second to a real terms reduction in NHS budget and whoever shouts loudest wins – so shout!

To support those campaigning locally for Shropshire MLUs join the Facebook group : https://www.facebook.com/groups/1219003658173471/

To join in a positive discussion about Freestanding Midwifery Led Units in rural areas and implementing the National Maternity Review for rural populations come to the fantastic Conference Chaired by Baroness Cumberlege 13th February for just £35 at the Shropshire Conference centre.  More info here: https://www.facebook.com/events/151748521970107/

 

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Review of the “Celebrating Continuity, Rhetoric into Reality, Policy into Practice” Conference

The 13th April brought us “Celebrating Continuity, Rhetoric into Reality, Policy into Practice” a conference created through a collaboration between AIMS, RCM, The Positive Birth Movement, Neighbourhood Midwives and a Birmingham NHS Trust.

So many exciting themes came out of the conference, together with discussions of common concerns and their solutions.  One quote from Beverley Turner underlined the whole of the day, “Women should be utterly supported throughout birth, and never just “winging it with a stranger”.  I would equally say that midwives should be able to support women through birth having clearly understood their needs and wishes via a relationship built through pregnancy, and not left just “winging it with a stranger”.

An interesting comment from Baroness Julia Cumberledge, following a question by Ruth Weston of Aquabirths, addressed the frustration of so many campaigners that CCGs were unaccountable, even to Monitor.  She announced that she was working in a team which was developing a new framework which, if accepted, would give the power to evaluate CCGs and influence their practice.  This could be transformational for continuity campaigns where CCGs are refusing to implement what is safest, cheapest and gives the best outcomes for families.

There was an important reminder at this conference that maternity is not just about getting a baby out, but at it’s core, it’s building Healthy, Happy Families.  It was noted by Professor Lesley Page of the RCM that within caseload models of care, we see a reduced level of child protection intervention.  While child protection falls outside of the maternity tariff, and is therefore not considered as an outcome of good maternity care, it is likely that it means that continuity of carer under a caseloading model leads to better bonding between parents and their babies, and a stronger family into the future.

One fear raised by an audience member was that midwives would be on call for weeks on end, and that was unsustainable, and indeed this is a concern that worries many.  The response given was that there are many necessary models of midwifery, and there is space for all needs, including shift work and midwifery teams.  Indeed, it was pointed out that fragmented, busy labour wards where midwives can’t take a break is leading to midwifery burnout all over the country, not only with our qualified midwives, but the trainees, too, as shown in this heartwrenching Facebook post which went viral recently.

A combination of talks and workshops, this event was hugely informative and inspirational.  Looking for positive ways to work on the implementation of continuity and caseloading, addressing the concerns and questions that came up, and reinforcing the message of support for each other.  A fantastic day with fantastic people, the conversations are continuing and the changes will happen!

Facebook: https://www.facebook.com/groups/celebratingcontinuity/

Twitter: #continuity2016

Report by Emma Ashworth

What is so difficult about Implementing Continuity of Carer?

Here is the script for the AIMS talk I gave at York University on Saturday 21st November. What do you think?

What is so difficult about delivering continuity of carer?

We thought we had made it in 2013 when the NHS mandate stated that maternity services must
“ensure that every woman has a named midwife who will make sure she has personalised, one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”

We have the empirical data now, how birth reduces miscarriage before 24 weeks, reduces prem labour and still birth. We know midwifery care from someone you know and trust care reduces the perception of pain, we know that intervention and instrumental deliveries are reduced and so on. And we know that women who have it want it again – they know the difference and want that relationship. We also know that it does not need to be just one midwife – one midwife is really important but actually two or three midwives is quite do-able for a woman to trust and relate to. Sandall talks of up to six midwives in her research being very clear about that: this is NOT 121 care she told a conference. But it is also not a parade of strangers walking in and out of your birth room with no connection to you, no investment in your wellbeing.

WE had the evidence, we had the policy, but implementation has got stuck every step of the way.

I think a good analysis of the nature of our dilemma is summarised in this clip from Yes Minister. The Department of Administration is implementing a national integrated databased. Jim Hacker the new incoming Minister is trying to ensure there are safeguards for individual liberties built into the database. But he is struggling to get anything to happen. He decides to go and talk to his opposite number who had held the post before the election. Here goes:

So what are the tactics of obstruction? :
1.  Administration is very new – there are alot of other things you should be getting on with
2.   Are you sure this is the right way to achieve it?
3.   It is not the right time – for all sorts of reasons
4. Practical Problems
• Technical problems
• Political problems
• Legal problems
• Administrative problems
5.   It is too late – there is not enough time before the next election

‘They will stall at every stage and will do nothing unless they are chased up.’

I would suggest this is why we are struggling to delivery continuity of carer. There are a range of technical financial and practical difficulties to be overcome. But if we sit down and work them through there will be a solution. However, this does not happen, challenges are thrown at us mixed together in a mishmash of politically motivated, genuine difficulty, emotional stuff and indifference to the issue.

Using Yes Minister as our starter for 10 let us look at some of the genuine barriers to implementation and what some key strategists say about them, look at a positive example of change and the key factors that could work elsewhere, before looking at what went wrong in Yorkshire – to think what could be done better. Finally what we can do.

Practical Problem: Strategic Finance: The money is not there to sustainably deliver this kind of care.

A couple of years ago Beverley Beech invited me at short notice to a consultation meeting at the House of Lords with Baronness Cumberledge and miraculously I could go! There I met Belinda Phipps then CEO of NCT. We had a good conversation – especially after I admitted that I had planned my question on the train down! My big question was – why are providers and the CCGs seeking to block any shift towards caseloading when the evidence base is so strong. I took notes on her answers turned them into a blog post with her approval and you can find it today on Born Stroppy. I would commend it for reading but here is an exert:

… in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost … 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 CS rate means they cannot cut costs because so many of the costs are fixed. This can result in 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 thereby 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 of CNST should stop being solely about being safe during intervention – without regard for how necessary or unnecessary it is.

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 aligned 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.

It is a huge chunk of stuff to take in – so spend some time on the blog – but it is absolutely clear that there are some big barriers to caseloading, here in the often archane structures of the NHS. which align buildings with healthcare, and pays for activity rather than health. This means cutting your C-Section and raising your HB levels may not save you money – even though on paper it should. It may explain that whilst Birthplace say FMUs work financially, they are still being closed down.

These issues are real but CAN be tackled and overcome – in the case of Birmingham Women’s below the finance issue was turned on its head as the Provider and CCG acknowledged that capacity and finance should DRIVE them to low risk women having homebirths and births in MLUs.

But first let us listen to the voice of a Strategic Finance director in Wales tackling big financial principles behind the financial policies:

Alan Brace Finance and Procurement Officer, Aneurin Bevan University Health Board, Wales. Health is a devolved responsibility in Wales.

Alan started with a photo of the gaping jaw of a crocodile: with costs going up and funding going down and the gap between the two widening. Our new focus he said is not the 5 million pounds we were planning for but just 1.1 million pounds to spend. And differently in Wales to England – the cuts come earlier and harder here.

