23
Preterm Birth Committee
Corrected oral evidence: Preterm birth
Monday 25 March 2024
3 pm
Evidence Session No. 13 Heard in Public Questions 180 – 193
Witnesses
I: Clare Livingstone, Professional Policy Adviser, Royal College of Midwives; Róisín McKeon-Carter, Chair, Neonatal Nurses Association; Professor Basky Thilaganathan, Spokesperson, Royal College of Obstetricians and Gynaecologists and Clinical Director, Tommy’s National Centre for Maternity Improvement.
Clare Livingstone, Róisín McKeon-Carter and Professor Basky Thilaganathan.
Q180 The Chair: Thank you all for coming this afternoon; we appreciate it very much. We know you are busy people and have a lot of work to do, but we would be glad to get your views about aspects in our inquiry. Basically, we want to find out how professional organisations can improve care for mothers and preterm babies through their members. Before we start, I would be grateful if you could introduce yourselves and your designation so we get you on the record, and then we will start with the questions. My colleagues have specific questions that you may know about but, no doubt, others will have supplementary questions as the discussion goes on. So, from my left, please, can I ask you to introduce yourself?
Professor Basky Thilaganathan: I am a professor of obstetrics at St George’s Hospital in London, and clinical director for the Tommy’s National Centre for Maternity Improvement, which is based at the RCOG and the RCM.
The Chair: You will forgive my colleagues if they do not try to pronounce your name exactly the same way you did.
Professor Basky Thilaganathan: You can call me Basky, or you can try for Thilaganathan; it is perfectly fine.
The Chair: Okay. I am only teasing you; we will try the proper name.
Clare Livingstone: I am a professional policy adviser at the Royal College of Midwives.
Róisín McKeon-Carter: I am a neonatal nurse consultant in University Hospitals Plymouth NHS Trust, and chair of the Neonatal Nurses Association, which is a charity organisation with 1,000 nurse members.
The Chair: Thank you very much indeed and, as I said, thank you for coming today; you are welcome. I am going to start off with Baroness Hughes.
Q181 Baroness Hughes of Stretford: Thank you, Chair. We are interested in hearing about the capacity and capability within the workforce and within the provision for mothers and preterm babies. I am going to start with staffing: are there any national standards for the levels of staffing—clinicians, midwives, neonatal nurses and so on—for providers to meet?
Róisín McKeon-Carter: Yes, there are and I will talk to nursing. We have a gap of 2,000 neonatal nurses in the country, and this was identified during the Neonatal Critical Care Transformation Review because we have a standard. It was written by the British Association of Perinatal Medicine and the standard is to have QIS intensive care nurses 1:1 for intensive care, 1:2 for high dependency, and 1:4 for special care. We have 200 units in the country and there are not enough nurses in the country to fill that gap. We have had funding from NHS England that came down for the qualified in speciality nurse, which is a specialist nurse. However, to run a service you need other quality roles, including educators, governance, risk, matrons, and managers. The paucity of nurses in the UK has been a huge issue because there has been overseas recruitment. There is no pipeline to fill this gap. The NNA would suggest apprenticeship nurses as a way to fill this gap, but the funding and the infrastructure are not there for them at the moment.
We have a very clear workforce plan written by GIRFT , which is the BAPM group, and the Neonatal Nurses Association. It includes undergraduate nurses through to qualified in speciality and advanced practice nurses, all of whom are necessary for a safe and effective service. If you do not have enough nurses, the outcomes for premature babies are poor, death and the outcomes are poor, so we know this is a critical piece of work. The Neonatal Nurses Association is calling for the GIRFT report, which is an excellent workforce report, to be published and have it on platforms so that we can inform ICBs, ICSs, and neonatal ODNs of what workforce we require, and get the funding in place for that. It has not been published by the NHS yet.
Baroness Hughes of Stretford: Do you know if the NHS has accepted the conclusions of that report? You say it has not published it.
Róisín McKeon-Carter: I sit on the National Neonatal Implementation Board, and they are very well aware of that GIRFT report. Recently, we asked when it will be published and available on the NHS platforms, and it said, “Not yet”. So that is what the call is: to get that published to inform the ICBs and the ICSs.
Baroness Hughes of Stretford: Thank you very much.
Lord Hampton: I did not catch the name of the report.
Róisín McKeon-Carter: It is the GIRFT—Get It Right First Time—report, in collaboration with the Neonatal Nurses Association.
Baroness Hughes of Stretford: Could I ask the same questions in relation to midwives and obstetricians, please?
Clare Livingstone: Yes. There is a nationally recognised workforce tool called Birthrate Plus. From that, we are able to extrapolate that there is a shortage of approximately 2,500 midwives in England and this is having a major impact on our ability to deliver care. As far as preterm birth is concerned, the work that midwives do is around prevention and it is such important work. The ability of midwives to carry out interventions such as support to stop smoking, which is a significant contributory factor, is really limited by the shortage of midwives. Unfortunately, it falls down in priority when core services are very short as specialist midwives can be called in to support a struggling unit at times. It is a real problem; it is a real challenge.
Baroness Hughes of Stretford: Just picking up the pipeline point that your colleague raised earlier, is there a plan to bridge that gap in the NHS? Is there an awareness of the need to grow that pipeline to fill that gap?
