Maternity Care Is Different From Other Forms of Health Care Because

1. Overview of Maternity care in the UKJane Sandall, Professsor of Womens HealthDepartment of Public HealthKing’s College, London School of MedicineKing’s College, Londonjane.sandall@kcl.ac.uk

2. Maternity Care Is Different From Other Forms of Health Care Because Latent in the care of women are ideas about motherhood, the role of women, families and sexuality The organisation and provision of maternity care is a highly charged mix of politics, cultural ideas and structural forces The role and status of midwives influenced by above © Sandall © Albany Practice ©Sandall © Albany Practice

3. European Union Activities of a Midwife • Provide contraception and sexual health advice • Monitor of normal pregnancy • Prescribe/advise on pregnancy examinations/screening • Provide parenthood preparation classes • Care for and deliver a woman and her baby • Recognise signs that things are not going well, for both woman and baby) • Examine and care for newborn • Monitor and care for the new mother, the baby and the family • Carry out prescribed treatments • Maintain records.

4. All midwives must be registered with the NMC Register for midwives and a register for nurses Currently 20,000 full-time equivalent registered midwives (& over 600,000 registered nurses) The NMC midwifery department promotes standards of practice and influences change to ensure all UK midwives adopt the most up-to-date clinical practices The NMC setsstandards for practice, education and supervision of midwives The NMC also investigates any allegations that a midwife (or a nurse) has not followed their code of practice The Nursing and Midwifery Council (NMC)

5. Education and training of midwives in the UK • Midwifery education and training programmes are only run at NMC-approved educational institutions. Courses take a minimum of three years, unless already registered with the NMC as a level 1 (adult) nurse, in which case the training is 18 months • 55 UK universities currently offer midwifery education programmes (not all offer the 18 month option) • Trainingtakes place at a university and at least half of the programme is based in clinical practice in direct contact with women, their babies and families • This can include the home, community and hospitals, as well as in other maternity services such as midwife-led units and birth centres.

6. 100 prenatal exams 40 women in labour 40 deliveries Active participation breech/simulation Episiotomy & suturing 40 woman at risk 100 postnatal women and newborns Observation newborn needing special care c/o women with pathology in O & G Medicine and surgery Midwifery EducationEU Directive 2005

7. Having a baby in England • About 99% women give birth in NHS and 1% in private sector • 649,837 births in hospital, an overall increase by 3.3% in one year • 2.6% of all NHS deliveries at home compared to 2.3% the previous year (2004-5) range 0.6-14% • 36 % of deliveries were conducted by hospital doctors and 60% by midwives • In 2008 19,555 midwives FTE and 1,570 consultants and 2,635 registrars, plus Drs in training • 74% of women with spontaneous deliveries spent on average one day in hospital • after delivery, women with instrumental deliveries one or two days and • women with caesarean deliveries between two and four days • NHS Maternity Statistics, England: 2004-5 and 2007-08

8. Current Policy

9. Maternity Care Pathway

10. Policy background on place of birth -NSF • Choice of most appropriate place and professional based on wishes, preferences and needs • Specific inclusion of home birth with risk assessment and adequate local support • Maternity care providers and commissioners ensure that: • The range of services offered constitutes real choice including home birth • Staff actively promote midwife-led care for appropriate women including community units, hospital based units and home birth with easy and early transfer DH and DES (2004) NSF for Children, Young People and Maternity Services, London, DH

11. DH choice guarantees by 2009 • 1. Choice of how to access maternity care • 2. Choice of type of antenatal care • 3. Choice of place of birth • 4. Choice of place of postnatal care • And… • Every woman will be supported by a midwife she knows and trusts throughout her pregnancy and after birth. DH (2007) Maternity Matters: Choice, access continuity of care in a safe service

12. NICE Guidelines on Home Birth • Women should be informed: • That giving birth is generally very safe for both the woman and her baby. • That the available information on planning place of birth is not of good quality, but suggests that among women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention. We do not have enough information about the possible risks to either the woman or her baby relating to planned place of birth. • That the obstetric unit provides direct access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia. • Of locally available services, the likelihood of being transferred into the obstetric unit and the time this may take. • That if something does go unexpectedly seriously wrong during labour at home or in a midwife-led unit, the outcome for the woman and baby could be worse than if they were in the obstetric unit with access to specialised care. • That if she has a pre-existing medical condition or has had a previous complicated birth that makes her at higher risk of developing complications during her next birth, she should be advised to give birth in an obstetric unit. • Clinical governance structures should be implemented in all places of birth. Intrapartum care: Care of healthy women and their babies during childbirth NICE Guideline 55 2007