Listen to this: Alan said: People get tired of the pressure to save money all the time. Traditional cost cutting strategies destroy value in health. And he said – I don’t want a job where all I do is cut peoples budgets. More than this he said: Ill health costs the NHS money – alot of money. – so how do we DO value in healthcare?

He was NOT talking about maternity specifically at any point during his talk but listen to his questions/comments:
How do we do value in health care?

Do we use expensive staff for low level work? Do we do tests not because they are clinically necessary but because it is protocol? Compliance with care Processes rather than focussing on what is needed can prevent improvements to care – and ill health costs the NHS money. Here are cost reductions that do not require cuts in quality – quite the reverse they may improve outcomes.

He said as an NHS we focus too much on the technical ability of clinicians but really we should be focussed on outcomes – the difference the care is making not on the Doctors ability. For instance Matin Kinik measured the variation amongst surgeons showing outcomes and results – and the variation was disturbingly great. Should we not be asking ‘what difference will this procedure make to the patient?’ And ‘what techniques have the best outcomes for patients’? Because ill health costs the NHS money.
We don’t know what makes the difference to patients says Brace. We tend to cut low cost care thinking we are protecting high value care- but maybe we are not. Low cost care was actually what was needed. On Radio 4 a couple of weeks ago a GP commented that a practice had got rid of their asthma nurse to save money and found that their costs actually went up because they were now referring into hospital far more often. Brace himself, gave the example of his elderly infirm mother whose health improved under the care of careworkers and deteriorated markedly in the care of highly trained, highly paid nursing staff.

And so we need meaningful cost knowledge so we can make proper value judgements – and we don’t have that knowledge at the moment, we don’t know the true cost of what we do.

Ill health costs the NHS alot of money, so improving care to reduce ill health will reduce its costs. And we need to use the most efficient practices and the low cost staff to do that.

This analysis is done in Wales in the context of the Eniron Bevan Commission set up by the Welsh assembly and reporting to the health minister. It looks at all reforms to ensure that the NHS remains recognisable to the principles of its founder – publically owned and free at the point of care.

When we turn his perceptive gaze upon maternity care: do we find healthy women in high cost facilities being cared for by over qualified expensive staff – and having worse outcomes there than healthy women cared for in dirt cheap homes or in MLUs by much cheaper staff? Are we subjecting healthy women to a barrage of tests and measurements which efficiency and evidence do not support – Michel Odent in Birth And Breastfeeding says so. Does medical process trump what is needed and wanted by women in the care of women in many institutions? Are we focussing on the qualifications of the clinician rather than asking what difference are they making to the outcomes? Are we cutting low tech cheap staff delivering breastfeeding support and continuity of carer thinking this protects the high value Obstetric unit – without analysing the true cost benefit of doing so. Does cutting continuity of carer and breastfeeding support really save the NHS money in the short medium or long term?

Being me I did put my hand up and say – this would all apply admirably to maternity care where midwifery led care is shown to promote normality and save lives and cut NHS budgets. He smiled wryly: in maternity the fight for restructuring care was not financial but in other places. A culture for instance that sees a unit ‘downgraded’ to midwifery led, and turkeys very definitely refusing to vote for Christmas. Nevertheless, Alan Brace has surely given us a moral and economic argument for implementing caseloading relationship care. The barriers to change are not necessarily here.

So let us inch our way closer to the political and cultural issues that enable or prevent continuity of carer by looking at how policy has changed in Birmingham as FMUs and a homebirth service have been set up with sustainable funding.

The story of the Homebirth team at Birmingham Women’s from the NCT Birth place Conference in June 2015

The information here is culled from 3 talks at the NCT Birthplace Conference in Birmingham in June: from Dr Tracey Johnston, Consultant Obstetrician and until recently Clinical Director, at the Birmingham Women’s Hospital, Diane Reeves Accounting Officer for Birmingham South Central CCG; Sarah Noble Midwife lead for Birmingham Homebirth Service
A homebirth team had been mooted for a long time in Birmingham, Dr Tracey had been involved in several failed attempts to set up a homebirth team: the barriers had been too great. But now these barriers were coming down:

• Finance and tariff issues. Significant change:- introduction of more granular tariff
• Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ And the lead clinician was clear that the Birth Place Survey had provided the incontrovertible evidence that enabled them to convince their colleagues.
• Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership to do this.
• Increasing population, young city, high birth rates issues of capacity – In the circs would it not be easier to do more of the same?
• Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to women not satisfied (promised service not happening). Not promoted as a result.
• GPs wary and unconvinced about having such a service:

There are some points worth unpacking further:
1: The finance issue: the pct had turned down the HB team proposals several times over several years but the argument was now turned on its head from ‘we can’t afford to’ to ‘we cannot afford not to’:
Tracey said: ‘the birth rate increase projections give us a capacity and financial time bomb, and therefore we should not be clogging up expensive obstetric beds with healthy low risk women – the safest and cheapest place for them is home!’
2. The HB team was not given an bottomless budget, but given start up costs and the maternity tariff, with 3 years to break even. AT 240 births it is a realistic target with a realistic turnaround time in terms of increasing HB numbers in the population. In their first year they were on track to sustainability in the three years. So this is not another Airedale MAMs or Better Start programme in Bradford: in Birmingham the funding is there forever and sustainability is built into the scheme with a saving to the Trusts being made.
3. Interesting are the objections from the GPs and how this was tackled – remembering that the CCG is a membership organisation. GP survey was circulated in July 2013 and 42 surveys completed. The main concerns were, medications, GP attendance, Transfers into hospital, new baby checks. The Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers or have to do the baby checks. They were worried that they would be responsible if things went wrong when they had no control over those things. It was Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings as well as good practice – like what midwives do.
Tackling the concerns of the GPs with real information, peer to peer advocacy for GP colleagues brought the GPs on side. And 12 months into the service none of the GPs concerns have been realised.
4. Tellingly the CCG lead Dianne Reeves, the GP board lead and the hospital clinical lead ( Tracey Johnston) were all women with personal experience of homebirth (one of them against clinical advice) and so they worked together to convince their peers, and increase homebirth in the area as a public health good as well as a real option for women. I think that here, Personal experience, emotional connection to the issue as well as robust clinical evidence gave these people a commitment to its availability for other women. Could this be what is missing in our Yorkshire commissioners and clinical leads?

Key success factors here
• Evidence, data, choice and capacity issues created a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
• Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
• Non recurrent spending requirements- initial pump priming ie To get the results and the savings long term, initial investment had to be made.
• Work to promote it to GPs- Peer to peer education seemed to be key. Plus educational events, GP networks
• MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place. This is a message to the battle weary MSLC reps amongst us.
• “Big social conversation” engagement events- reaching diverse communities. Community participation not a top down approach. Making sure the service meets women’s needs.
• Strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

And Dianne Reeves stated that they were Commissioning for Quality all round here

• Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
• Continuity of care is important: 3 or fewer midwives through whole package of care. The head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway. This actually meets the criteria of continuity in the Sandall Research.
• Breastfeeding rates 75%. Current rate at discharge is 80% so high BF rate is expected and being delivered
• Incident reporting and monitoring – this has to be as rigorous as in a unit
• Diversity of users – not just for hippies. Sighs.

