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.
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Watching choice disappear

It was only about eight weeks ago that I was writing up good news. NICE (The National Institute for Health and Care Excellence) confirmed that it’s safer for around half of women to give birth at home or in a midwife led unit.
Hooray, we thought… the evidence is out there, the cautious and well respected NICE is reinforcing the benefits and better outcomes found in a natural birth.
Yet…
Since then, Calderdale Hospital Trust has failed to renew their consultant midwife’s contract and closed the long standing birth centre “temporarily” due to sickness rates. Also, the MAMs service in Airedale is shutting (this is breaking news so we have few details yet). And GPs have been sent a letter scaring them with unfounded concerns about local midwifery service 1-2-1, leading many to refuse to refer women wanting to use their services.
The debate about the guidelines was how we could increase access to natural birth to let everyone have the chance. But here in Yorkshire right now, women are being left without choices, without certainty and with the higher risks associated with hospital births: more interventions, much higher chances of a C-section, stressful environments that interrupt Oxytocin production and so on.
There are many complex reasons why any of these things are happening, but what I think links them is a clear lack of commitment to natural birth in commissioning, despite the guidelines.
Natural birth services are being seen as an ‘add on’ that can be dropped, because they aren’t closing labour wards! So can we hold commissioners to the guidelines? While health professionals get to make the final decision, “Healthcare and other professionals in the NHS are expected to take our clinical guidelines fully into account when exercising their professional judgement.” (NICE website) Therefore, we can argue that they aren’t taking guidelines fully into account if that’s what we believe, but we don’t have the right to overrule the commissioning judgement automatically.
When the future’s uncertain, one of the best things we can do is to keep sharing our experiences. The other thing we can all do is “ROAR”, as Sheena Byrom puts it. We’re organising petitions to make sure the health professionals making these decisions know that we care what happens to women during a very vulnerable experience. Here’s the link to the Calderdale petition.
Things we start to take for granted can disappear if we don’t roar.

Women are voting with their feet for one to one midwifery care

Midwife 4 ME:

Women in West Yorkshire choosing one to one midwifery care

Scores of women throughout West Yorkshire and beyond have been voting with their feet in the last few weeks as news got round that One to One midwifery (Northwest) Ltd had set up in West Yorkshire.  One woman said “I referred myself to them because I wanted to be guaranteed a homebirth without staffing issues”.  Another said she had seen four different midwives postnatally and had seen different midwives ante-natally and through her birth.  This time she wanted to have the support of the a midwife who knew her.

At present local Commissioners are not supportive of the choices these women are making:  saying “We are not commissioning One to One midwifery at present.  We recognize that caseloading midwifery is in the NHS mandate but although it is a commissioning stance, it is not a priority for the CCGs ( GP commissioning groups) amongst its wider commissioning priorities.”  The CCGs say that it’s patient engagement exercise last year did not reveal this as a priority for patients generally or the mothers they consulted.

Ruth Weston, Co- chair of the MSLC says:  “We do not know who the CCGs consulted with but we do know this did not include the MSLC, NCT or Airedale Mums.   More consumer and Voluntary sector groups are being contacted for whether they were consulted.”

In the meantime, several consumer organizations have been writing to the local CCG Commissioners requesting, in the light of medical evidence, that women’s healthy choice is respected and paid for when they seek a care provider offering one to one midwifery care.   Airedale Mums have also set up a petition at

http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/

Beverley Beech, Chair of AIMS ( www. aims.org) wrote to the CCG Commissioners saying:

“The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:
 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”
The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.”

The full text of letter with 34 citations is given at the end of this blog.

Local Campaign Group Airedale Mums wrote:

” It has come to our attention that an amazing opportunity could be opened up for the women of the district through the commissioning of private care provider One to One Midwifery.  Airedale Mums have met and corresponded with One to One Midwifery and we were very impressed by their model of care and record of normal birth in the Wirral. Several of our members attended the Open Day in Bradford last month and were further enthused by the transparency of information and the excellent attitude of all the One to One representatives.

We have also been asking questions at the MSLC over recent months about how the Commissioners and Acute Trusts are going to handle the requests of women who would formerly have chosen Independent Midwifery care – no solutions have been put forward.

For this reason we have been utterly baffled to discover there is high level opposition to this service from the Area CCG’s.  Bradford may have taken steps to introduce Midwifery led intrapartum care, but our district is way behind the game when it comes to case-loaded antenatal and postnatal care.  Many of the women who engage with Airedale Mums have seen up to 12 midwives for antenatal care alone.

The prospect of a family being given named Midwife care throughout pregnancy, birth and the postnatal period (up to six weeks) is no longer a halcyon dream.  Not only that, but this care can, and IS being provided at the same tariff as comparably less successful models being used within the NHS.”

Women of Yorkshire and the UK in general it is time to vote with our feet, our pens and our voices for the care we need.  It is being offered to us here on a plate, but if we do not write those emails to our MPs  and local GP commissioners, if we do not sign the petitions, if we do not start voting with our feet and referring ourselves ( do we have to be pregnant to refer ourselves in?!) into to One to One Midwifery and Neighbourhood Midwives even if they cannot currently provide our care, then we will be doomed to suffer another generation of fragmented, factory, care leaving us and our daughters traumatised, alone and angry.

