Over recent months various reports relevant to maternity services have been released. Dr Jenny Hall, Editor, Maternity and Midwifery Forum highlights points from the reports, encouraging us to use them to make change.
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Over recent months, with the current transitions of government here in the UK sharing headlines with war atrocities and climate catastrophes you would be thinking there wasn’t anything going on around maternity services. Yet, quietly in the background, there have been reports and documents released of which we should all be aware. Some of these reports and documents will have further dedicated summary articles, but for now my intention is to draw your attention to encourage you to seek out.
Equality data
Back at the start of the summer the Equality and Human rights commission, an independent statutory body focussing on the Human Rights act (2010), with a remit across England, Scotland and Wales, looked at some of the concerns around race disparity across maternity. The briefing paper (2024 Policy briefing on using equality data to understand and tackle race inequalities in maternity and antenatal care ), advises on the importance of collecting race and equality data in order to establish more effective change. They point out that poor collection means it is not possible to establish the potential impact of policies or practices and improve care. The briefing is just for England, but it highlights the need of capturing good data, and the responsibility of all of us to complete all documentation accurately. Leaders particularly, should take note, as well as those midwives working in Digital transformation.
MBRRACE-UK | NPEU
The concerns around inequality and race continue in the latest report on Maternal deaths from MBRRACE. ( Saving Lives, Improving Mothers’ Care 2024 – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22 | MBRRACE-UK | NPEU). This focusses on the period from 2020-22 (including the COVID-19 pandemic) and follows the last from 2017-2019 (see here for summary). It is always important for us to read these reports in detail, though understandably painful, as they show so often how small things can make such a difference and how missing care can have truly devastating effects.
A major aspect of concern is the increased number of maternal deaths since the previous report, even when removing those who had died from COVID-19. We should all sit up if the trend is getting worse, after years of concerted improvement. The main reasons for death (removing COVID) remain Thromboembolism and Cardiac conditions, closely followed by mental health concerns. Inequality and deprivation are also a highlight, with those living in socially deprived areas twice as likely to die as those in the less deprived.
Further, racial disparity remains with a nearly three times difference for women from Black ethnic backgrounds, and almost twice for those from Asian ethnicity, compared to white. Language needs to be highlighted in digital records and appropriate interpretation services and documents in different languages should be accessible from early pregnancy. Cancer is also raised as an issue, with many women now entering pregnancy with a previous history of tumours. Midwives should be forefront in ensuring quick referral for assessment and support. As always, the report needs careful reading and action across all areas of services.
Midwifery models of care
The next report for reading came from the World health Organisation (WHO) with their global position paper on Transitioning to midwifery models of care: a global position paper. It highlights what they mean by ‘transitioning’ in that it:
“refers to the process of reorientation of health systems away from the currently prevalent fragmented and risk-oriented model of care to a midwifery model of care in which women and newborns, starting from pre pregnancy and continuing all the way through the postnatal period, receive equitable, person-centred, respectful, integrated and high-quality care, provided and coordinated by midwives working within collaborative interdisciplinary teams.”
It is a strong message of support of midwifery-based systems. The paper provides useful definitions of the expected role and scope of a midwife and the case is presented for increasing access to good quality midwifery care with the evidence behind it.
It is based on Lancet maternity series Quality Maternal and Newborn Care Framework and the guiding principles for the change are:
- Equitable and human-rights-based care enabling access for all women and newborns
- Person-centred and respectful care encouraging a trusting relationship and partnership between women and midwives
- High-quality care aligned with the midwifery philosophy of care
- Care provided and coordinated by autonomous, educated, regulated and supported midwives, in all settings and at all levels of the health system
- Integrated care provided within interdisciplinary teams in networks of care
None of this will be new to us in the UK, but the endorsement from WHO should be something to take forward and use to foster appropriate change.
Northern Ireland review
Next came the report from Northern Ireland, led by Professor Mary Renfrew, Enabling Safe Quality Midwifery Services and Care In Northern Ireland | Department of Health. More will come about this in the new year. There is so much in it, that it is important to read thoroughly rather than rely on soundbites grabbed by the media. It is a masterclass in undertaking a review of services, showing the clear methods used and the evidence underpinning the conclusions. The full inclusion of stakeholders in the formation of the review is a further strength, in order to take transformation forward.