Message to everyone out there:
• Build sustainability into your business plan
• Strong cross professional leadership needed. Key here was GP leadership.
• If it fails this time around keep pushing: its time will come.

In this example, the key elements for success were:

• Clinicians – doctors with personal experience/sympathy in key positions
• Evidence of high quality – Birthplace
• Financial and capacity imperative –
• Careful and painstaking teamwork bringing key gatekeeping groups on board ( eg GPs and women and their families).
• Long term Financial sustainability built into the package

Interestingly – and pertinent to our discussion- women are at the end of the process, they are being persuaded to make this choice now the HB service is in place. Evidence rather than demand is the driver in promoting the service to women – demand is being created for the good health of women and babies – which also saves the NHS money!

So my question, in the light of this example –

What is missing in Yorkshire (and elsewhere) when it comes to implementing the strong evidence for continuity of carer in clinical practice?

Pause for discussion and questions.

So in the light of all this positive stuff: What went wrong in Yorkshire?

That has been my question for the last 2 years. What is missing in Yorkshire – not the evidence, not the finance – is it the leadership? Is it the vision?

Here is an account I wrote 2 years ago about what happened whilst I was chair of the MSLC in the thick of it. Remember, we are trying to tease out the learning points from this negative experience. See what you make of it – what is missing in Yorkshire?

Women and organisations serving the most vulnerable women in our area were throughout my tenure as MSLC chair (2009- 2013) saying at every MSLC meeting: we need personalised care, we want personalised care, we are concerned that the Trusts are saying they cannot deliver it, we are concerned that independent midwifery is not going to be an option for those of us who are willing and able to pay for it and so our choice of having continuity of midwife carer will be entirely gone. There was no response from the outgoing PCT nor the incoming CCG. The Trusts said basically (and I am paraphrasing here) with all due respect ‘no way can we deliver this kind of care’, One Trust despite all the evidence said that women did not want this kind of care when asked. I have the minutes, letters and emails to back me

As chair of the MSLC I invited IMUK and One to One Midwives to talk about their models of care and what they could offer the NHS. I spent months setting up a meeting between One to One Midwives and the PCT/CCG at the time to discuss the possibility of this care in the poorest wards of the city, with the most vulnerable women, where infant mortality is unacceptably high. I was stone walled, patronised and ignored. They only engaged with me seriously when I started publishing the letters and emails they had sent me on my blog in May/June 2013 . . . .

All change

Then, on April 1st the world changed – and after 20 years it really felt like that! I missed it because I was on holiday!. I came home to a pile of emails. One to One (North West) Ltd had set up in Bradford. Due to the amount of interest generated, an information day had been planned. The women’s networks were hot with the news – at last independent midwifery on the NHS, at last the quality of care we had all been wanting and waiting and working for over so many years! I turned up late to the ‘drop-in’ session to find well over 100 women there complete with babes and toddlers. Tea, coffee and water had run out and there was a desperate need for a microphone! No one, least of all One to One had anticipated this interest. It was the Who’s Who of women and midwives in our region: NCT teachers, doulas, La Leche League leaders, student and experienced midwives, a couple of commissioners squashed in alongside some breastfeeding mums and burgeoning bumps. The place rocked. We were excited – at last women could choose mother centred care on the NHS and it would not cost the NHS any more money. Indeed as the invoicing was retrospective it would save CCGs money, with all the future benefits and savings that One to One’s excellent results show.

In the weeks that followed, the One to One presence in Bradford went from one midwife to five, driven by the number of referrals coming in. Women told me of their relief that at last they had a midwife who listened to them, supported them and worked out a pathway that enabled their wants and needs to be met – woman centred care!

But the good times did not last for long. One of the Trusts in our area and the CCGs were absolutely furious that One to One had begun working in the area without invitation. Although the issue had been raised at MSLC meetings, although I had written many times and asked for meetings about the delivery of continuity of carer, particularly to the 300 most vulnerable women in the area, we were told that this advent was a complete surprise, they had no notion it was going to happen. To tell the truth, I had had no notion that it was going to happen on April 1st but I had been saying for months, even years, that this was going to happen at some point. No one was listening!

So there was a huge row. Heated meetings between CCGs and One to One (North West) Ltd. The CCGs refused to pay invoices. Without any consultation with the women involved (where is the woman centred-ness in all this?), for reasons I cannot understand, and flanked by providers (which in itself surely constituted a conflict of interest), the regional division of NHS England backed up the CCG/provider alliance against women’s choice, and against One to One Midwifery (North West) Ltd. They said that women were free to refer themselves into the service, and One to One were free to deliver it, but the CCGs did not have to pay the bill! Have you heard anything so ludicrous? I run a business – that is not how business works, if it is OK for women to choose a service then it is OK for the service provider to be paid.

At a stormy MSLC meeting in July women were told:

• That they were mistaken in their choices.
• Why would a woman want to choose this service when they had so many options already available to them.
• Women do not know what they are choosing.
About One to One Midwifery they said:
• how dare they come in and destabilise our service provision.
• how dare they come here and not ask our permission first.

My only response could be, “Women should have a right to make the choice of their carers. Women do not have the choice of one to one midwifery care in the current provision. Don’t women have a right to choose their care?” I just had to repeat it over and over again – because they were not listening.

The two ordinary mothers there – both of them attending for only the second time: were intimidated by the attitude of the provider and CCG representatives. One mother said nothing at the meeting but facebooked me to say:

“I felt very intimidated after the meeting and it caused me quite a bit of stress.
I don’t really understand what the meeting is for if service users can’t describe their experience of the service, it’s providers and how they felt about it. . . . As a service user who would be described as high risk with ‘alternative”’choices, I am very attracted to what the One to One midwives are offering as I already know Bradford and Airedale cannot accommodate all of my needs, for example a named midwife.
I was at the One to One open day in Bradford the other week and the impression I got was One to One wanted to listen to my needs and accommodate me. I did not get this impression from the MSLC meeting, more that I had to fit in with what the care providers are offering, like it or lump it. Doulas and all. There was no room for discussion and the meeting was not the place for it. – you can quote me on that”

Providers and commissioners did not want to listen to what women wanted, they did not want to hear the reasons why women wanted to choose One to One midwifery care. At the MSLC meeting their voice was devalued even more when commissioners and providers said that they did not want to hear the voices of the kind of women that come to the MSLC! The CCGs are currently on the lookout for ‘ordinary women’ who do not go to MSLC meetings. They want to find out if women really do want One to One care in our district. There apparently is not enough evidence to prove women want women-centred care and they are not going to act on the medical evidence such as the Cochrane review alone – not for this clinical decision anyway.

I was told by the CCGs that:

• They don’t want a dead baby on their hands.
• Local care pathways between One to One and Trusts had not been set up and would not be set up. Both Trusts have care pathways for women with independent midwives and one Trust has set up specific care pathways with women with One to One midwives.
• Care pathways are a condition of being commissioned but being commissioned is the only way these pathways can be set up – a circular argument to keep out competition.
• I have a dossier of cases of women who say they been bullied by one of the Trusts because they have chosen One to One midwifery rather than the Trust to deliver their care.
• One to One midwives have been victimised and verbally abused by employees of some providers when attending births or hospital appointments with women.
• Both NHS providers say they cannot and will not deliver one-to-one care to women by 2015 if at all – and say that women are telling them they are happy with their care.
• then they said it is a national project and so our CCGs cannot do anything until the whole nation agrees to do something.