You can join the campaign by doing three easy things:

  1. Signing the petition:http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/
  2. Writing to your local MP and your local CCG Commissioner. You can write to your MP asking her/him to forward your letter to the local commissioner.  A good framework for a letter is given above by Airedale Mums and Beverley Beech.
  3. You can go to  www.M4M.org.uk and sign up to the national campaign which has a lovely postcard to save you the hassle of writing a long letter.

If you want to do more, contact me or Airedale Mums if you live in West Yorkshire, if you live elsewhere contact M4M (  Midwifery 4 Me) or AIMS.  Now is the time to act.

Full Text of Beverley Beech’s Letter complete with 34 citations:

Dear Mr Pue

I am dismayed to hear from our members the difficulties they have been having in being able to refer themselves to One to One midwifery practice, and very disturbed by the reluctance of your Commissioning Group to commission these services.

The Government has made it clear that there should be more community based care and the Birthplace Study showed that women and babies were safer birthing at home or in free-standing midwifery units.  In their recently published NHS Mandate it states:

 “Ensure every woman has a named midwife who will make sure she has personalized one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern.”

The One to One midwifery service provides precisely this service.  I understand that nearly 100 women have referred themselves to One to One in the last month alone, and more are trying to do so every day.  This group has a team of extremely skilled midwives and it is puzzling that your group is not enthusiastically embracing this service.  Not only does it improve the quality of care to women and babies, reduce mortality and morbidity but also saves an enormous amount of money (see references 1-34).    I do wonder just how much evidence of quality care and benefit is needed before action is taken?  One would have thought that this would be a no-brainer and I would, therefore, appreciate it if you can explain to me why you are not supporting this service.

Yours sincerely
Beverley A Lawrence Beech
Hon Chair
Association for Improvements in the Maternity Services

The following documents support the statements that are made in this letter:

  1. Only 1 in 5 women will be attended at any point in their labour by a midwife they have met before:

Redshaw M, Heikkila K. Delivered with care: a national survey of women’s experience of maternity care 2010. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2010. Available from: https://www.npeu.ox.ac.uk/files/downloads/reports/Maternity-Survey-Report-2010.pdf

  1.  Only one in 10 will have a midwife they have met before, while in other places nearly 1000 of them will be left alone in labour or after the birth when they are frightened

Healthcare Commission. Maternity services review 2007 Data tables for 148 trusts in England. Available from: http://webarchive.nationalarchives.gov.uk/20101014074803/http:/www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/maternityservices.cfm

3. Over 1 in 4 women will have a caesarean operation.NHS Information Centre. NHS maternity statistics, England: 2011-2012. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/hospital-care/maternity/nhs-maternity-statistics-england-2011-2012; http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1941

  1. 8 in 1000 babies die at or around the time of birth.  Sands. Preventing babies’ deaths: what needs to be done. Sands; 2012. Available from: http://www.uk-sands.org/fileadmin/content/Media/PREVENTING_BABIES_DEATHS_REPORT_2012LR02.pdf
  1. One in ten women will become depressed following the birth.  Just over 1 in 3 women will appraise their experience as ‘traumatic’ and 2 in 100 women will develop post tramatic stress disorder (PTSD).  Alder J, Stadlmayr W, Tschudin S, et al. Post-traumatic symptoms after childbirth: what should we offer? J Psychosom.Obstet Gynaecol. 2006;27(2):107-12.
  1. Tyler S. Commissioning maternity services. A resource pack to support Clinical Commissioning Groups. Available from: http://www.commissioningboard.nhs.uk/files/2012/07/comm-maternity-services.pdf

The way a woman is supported and cared for during her pregnancy and birth, and in the days and weeks following, profoundly affects her and her partner’s ability to parent their baby

7.            Allen G. Early intervention: the next steps. London: The Early Intervention Review Team; 2011. Available from: http://dwp.gov.uk/docs/early-intervention-next-steps.pdf

  1.   Odent M. The scientification of love. Free Association Books; 1999.

9.            Solter A. Tears for trauma: birth trauma, crying, and child abuse. 1996. Available from: http://www.primalspirit.com/pr2_1solter_tears.htm

10.       The way that a baby develops in utero and in the weeks after birth is influenced by the quality of care that parents receive   Field F. The foundation years: preventing poor children becoming poor adults. The report of the Independent Review on Poverty and Life Chances . London: Independent Review on Poverty and Life Chances; 2010. Available from: http://povertyreview.independent.gov.uk/final_report.aspx

11.       Quality maternity services should be defined by the ability to provide a safe transition to parenthood and a positive and life enhancing experience.  Midwifery 2020 UK Programme. Midwifery 2020: delivering expectations. Edinburgh: Midwifery 2020 UK Programme; 2010. Available from: http://midwifery2020.org.uk/documents/M2020Deliveringexpectations-FullReport2.pdf