The review was commissioned following a Coroner’s inquest in a baby’s death that had concerns about safety in a Freestanding Midwifery-led unit. The stated aim underpinning the review:
“…was to identify the key conditions for safe, quality midwifery and wider maternity services in all settings in NI, to ensure that safe, equitable, respectful, compassionate, and evidence-informed midwifery care is available for all women and newborn infants, wherever and whenever care takes place.“
The review provides a context of current background and settings in maternity services, pointing to the high levels of deprivation and inequalities, already mentioned in the other reports in this article. It evaluates current care and addresses the concerns around quality and safety raised by the Coroner’s inquest. The positive aspects of services already in place are also identified.
The analysis uses key questions based on the Lancet maternity series Quality Maternal and Newborn Care Framework (on which the WHO report above is also based) (p 132):
QMNC Concept 1
Are women, babies and families the focus of care and services?
QMNC Concept 2
Do women and babies receive safe, quality care across the whole continuum?
QMNC Concept 3
Do all women and babies receive the universal care they need? a) Equity b) Education, information, health promotion c) Assessment, screening, and care planning d) Optimising normal processes, preventing complications
QMNC Concept 4
Do women and babies with complications receive the additional care they need? a) Identifying complications and providing first line management b) Medical, obstetric, neonatal services
QMNC Concept 5
Does the organisation of care and services ensure safe, quality care for all, with continuity and integrated across settings?
QMNC Concept 6
Is there a shared culture, and shared values and philosophy that strengthens women’s own capabilities?
QMNC Concept 7
Are staff supported and enabled to provide the full range of their knowledge and skills?
It is not possible to go into detail here, and it is recommended to read through and recognise the trauma many women are experiencing through the lack of appropriate care. We could all do well to use these questions to challenge our own practice areas and seek ways to make the appropriate changes.
The recommendations from the review are far reaching, across all levels of the maternity services, including appropriate investment and transformation of data monitoring. The key will be relational services, with women at the centre of care and local community-based units and home births safely supported. The depth of analysis provides a blueprint for successful transformation.
In response to the publication the Northern Ireland Health Minister Mike Nesbitt announced that a new maternity and neonatal partnership would be established to ‘drive forward’ the improvements in care. This is an encouraging response, and though it will take time, provides a strong support to the transformation required.
There is much in this review that rides counter-culture to the approachto change in the other UK countries and the media. The approach to safety is constructive and consistent with research evidence starting with recognising and optimising physiological childbirth processes and what women want. Midwifery continuity of care is supported along with opening of community-based midwife-led units. It also addresses the depth of inequity and inequality in the community, which points to maternal needs as a public health concern.
Alongside the publication of the WHO position paper, this provides an increasing endorsement for midwifery to be strengthened across all maternity services.
State of Health
The final report produced in October is the Care Quality Commission State of Health care and adult social care in England 2023/24. An annual summary based on surveys and reports produced during the year demonstrates how services generally have been struggling in the current economic environment (though it does beg the question following the removal of single-word judgment by OFSTED for education reporting if CQC judgment needs overhauling). Maternity services are pulled out as a continued area of concern, pointing to 47% as requiring improvement or inadequate. Issues on leadership, safety, recruitment, poor building maintenance, lack of equipment, and inequalities were highlighted, alongside poor communication, triage and reporting of adverse events.
This clearly identifies a baseline for the new Labour government to realise that services are at an all time low and need a strong focus for change.
Where do we go from here?
It is up to us now to take all these reports and question where we want to go. On one level it paints a gloomy picture of how low maternity services have reached in the UK and we could truly question how we have allowed it to get so bad. It is also a terrible state of inequity we have across our society, particularly for women and families from different races and cultures. But the reports also provide us with opportunity. With the strong support from the WHO and now the report from Northern Ireland we have choice to fight back and reclaim relational midwifery as the way forward. I hope all of us have the strength and given the resources to make it happen.
Dr Jenny Hall
November 2024