And there was I thinking that the CCGs were set up to be closer to their population and to commission on behalf of that population for the good of that population – not for the good of the providers. And there was I thinking that the Government policy was about choice, about women being able to make the healthy choice of having one mother one midwife care. It hurts, it hurts mightily because I really did not want my experience of care 20 years ago to go on being repeated today. I wanted my daughters to have a better quality of care than I received from the NHS.

Where things are at now

I am not on the inner circle now and exhausted had to take a step back for a while. It is very interesting as I am at the hub of a maternity network – how little I get to hear!. But here are some key points.

1. Solicitors letters have gone back and forth for years. The Commissioners continued to refuse to pay 121 Midwifery Northwest, Monitor and NHS England did sod all to ensure payment or continuation of the service women were demanding and One to One eventually had to withdraw from Yorkshire.

2. Local women were going to their GPS asking to be referred to One to One Midwives for quality care and their GPs were turning them down. It took some digging and an FOI to get the letter from the Commissioners – which basically raised a list of serious concerns all of which would be met by passing a CQC inspection which they did. Not one GP checked with CQC regarding safety of practice. The CCG letter was a cynical roose I believe to ensure no GP would refer a woman to One to One. GPs told women (and the letter implied) that they could be responsible for paying for the service out of their own budgets – GPs did not know that their referral OBLIGED the CCGs to pay – hence the letter to put them off!

3. Monitor received complaints from a local service user group about anti-competitive practice – tributes here to Airedale Mums once again. They agreed with the complaints and letters went back and forth but NOTHING ACTUALLY HAPPENNED TO CHANGE ANYTHING.

4. Meanwhile every month at my homebirth group women complain that they still cannot choose One to One midwifery. Most don’t complain about their current midwives per se but they are not getting relationship care, nor are the midwives!

5. One further thing about this saga. As I say, I had spent months trying to get a meeting with the CCGs leads trying to bring together people for a conversation about delivering continuity of carer to the most vulnerable women in Bradford – the ones at greatest risk of losing their baby for instance. I had not got anywhere. When One to One arrived in Bradford and were having a significant impact senior managers demanded a meeting with me to discuss various conflicts of interest. I probed and discovered that they were saying that I had been advocating for 121 Midwifery because I was being paid by them – not because quite stupidly I might want implementation of medical research for the betterment of women and babies – Lord No! I wrote a letter refuting this and calling it out and sent it to everyone I could think of – all the MPs, Beverley Beech Belinda Phipps, if I had an email address I sent it. It ended that line of personal attack on me. Notice the tactic of ‘don’t play the issue play the woman’! – That is an episode in Yes Prime Minster called ‘man over board’

I did however agree to the meeting. I took in a colleague from the MSLC who would become the new Chair. I was to play bad cop (as they already had the black hat firmly on my head) and she was to play good cop. It worked like a dream for the future of the MSLC. When it came to One to One Midwifery the Commisioner wanted her say and I was all ears: She lambasted One to One Midwifery but then said that by the end of 2015 they would ensure that this care was delivered to women in Bradford and if the local providers could not do it they would commission an outside service. That was 18 months ago. We are still waiting.

So I went to the 2015 BRI AGM and asked for the details of this fantastic service which women had been promised by the end of 2015 and so should surely be celebrated. That was September 16th – I received the response this Tuesday 17th November, 2 months later. And here it is:

From an acute provider perspective we have discussed models of personalised care over a long period of time. We have taken note of the evidence, the outcome of the stakeholder event  held at the Trust last year and also the commissioners’ views

 Following the evaluation of the MAM project in Airedale our commissioner asked us to pilot an alternative personalised care model as although the Airedale pilot evaluated well from the women’s perspective there were unexpected pressures on the MAM team.

 This new project in Bradford Better Start area focuses on enhancing ante/postnatal care, continuity of care, all women in the project knowing and seeing the community midwife regularly.  Caseloads are much smaller than usual and The midwife is the key  care coordinator and contact for all women on the caseload.

 Continuity of care throughout ante and postnatal periods is a focus (which tends to become lost in projects including intrapartum care)  We are aiming for a maximum of 2 midwives ante/postnatally.

 We are  not aware that a case loading option involving intrapartum care  was promised to all women and we need to do the pilot to evaluate the model and plan sustainability. As we have highlighted previously there are no Trusts in the UK where ‘one to one’ style care is a universal offer as it is complex and expensive to roll  to roll out across a whole service; there still needs to be a core hospital based services and this has to be staffed as well as the case loading teams. This is why we have decided to use the chosen model as a pilot.

So what went wrong in Yorkshire? Lots of things that is for sure. And that question is one for our discussion – alongside the more positive question: what do we do differently in Yorkshire to get a different scenario? But in the light of the previous stuff we can pull out some ideas:

• A lack of vision and leadership over several years – we don’t have peer to peer mentoring on this issue within and across professions
• This is not a priority for CCG commissioning, nor local Trust provision. This has not been something to be worked towards.
• Key people do not believe this is deliverable and so despite the great need chose not to engage with anyone with a different view point
• There was a lack in partnership working therefore across sectors, people who should be working together are viewed as competitors, women’s demands for this care are seen as threats – labelling ordinary women as hippies and ‘those kind of women’ once more devaluing our input so that they don’t need to regard it.
• Geraldin Butcher at the RCM conference said: New Zealand Midwifery only flourished after identifying with women and actively involving women in decision making.

And if Monitor had teeth and NHS England had backbone and the NHS mandate was a serious piece of policy to be implemented rather than a ‘nice to have’ maybe things would have been different. And if we had vision and leadership from those with most power and influence in the system rather than kicking it into the long grass with another Maternity Review – things may have shifted because good quality maternity care – continuity of carer- is an investment in health that saves the NHS money whilst saving baby’s lives and women’s health. Remember ill health costs the NHS alot of money!

So what do we need?

We need cando leadership– looking at the barriers to change whether it be GP attitudes, Midwives burnout or financial constraint- and instead of using them as reasons for inaction, sit down and work out a way to overcome the barriers. Example after example I have found across the UK shows that with the right attitude barriers to implementing new and improving services – including continuity of carer – have a solution: The biggest barrier is the willingness of leaders to take this challenge on.

What needs to change and what can we do?

We need vision and leadership in Yorkshire and so we need to seek out allies and friends in Trusts and CCGs and other organisations and we need to recruit clinicians, commissioners and HOMs with vision and commitment to making this happen. We need to find the Diane Reeves, the Tracey Johnstones and so on, of Yorkshire – we need people to stand up to the plate and play their part as we play ours. We need visionary midwives with ideas and plans and strategies, with courage and audacity to make them happen. We need MSLC Chairs and reps who just keep the subject on the agenda month after month, year after year, passing the baton down to the next generation until it happens.