  1. Providing a model which ensures that women can be seen in a community setting where appropriate and focuses on the needs of the woman and her baby and enhances the woman’s experience.  Royal College of Obstetricians and Gynaecologists EAG. High quality women’s health care: a proposal for change. London: RCOG; 2011.
  1. One in five women is left alone in labour.  Care Quality Commission. Maternity services 2010. Available from: http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/maternity-services-survey-2010
  1.   10-15% of women suffer from postnatal depression.  National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance. National Clinical Practice Guideline Number 45. London: The British Psychological Society and The Royal College of Psychiatrists; 2007. Available from: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11004
  1. 8% of babies are born prematurely.  Office for National Statistics. Preterm births data (2007, Accessed 26 March 2013). Available from: www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-50818

16.       69% of new mothers start breastfeeding exclusively, but a week after birth, only 46% are doing so.  Health and Social Care Information Centre. Infant feeding survey 2010. Health and Social Care Information Centre (IC); 2012. Available from: http://tinyurl.com/afu6yb2

17.   The birth rate increased by 22% between 2001 and 2011.  Royal College of Midwives. State of maternity services report 2012. London: RCM; 2012.

  1.  More older first-time mothers are giving birth.  HM Government. General Household Survey. Available from: http://data.gov.uk/dataset/general_household_survey
  1. There is an acute shortage of midwives.  Front Line Care: the future of nursing and midwifery in England. Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England 2010. London: The Prime Minister’s Commission on the Future of Nursing and Midwifery in England; 2010. Available from: http://cnm.independent.gov.uk/wp-content/uploads/2010/03/nursing_midwifery_report.pdf

20.       There is no financial incentive to provide continuity of midwifery care, but the improved outcomes demonstrated by this service generate significant savings.  van der Kooy B. Continuity of care: the elusive key to improved maternity outcomes . Pract Midwife 2013;16(4):16-7.

21. Centralisation of maternity care in fewer, very large impersonal obstetric units create increased travel time for women in labour.  NCT. Location, location, location: making choice of place of birth a reality. London: NCT; 2009.

22.  . Student midwives have a high drop out rate because after qualification they are unable to practise in the way that they wished.Centre for Workforce Intelligence. Workforce risks and opportunities: midwives. Education commissioning risks summary from 2012. Woking: Centre for Workforce Intelligence; 2012. Available from: http://www.cfwi.org.uk/publications/midwives-workforce-risks-and-opportunities-education-commissioning-risks-summary-from-2012

23.       Fewer women having the support they need to have straightforward births

Downe S, McCormick C, Beech BL. Labour interventions associated with normal birth. British Journal of Midwifery 2001;9(10):602-6.

24.       Fewer women having one-to-one midwifery care in labour in obstetric units. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.

25.       The required ratio of one midwife to 28 women is not being met.  Smith H. Daily Hansard debate 17 Jan 2012. Midwife and maternity services. Available from:

http://www.publications.parliament.uk/pa/cm201212/cmhansrd/cm120117/debtext/120117-0004.htm

26.   Each woman should have a named midwife they can get to know and trust and who they will see during their pregnancy, birth and after their baby is born.  Association of Radical Midwives. New vision for maternity care. Hexham: The Association of Radical Midwives; 2013. Available from: http://www.midwifery.org.uk/wp-content/uploads/2013/02/The-Vision-2013.pdf

27.  To provide care in line with the evidence will require the establishment of maternity networks with most care based in the community.   NCT. Innovative, integrated and in the interest of families: the Maternity Network approach. London: NCT; 2010.

Good evidence demonstrates improved outcomes from midwifery case-loading models providing continuity of community-based care

28. McLachlan HL, Forster DA, Davey MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119(12):1483-92.

29. Milan M. Independent midwifery compared with other caseload practice. MIDIRS Midwifery Digest 2005;15(4):439-49.

30. Improved birth outcomes generate significant financial savings.  NHS Institute for Innovation and Improvement. Delivering quality and value. Focus on: caesarean section. Coventry: NHS Institute for Innovation and Improvement; 2006. Available from: http://www.institute.nhs.uk/quality_and_value/high_volume_care/focus_on%3a_caesarean_section.html

31. Increased breastfeeding rates have the potential to save the NHS £40m a year.  Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK; 2012. Available from: http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf?epslanguage=en

32. Payment by Results is not well-suited to promoting continuity and co-ordination of care.  Appleby J, Harrison T, Hawkins L et al. Payment by Results: how can payment systems help to deliver better care? London: King’s Fund; 2012. Available from: http://www.kingsfund.org.uk/publications/payment-results-0

33.Independent midwives need to have insurance and guaranteed access rights to support women giving birth on NHS premises.   Independent Midwives UK. Current situation with regard to the forthcoming requirement for mandatory Professional Indemnity Insurance. 2012. Available from: http://www.independentmidwives.org.uk/files/pii_update.pdf

34.  Midwifery led care when compared with models of medical led care and shared care was associated with several benefits for mothers and babies, and had no identified adverse effects.  Hatem M, Sandall J, Devane D, Soltani H and Gates S.  Midwife-led versus other models of care for childbearing women, The Cochrane Collaboration, http://apps.who.int/rhl/reviews/CD004667.pdf