15. Choice of place of birth – the reality! • In NPEU study (Recorded Delivery 2007) 38% of women were given the option of home birth at the booking interview (cf 18% in 1995) • 57% given choice to have baby at home in 2008 (HCC Survey) • However, rates of home birth in England for 2005-6 were 2.6%

16. Home births 2001-2007

17. Birth Centres/midwife-led units 25 AMU 54 FMU HCC Data 2007 www.npeu.ox.ac.uk/birthplace

18. Birth Centre activity levels in England 05/06 Tyler 2007

19. Birth Centres • Any BC under 300 births/yr needs to take on additional community midwifery activity to be financially viable • BUT must balance financial affordability with wider policy agenda around choice, quality, access, reducing inequalities, recruitment and retention and capacity • Commissioning Frameworks assessing what % of women categorised as low medical complexity and low/high social complexity could give birth either in midwifery units or at home • Tyler 2007

20. Defining normal birth Women who: Started labour without induction. Did not have any anaesthesia. Did not have a caesarean. Did not have an instrumental delivery Did not have an episiotomy

21. Trend in ‘Normal’ Birth Rates

22. Childbirth interventions 2007-08 • An estimated 47% (51% including home birth) of deliveries were ‘normal deliveries’ defined as those without surgical intervention, use of instruments, induction, epidural or general anaesthetic - slight increase on previous year • Caesarean rate rose slightly to 24.6% • 20% of labours induced • 12% were instrumental deliveries • During labour 36% of women had an epidural, general or spinal • anaesthetic • 13 % of women had an episiotomy • NHS Maternity Statistics, England: 2004-5 and 2007-08

27. Normality – priorities for implementation from NICE • One to one care: a woman in established labour should receive this as significantly less likely to have CS or instrumental birth, will be more satisfied and have a more positive experience of birth • Use of water: the opportunity to labour in water is recommended for pain relief as it reduces pain and the use of regional analgesia. Immersion in water has the potential to reduce by up to 90% the proportion of women who report severe pain in labour. • Intervention should not be offered or advised where labour is progressing normally and the woman and baby are well.

28. Women’s experiences • In 2007, the proportion of women having pethidine was lower (33% compared with 42% in 1995) • The use of continuous electronic fetal monitoring in labour was lower (41%) than in 1995 (53%), with greater use of different types of intermittent monitoring. • 38% indicated that at this stage home birth had been a possible option, which is greater than that reported for 1995 (18%). • 93% women reported doctors talking in a way women could understand compared with 66% in 1995. Redshaw et al 2007, Recorded Delivery, NPEU

29. Current policy concerns UK • 2008 • Choice in place of birth • Safety of out of hospital birth and midwife led care • Rising caesarean rates • Reducing Inequalities • System safety • New in 2009 • What models of care are cost-effective • Maternity workforce and skillmix

30. Implementation – what will it take? • Dissemination and discussion at Trust/PCT level on current practice and where it deviates from guideline • Midwife as first point of contact (NSF) (13% only in NPEU 2007 cf 12% in 1995) • PSA Delivery Agreement – first contact before 12 weeks • Strategy to ensure competent and skilled mws to support increased number of births outside obstetric units if active promotion of choice of place of birth takes place • Significant changes in the ways midwives work to enable one to one support – admin, support roles, role at CS • Review of models of midwifery care and skillmix • Targets - see 10% home birth in Wales • Will to change

31. Evidence, Professions, the public and policy

32. Research Agenda • What are the outcomes for women at low risk in different birth settings? - Birthplace • Can quality and safety be improved by different models of care? – Implementation of models of midwife-led care (Cochrane) • How can inequalities in outcomes (maternal and perinatal mortality and morbidity, health and wellbeing) be reduced? • How can care be improved for socially excluded groups? • Can improving the quality and safety of maternity care save money??? • What is the best staff skillmix in maternity care? • How can system safety be improved?

33. jane.sandall@kcl.ac.uk