And we need activists, many many activists, mothers, doulas, birthworkers who keep asking for care they don’t get, keep complaining, keep writing letters, keep asking questions at public meetings, keep raising the issue in ‘consultations’ and Reviews, keep organising and marching at demos. People who will talk to women about good birth and good care in supermarkets, in toddler groups, at the school gate, in the cafes and pubs, on Radio, on TV in social media and in the newspapers. Women and men who ensure that the demand for quality maternity care is never off the agenda and that every mother father and grandparent knows the difference between the care they are getting and what they should have.

I was in despair really writing the end of this talk because what difference can I make? After all the effort I and others have put in – what has been the result?: Our daughters getting the same care as we had! Then I watched Chicken Run and watched Ginger try over and over and over again to escape the chicken farm – not just herself you understand – that would have been relatively easy – but EVERY CHICKEN ON THE FARM!. And after every failure there was always another plan, another idea. She was tough and she persevered – but boy! did I cry her tears when she sat wondering what they were going to do next.
I have no big promises and prizes to offer you today, but I am not giving up – and I hope you won’t – because our daughters deserve better and so do we!
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How to Commission a Homebirth Serivce – by a CCG Commissioner

Notes from 2nd July NCT Birthplace conference, Birmingham Medical School

Diane Reeves Accounting Officer for Birmingham South Central CCG:

Commissioning a Homebirth Service

These are a mixture of my notes of the presentation pulling points from the power point slides. I have labelled my comments clearly and where I have lifted slides the extra speaker comments are in italics from my notes. Italics can also denote my interpretation of what was said.

For the full slide presentation and recording go to: http://www.nct.org.uk/professional/events

Personal story –She was present at the birth of her sister in 1965, and 3 years later with her younger sister she ‘giggled’ through the birth of her brother. Diane is a GP by profession and has 4 children. Three were born at home, one against medical advice.

Comment: in her talk this experience and understanding clearly influenced her work as a clinician in this area and she was open about the fact that it had. She said that she convinced her peers with medical evidence, but her personal experience was what kept this as a priority and kept her pushing with her CCG colleagues. It also helped that her Commissioner colleague for maternity services at the CCG was a GP who, along with her siblings, had been born at home. They both felt that peer to peer discussion was what worked in pulling this off.

It was clear from Diane’s presentation, her colleague the commissioner in the audience and the senior Clinician speaker earlier in the day that there had been a number of them convinced of the need, and wanting to set up, a homebirth service in Birmingham, however, the barriers had been too great until now.

Key barriers were:

  • Finance and tariff issues- introduction of more granular tariff
  • Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ
  • Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership.
  • Increasing population, young city, high birth rates- links to capacity – easier to do more of the same?
  • Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to patients not satisfied (promised service not happening). Not promoted as a result.

GPs were also wary and unconvinced about having such a service:

What were the GPs concerns about the service?

GP HB survey findings

GP survey circulated in July 2013

42 surveys completed

Main concerns:

  • Medications •Attendance – •Transfers •New baby checks

Comment: Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers. Thought they would have to do the baby checks – but midwives can do it. Worried be responsible if things went wrong when they had no control over it. Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings.

W hat made it succeed:

  1. A cross section of convinced and committed professionals pushing for it over a long period of time. Doctors, midwives, women.
  2. Peer to peer advocacy important.
  3. Building sustainability in terms of finance and numbers is important right from the start – the service had to work on the Maternity tarrif alone – this has been a problem with past projects.

What made it happen? Key success factors

  • Evidence, data, choice and capacity issues creating a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
  • Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
  • Non recurrent spending requirements- initial pump priming . To get the results and the savings long term initial investment has to be made.
  • Work to promote it to GPs- educational events, GP networks Peer to peer education seemed to be key.
  • MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place
  • “Big social conversation” engagement events- reaching diverse communities (but BSC patients only at present) Community participation not a top down approach (more of this in another presentation)

I would add strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

Commissioning for Quality

  • Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
  • Continuity of care is important: 3 or fewer midwives through whole package of care. Another presentation by the head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway.
  • Breastfeeding rates 75% – high BF rate is expected and delivered
  • Incident reporting and monitoring – this has to be as rigorous as in a unit
  • Diversity of users – not just for hippies

Diane showed a video of an interview with South Asian couple. They could not understand this thing about being given toast after the birth. She said ‘Why am I being given warm bread? Is it some kind of ritual?’ Remembering the cultural aspects of communication and birth!

Sustainability and where they are at: 240 births is the breakeven point for sustainability and in their first year they are on target to meet this point within three years. For equity however the HB team needs to be rolled out across Birmingham. Also, HB team in first year – none of the GP concerns have been realised!!!

Message to everyone out there:

  • Build sustainability into your business plan
  • Strong cross professional leadership needed. Key here was GP leadership.
  • If it fails this time around keep pushing: its time will come.

Homoepathy for Pregnancy and Childbirth: An Introduction

Homeopath Abi Briant-Smith came to Bradford Choices last Tuesday and kindly wrote up her talk so everyone can enjoy her introduction to homeopathy for childbirth.  Here it is:

It was great to meet up with the group last Tuesday. We covered quite a lot of information so here’s a summary of what we covered with some links to useful online resources.

Homeopathy is a 200 year old system of medicine that uses highly dilute substances to trigger the body’s own healing process. It is based on the principle of “like cures like”, so a substance taken in small amounts will cure the same symptoms it causes if it was taken in large amounts.

Homeopathy is used by over 200 million people worldwide, with around 6 million users in the UK. It is evidence based and is safe to use for babies, during pregnancy and whilst breast feeding.

During pregnancy is a great time to discover the benefits of homeopathy. Anxiety, irregular contractions, labour pains, exhaustion and post birth healing are just some of the issues that women use homeopathy for during and after their labour.

As homeopathy is a holistic form of medicine the best results are experienced when a remedy matches what the person is experiencing both emotionally and physically. If using remedies during labour I would recommend a birth partner gets involved as a labouring mum to be will be too busy to think about which remedy she might need!

In terms of taking a remedy – find one that best matches the symptoms, take one remedy and notice what happens. If symptoms have improved or are still improving don’t repeat the remedy. If the same symptoms as before start to return another dose of the same remedy can be given. If new or symptoms start to appear a different remedy may be needed that matches the new symptoms. Some remedies may need to be repeated frequently and symptoms may change as labour progresses so a change in remedy may be needed at different stages. For long term or recurring symptoms I would recommend seeking advice from a qualified homeopath. Expert medical advice should always be sought in serious situations or if complications arise.

My top recommendation would be to have Arnica as part of a childbirth kit as most women will benefit from a dose of Arnica after giving birth. It can really help relieve sore muscles, swelling, bruising and after pains, particularly when the abdomen/womb feels really achey.

Arnica 30c is available from many pharmacies and health food shops. I recommend taking 1 dose of Arnica 30c three times a day over 3 days, or 1 dose of Arnica 200c each day for 3 days. This remedy can also be crushed and given to the baby if labour was long, they are bruised or have had forceps delivery.

If you would like more information about using homeopathy during childbirth I run childbirth consultations for expectant mums and their birth partner. I also run workshops for doulas and midwives. Please get in touch if you would like more details.

The link below covers some of the remedies commonly during labour:

http://homeopathyplus.com.au/labour-and-birthing-remedies/

For other issues such as morning sickness, haemorrhoids, constipation and post-natal care the link below has some useful remedy suggestions:

http://www.homeopathycenter.org/pregnancy

Abi Briant-Smith RSHom

abibriant_smith@hotmail.com

Facebook: Abi Briant-Smith Homeopath

07970 067049

Dreaming and Practice: Notes from Midwifery Today Conference 2014, Bury St Edmunds, UK,

midwifery today conf 2014midwfery today conference 2

Midwifery Today Conference May 2014, Bury St Edmunds

These are some notes taken at the conference but they are really only a small representative sample of the practical workshops, seminars and main sessions attended. Most of all I met strong, inspiring courageous midwives, working sometimes against the odds , for good birth.

The strongest memory: Outside in the dark watching an amazing fire eating display by a midwife.

Quote of the conference: ‘I’ll give myself a treat and go and have a pee.’ Sara Wickham: “Having a pee is not a treat!!”

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Jan Tritten and Robbie Davis-Floyd – International Activism

Jan Tritten’s Introduction:

Quote Harriet Tubman ( the anti slavery activist):

“Every great dream has a dreamer”

Barriers to YOUR dream include: Fear – the antidote to this is Faith

Answer the call – stories of women around the world who have felt a call to midwfery and have had health and other problems until they answered the call.

  • Lies and myths are rampant
  • But we have dreams and callings to follow
  • Birth is sacred ground
  • We are called to a calling to change childbirth and to the benefit of both women and communities
  • What is YOUR dream/vision?
  • Don’t share dreams with negative people
  • Take first step then next step – implement your dream one step at a time
  • Dare to dream and dare to do it.

Participants in the workshop shared their stories:

NZ Chair of Council of Midwives shared their work in Bangladesh setting up midwifery led birth practices with good effect.

Midwife in Philippines told her story of being called by the local Bishop to set up a clinic in the Church because of his concern for the health and wellbeing of local women ( the hospital care was not good enough)

She talked of the importance in her practice of trusting the Higher One she also said that ‘what you believe can be done’

Robbie Davis-Floyd talked about the IMBCI and the 10 steps for implementation of mother/baby human rights.

She talked about the 4 demonstration sites about the world. the full stories can be found on the IMBCI website

One is in Brazil, in a hospital which has now become a ‘high risk’ hospital for high risk women in the region. Even so their CS rate is 25%. Every woman there has a doula.

Then the amazing story of Mercy Mission in the Philippines with their birth centre in a poor district ( recently flooded they piled the beds up on top of each other so women could birth out of water and midwives wading in the water – coz women still coming to birth!)

They set up a maternity clinic in the disaster zone last year, in tents, with no water, no electricity and no sanitation, women traumatised and lacking food and essentials – but still implementing the IMBCI 10 steps.  they maintained their 2% CS rate even within this situation. Amazing work – worth looking up.

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Fear in Midwifery and Birth Workshop by Eneyada Spradlin-Ramos and Elena Piantino

Fear is not necessarily a bad thing – it can be a signal that a change is taking place, a call to pay attention, of the balance being changed. Fear is not necessarily a bad thing

Richard Davidson of Harvard re mindfulness – be aware of changes within yourself and room.

@ finding homeostasis for the brain
Homeostasis is the brain in equilibrium/balance. A perceived threat or stressor upset s homeostasis our balance – there is a response eg- fight or flight or fear. Then there can be a process of adaption to a new homeostasis.

In some contexts, the adaptive process makes midwives immune to situations (eg in a medical hospital context on large busy labour ward) that can upset or hurt women – midwives can act without compassion because they have adapted to their context and no longer feel the stressors and fear.

Fear alters our perception of risk and danger and it numbs empathetic responses
eg. homebirth – perceiving risk where evidence does not
decision making effected by emotional stress

Antonio Damasio, Neuroscientist found that brain damaged brains that cannot feel emotion also cannot make a decision.  He said: ‘Every decision is made with a cognitive balancing and tipped by an emotional factor.’

Fear affects labour – blood for fight or flight goes to arms and legs but not for thinking.  No blood to womb so contractions go off, fear tension pain cycle.

Coping with fear/uncomfortable emotions –

Short term coping mechanisms are:

Keeping busy, withdrawal, distraction and parties, letting off steam on other people (shouting and intolerance), expecting and working for the worst, abuse of substances etc.

Positive coping mechanisms:

Recognise triggers, know difference bet feelings and reality
Be aware re feelings/fear: is it history and memory ( what happened last time), is the fear coming from another person in the room, or what someone has brought into the room from elsewhere?
Emotions – is fear coming from in me, of from outside
Express/feel emotions, acknowledge and accept them – not block or repress them.

Other coping mechanisms: journalling, art therapy, red tent sessions ( safe spaces to share feelings without judgement or advice).

Red Tent specific experience:- talking stick. With stick – talk not interrupted. People can and do cry – but nothing said, no advice just accepted.

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Twins  – with Jane Evans

Notes pick up when Jane is talking about nutrition:

Everything is the same more but more!

Tweak the diet because pregnancy is not the time to completely change diet all at once.

Mums need plenty of protein for growth; Vit B and Vit C – via whole grains and meat.  Complex carbs via beans and pulses.

Problems in pregnancy is often to do with liver problems – 2 babies twice the stress on the liver. So beans and pulses needed. If Mum not into lentils – suggest brown rice once a week as ‘medicine’, also soya, quinoa etc. As an aside: This is why students survive for years on beans on toast – cheap and nutritious. all there to support liver.  Mums need to drink plenty of water.

Salt is important: good sea salt. Himalayan pink salt. Can test if woman low is slat ( sodium?) give her glass of water with half, the teaspoon of salt – if she not taste a glass of water with salt in it then she is low on sodium. Also if woman eating crisps and chips etc. say they are needing salt so instead of eating crisps and chips and processed food add salt to their food instead. found that having enough salt in diet/body reduces swelling odeoma and incidence of pre-eclampsia.

Make sure eating iron. if not meat eating make sure getting it anyway.

Nutritionist in group said: they have worked out woman needs 300 calories extra over normal diet when pregnant, breastfeeding need 500 calories extra. It will be more for twins – up to double? Tweak diet and change it gradually.

Keeping woman safe and healthy through the pregnancy:

Not just check haemoglobin. also look at mcb, hcb .  Reason Eg. You can have normal haemoglobin but low ferotin and have problems mcb 70-99 normal so don’t iron supplement. If symptomatic then check ferotin. to supplement, avoid pharmaceutical iron which has bad side effects and not easily absorbed – try spatone ( favoured) also floradix.   Food and nettle tea also suggested.

Tweaking diet gradually:  Eg.ple feel better after eating veg so encourage to eat more veg. This starts a good habit for feeding themselves and their children in the future.

32-34 weeks is the crunch point – at this point need to make a big issue of food. There is less room for food but need to be constantly eating – feeding the babies. If you can get through the 32-34 crunch time to get calories into woman and babies, then the pressure is off after and then they can eat back at normal pregnancy rate. If this is done then pregnancy normally goes to the natural term – whatever that might be.  Normal term is usually the length of pregnancy for her previous (singleton) baby. (One example:1st baby 40+12, twins 40+11 days)

Concern: Induction of twins at 37 weeks – why do this when infant mortality risk of twins is at 37 weeks – so why induce at this dangerous time. why not wait until babies are ready to come out?

Obstetric practice. Concern re serial scanning. Research show that the thing that scans do is restrict the growth of the baby – so routine scanning is not good for the babies’ growth rate.

Palpating is good. then scanning when it is needed – scanning: need it when need it but not for routine. Midwife should palapate regularly: you are saying hello to the babies so they know you & you know them. Ask mum what she is feeling. Check differing sizes and think if differences are normal or pathological eg could it be boy/girl differing physiology. If you have concern offer scan to check.

Position of Babies for Birth. ‘Twin babies dance all over the place’ – 2 babies move about more than 1 baby. For birth the most stable is head down head down – but they can move as birthing. Eg. first baby head down for birth, when 1st come out then other baby will change position to birth –  unless lying on back(obstetric method)then movement is restricted.

Leaving cord attached after birth of first. As contractions start for the second the cord starts closing down so cut cord and give baby to dad.

Timing between each baby – does it matter? Listen to the heartbeat if all OK – wait. For mum contractions usually restart after half and hour.so if baby ok why rush it? Heartrate (decelerations) can drop very low. if baby ok before prob ok – keep listening and if a continuing problem ( eg baby’s heart rate not pick up) then need to act. Between babies, cervix can pull in – eg to 5 cm but dilation is fast.

Placenta. Some women want to push out placentas.
Remember there is alot of placenta: ‘two handfuls of placenta’. Jane holds to cord of first baby ( which has been cut) as bearing down. Very satisfying to have one big one out. But often placentas will abut as one placenta can support the other. Placentas coming out separately not like as not know which one is which.

Remaining upright during births is what works – this point repeated several times.
About 25% of her twins babies have to have a cs despite their care.

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The following notes are from an unscheduled session so I do not have name of the speaker, however, the following was too interesting to omit!

Quote from Grandma Beatrice, South Dakota who told twins birth story. She said she washed her hands then moved baby so baby born safely. Asked how she knew what to do, she replied:
‘Mother knows how to give birth, woman knows how to help’

Working in a remote area in Afghanistan setting up maternity services
Talked about how women generally treated – photo of a man with a whip fighting women back trying to get food.
Early marriage – photo of woman who aged 15 got married to 70 year old man had 10 children, he now dead.
She went with French NGO, decided to work with traditional midwives as they are always there – ngos will leave
But then Afghan Government adopted US/CMU programme to get rid of traditional midwives and train new set of midwives. They worry: it will be white uniforms and hosp care and this not work in poor remote areas.
Talks about looking at US aid programme and traditional midwifery program and how we bring them together. Lack of life choices: Choice for these women is having access to ANY care or none

‘We want local women and mothers to be the experts not us. We are wary of coming in and telling them what to do and what is happening.

Inuit in Northern Canada. How to preserve the tradition.  Women not telling their story because they do not speak/write in English or other mainstream language.

Photo: This how women Inuit traditionally give birth, isolated in their own little hut/igloo. With fire in there. Very hot in there and steamy .
The amazing story of the Inuit people. Harrowing story of oppression and suffering. Then one community took birth back for themselves, replaced the medical man with a strong Anouk woman. Made decision not to continue the medical practice of taking the women away from their communities for 6 weeks around birth, to boarding houses by hospitals thousands of miles away. They knew that some women might die if they not travelled to city hospital for 6 weeks – but the disruption and damage to family and community life so great that the community decided to take that risk. However, outcomes vindicated their decision: although no immediate access to cs – 8 hours (until recently, now 2 hours) – their outcomes have improved anyway. The old prescriptive hospital model did not work for outcomes either!

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Sara Wickham – Homebirth Emergencies in Perspective

Sara Wickham’s session was excellent and way over my head as a lay person.  Midwives please do not use my notes as an alternative to spending time with Sara the expert!  Find her website here and book a session with her: http://www.sarawickham.com/

The more we deal in physiology the less likely we are to see an emergency. Also find that there are fewer emergencies the longer you are in practice Experience and normal physiology support safety.

Piece of recent research: proportion of cord prolapse associated with ARM
(2013) Results:  risk of cord prolapse at home is vastly reduced because the key reasons for cord prolapse above are not done in home/physiological practice. Research showed that as practitioners got better at supporting physiological 3rd stage then incidence of pph reduced. There is alos the question of measuring blood loss/defining pph.

Cases of ‘Safety Labour’ – women have a very long slow labour, eg. one case 40 hours because short cord and needed long labour to descend safely (and gave birth choosing lateral lie and leg up). Another example: slight heart defect and so need a long gentle labour – fast one would be too much.

Necessary Prep for Home emergencies:  which included making sure you had good backup, looking after yourself and making sure you had the right equipment checklist and rountines.

Other tips included, working with people you trust, dont’t fear fear doing the dummy run! Oh yes and be ready to ask for help or check stuff when you need to!

Why aren’t all emergencies equal.

Sarah’s Top ten tips for emergencies

Sarah then went through the research showing the incidence and circumstances of emergencies. Basing it on a homebirth caseload of 25 per year. Some of the emergencies on this baisis would be about once every 63 years! I was not able to get all the figures down but they were extremely interesting.

Eg. Incidence of pph in home environment based on 25 HB’s per year = 2-4 years; serious one every 5 years. This reduces with practitioner skill.

After looking at the incidence of main obstetric emergencies pertinent to the home environment, Sara said there were just three skill sets most needed regularly! So make sure you have these skills most practiced and uptodate
Other emergencies will happen between once in 20 and once in 50 years.

Sarah finally talked about her pph emergency kit which included the partner!

Birth is a human rights issue

Birth is a human rights issue! 

Here is the powerpoint presentation I am going to deliver to the 3rd year midwifery students at the end of my seminar on women-centred care tomorrow, Friday 17th January 2014.

Be part of making change happen, help us to change the way the wind blows!

Birth as Human Rights Issue

For patient safety and justice: a newsletter

For your information and interest.  Here is another organization fighting for justice with some relevant information for those of us working with maternity care as a human rights and justice issue.

The organization is looking for Trustees by the way.

 

WELCOME TO OUR LATEST UPDATE ON ISSUES CONCERNING PATIENT SAFETY AND JUSTICE

In this edition:

1   ‘DUTY OF CANDOUR’ STILL ON A KNIFE-EDGE

2   GOVERNMENT RESPONSE TO FRANCIS  MID STAFFORDSHIRE REPORT

3   DH AGREE TO ISSUE CLEAR GUIDANCE ON COMPLAINTS AND LITIGATION     FOLLOWING THREAT OF JUDICIAL REVIEW

4   THE ‘BIG GIVE’

5   AvMA IN THE NEWS 

‘DUTY OF CANDOUR’ STILL ON A KNIFE-EDGE

One of the measures announced in the Government’s response to the Francis report on Mid Staffordshire was a statutory Duty of Candour on organisations – something which AvMA has campaigned for for years.  However, as things stand, the duty would be limited to fatal cases and those resulting in ‘severe’ harm only.  In our view, such an arrangement would actually make things worse rather than better – effectively legitimising the cover up of all incidents deemed less ‘severe’ than this.  As a direct result of intervention by AvMA, the Secretary of State, Jeremy Hunt, has agreed to review this arrangement and consider bringing all incidents suspected of having caused significant harm (‘moderate harm’ and worse as defined by the NHS) within the scope of the duty.  Mr Hunt has asked Norman Williams (President of the Royal College of Surgeons) and David Dalton (CEO of Salford NHS Foundation Trust) to report back to him before Christmas.  He is worried that an ‘unintended consequence’ of including all incidents of significant harm would be to over-burden healthcare providers with bureaucracy.  AvMA has pointed out that NHS bodies already have a contractual duty to disclose significant incidents of harm, and have been practising “Being Open” guidance which also covers these incidents for years.  The Duty of Candour will take the form of statutory ‘fundamental standards’ for registration with the CQC.  Read AvMA’s briefing for more information on how the Duty of Candour should be framed.

GOVERNMENT RESPONSE TO FRANCIS MID STAFFORDSHIRE REPORT 

Jeremy Hunt delivered to Government response to the Francis report on 19th November.

AvMA is continuing to press for the statutory Duty of Candour on organisations to include all incidents of significant harm (see separate article).  We are also seeking to persuade Ministers that a creative drafting of the CQC regulations, which will encompass the new duty, could go a long way to meeting the objectives of Francis’s recommendations which have not been accepted.  For example, the recommendations for an individual duty of candour and offence of preventing others from complying with their duty were not accepted.  However, AvMA is calling for the organisational Duty of Candour to include a requirement to discipline or refer to regulators any individual who prevents the organisation from complying with its duty.  We are also asking for an explicit requirement on employers to support and train staff in complying with the duty.

Other recommendations which AvMA were disappointed not to see accepted include:

  • national guidance on minimum staffing levels (however we are assessing the Government’s alternative proposals, which Robert Francis QC himself seems quite content with)
  • regulation of healthcare assistants
  • ring-fenced funding and consistent national model for Healthwatch
  • regulation of managers.

The Government has made much of only having rejected 12 of the 290 recommendations.  However, a closer look reveals that many are only agreed ‘in principle’ or partly agreed.

DH AGREE TO ISSUE CLEAR GUIDANCE ON COMPLAINTS AND LITIGATION FOLLOWING THREAT OF JUDICIAL REVIEW

The Department of Health has agreed to issue new clear guidance making it clear that NHS bodies must investigate complaints, notwithstanding any intended or actual legal action by the complainant.  This followed a threat of judicial review by AvMA.  AvMA has come across a number of examples of NHS bodies in England wrongly insisting complaints are put on hold purely because litigation is intended or taking place re clinical negligence.  The DH removed the bar on complaints being investigated whilst litigation was in train or intended, after lobbying by AvMA, when it revised the complaints regulations in 2009.  However, the lack of clear guidance has meant that some trusts are unaware of the change, whilst others have chosen to use the loophole to put complaints on hold simply because of litigation.  In a test case AvMA helped a claimant take to the Ombudsman, she could not intervene because under existing arrangements trusts had a right to do so.

HELP AvMA MEET THE ‘BIG GIVE’ CHALLENGE

AvMA is one of the charities chosen to benefit from the Big Give challenge this year.  By donating on line, on 5th, 6th and 7th December, you can help AvMA double the value of your donation by drawing on anonymous donors as part of the scheme.  Please donate whatever you can on 5th, 6th or 7th December and it will make a huge difference to our work.  For full details click here.

RESEARCH PROJECT ON ADVERSE DRUG REACTIONS:

The Medway School of Pharmacy, University of Exeter Medical School and the Centre for Health and Social Studies at the University of Kent are undertaking a research project on patients’ experiences of a suspected adverse reaction to a medicine.

If you would be interested in taking part in their research project please click here

AvMA RECRUITING TRUSTEES:

Due to recent retirement of trustees, AvMA is looking to recruit new trustees to join its board.  This is a voluntary position but all out-of-pocket expenses are paid.  In addition to a strong commitment to the aims of AvMA and relevant experience, we are looking for people who can add diversity to the board which is currently light on younger adults; people from ethnic minority backgrounds; and disabled people.  Click the following for more information:  Role Description.

If you are interested please write in with your CV and coverinjg letter explaining why you would like to be a trustee and how you think you could contribute:  Trustee Position, AvMA, Freedman House, Christopher Wren Yard, 117 High Street, Crokydon CR0 1QG.

Birth as a Human rights issue: Conference notes

The Midwifery Today Conference was a breath of fresh air, inspirational and challenging. 

 Here are some highlights from my notes.  First of all Birth as a Human Rights issue:

The discourse on human rights is relatively new ( as opposed to the rights of landowners, kings and oligarchies)

We are just catching on that Birth is human rights issues

19 years ago Maternal Mortality was included in the Millennium goals.

And since then the development of the understanding of preventable maternal mortality and morbidity as a pressing human rights issue.

The UN Human Rights commission is now saying re maternity:  No customs, traditions and practices can be involved that do violence to women.

There is a link between money (for instance, where birth is big business for doctors and hospitals) and fear of what may happen at birth.

Robbie Davis-Floyd: says: Birth is not something women just do, it is something we actively choose to do.

The force of law cannot be used to take away options [for how and where we give birth and with whom] sic

Several organizations now working on birth as a human rights issue:

Hospitals can work to achieve the 10 Steps as a means of providing optimal MotherBaby Childbirth Initiative (IMBCI) originated from the work of the International Committee of the Coalition for Improving Maternity Services (CIMS). The inspiration and foundation for the IMBCI is based on the philosophy and principles of CIMS, a coalition dedicated to promoting a wellness model of maternity care that will improve birth outcomes and substantially reduce costs, and to supporting new global efforts to improve the health of women and babies. CIMS is a life-long partner in support of the mission of IMBCO.

The International MotherBaby Childbirth Organization (IMBCO) was created in partnership with Childbirth Connection, a U.S. based not-for-profit organization dedicated to improving the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care for all women and their families.  See previous blog post for the mother/baby rights in full.

  • The White Ribbon Alliance campaigns against violence against women.  a whole arm of this campaign is about dignity and respect and good care in pregnancy and childbirth. cf their website for stories  and campaigns happening around the world.  Join the alliance to be part of change happening.  Some excellent videos and some shocking stories too.   http://whiteribbonalliance.org/campaigns/

 The talk ended with singing and dancing!

 Birth truly is a human rights issue!  And we can be part of making change happen.  These websites and organisations show that if we do, we join thousands of women and men around the world who are working towards the same goals.  We may feel that our part is small and parochial but be clear our actions are part of a global movement that we can also join and which makes our actions larger than the sum of the whole.  Inspirational and challenging!

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?

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