Clare Livingstone: Absolutely, yes. There are significantly more training places for midwives now. This is starting to show through, and numbers are slowly rising. We now have 1,000 more midwives than last year. However, retention is one of the issues we are facing. As fast as we are able to recruit new midwives through that pipeline and other initiatives—such as apprenticeships which are really helping with that—the challenge is holding on to the ones that we have, particularly the very experienced midwives who are able to offer support in placement to students and give them a good learning experience. So, yes, there is a pipeline and there are signs of improvement, but there are real challenges as well with that.
There is an attrition of students as well. Our student midwives encounter quite a number of challenges financially now that they are having to pay fees for their university courses, which did not use to be the case, and the lack of bursaries. Midwifery and nursing students at university are different from students on other courses who can work to support themselves, because midwifery and nursing students have full-time placements and are rostered to work on a shift pattern alongside their mentors, so it is very difficult for them to find work to support themselves compared with other students.
Baroness Hughes of Stretford: In relation to the issue of retention of midwife students, is it students dropping out before they have qualified, or is there a retention problem with people once they have qualified and are working as well?
Clare Livingstone: I think it is a 56% attrition rate of student midwives, which really shows just what an issue this is.[1] There are a number of reasons for this. At the Royal College of Midwives, we know there are financial reasons for students leaving. They leave for health reasons, or because it is not as they had expected it to be as a career. They find the experience is too overwhelming, or just not the right choice for them. It is really hard out there; I feel very sorry for student midwives: it can be very tough, even traumatic, to be on a shift where they are not feeling supported and to see some of the things that they see.
Baroness Hughes of Stretford: Thank you. Could we cover the same ground in relation to obstetricians, please?
Professor Basky Thilaganathan: There are a number of reports—Ockenden, Kirkup, Health and Social Care Committee reports—that clearly indicate the shortage of the obstetric workforce. Thankfully, attrition rates are coming down slowly, but burnout is still a major issue for our young obstetricians, and that is evidenced by the rota gaps we have throughout the 110 hospitals in England.
The RCOG completed a workforce planning tool for the DHSC and submitted it over a year ago now. Planning for the obstetric workforce is far more complicated: we have different levels of obstetricians at different levels of training and we have hospitals with variability in the levels of complexity of the cases that need to be addressed. It is not as simple as saying an X number; it depends on the skills mix and the training. That is quite a complex tool that has sat with the DHSC now for a while, and we have not heard back. I would urge us to find out what the outcome of that complex assessment was.
A secondary issue is that the NHS long-term workforce plan clearly commits to increased medical graduates, but that does not help us with the speciality training required to get people into obstetrics. Therefore, there is a real likelihood that we will end up with a bottleneck of medical students and young doctors but no availability to put them through speciality training. So there really needs to be an expansion of speciality training in obstetrics and gynaecology.
Baroness Hughes of Stretford: In terms of people who are actually in the workforce rather than training or trying to get into training, do you think the fact there are such significant shortfalls in the number of people needed in each of those groups—neonatal, midwifery and obstetrics—is significantly affecting the decisions of others to stay in those professions?
Róisín McKeon-Carter: When young nurses come to us, they look to see the matron, for example. Matrons and managers are the most, for want of a better word, harried group because they have to appease the hospital trust they work in and try to reach nationally set benchmarks which are published. They also try to support the nursing workforce. I talked about the quality roles and it applies to the midwifery team as well. The quality roles are really important—including allied health professionals, psychologists and other professionals—to support the pathway for women, including preterm babies, and for staff. That infrastructure is not in place.
We talk about resilience: the NNA has supported a lot of well-being days and webinars for managers and matrons to fill the gap that is evident for our neonatal nurses. The neonatal nurses do not get any additional time to study after they have qualified and they have to do a lot of the study in their own time, with some nurses even paying for their own master’s programmes. There is not a good, benevolent structure in place to really look after our staff.
Baroness Hughes of Stretford: A pathway through that is provided for them.
Róisín McKeon-Carter: The pathway is there, but—
Baroness Hughes of Stretford: Yes, but they have to do it themselves?
Róisín McKeon-Carter: They have to do it themselves in their own time. Many of our young nurses and midwives have families so it is very difficult for them.
Baroness Hughes of Stretford: Thank you. I would just like to finish by asking about the preterm birth lead team recommended in the Saving Babies’ Lives care bundle. Do you feel that is the right approach that everyone should aspire to in order to improve the effectiveness of care and the outcomes for mothers and babies? If you do, is that deliverable by all providers? I presume, given what you have said, you would say no but I will ask the question anyway. Professor, do you want to start and then we will work along?
Professor Basky Thilaganathan: No, absolutely. In all areas of medicine where there is a specialist team dedicated to a specific disease entity or an outcome, you can make an impact. As you say, the issue is: do we have enough staff on the ground, and do we have the specialities in place? On paper, you can nominate the right number of people in any given hospital, but if they do not have the time to commit to making that their dedicated goal, then they will not be effective. The idea is a good one; it may fail in delivery.
Baroness Hughes of Stretford: There are certain recommendations in that model for the number of obstetricians, midwives, and neonatal nurses to be in that lead team, are there not?
Professor Basky Thilaganathan: Three-quarters of the hospitals in England have a specialist preterm birth service. They may not have all the members of the team outlined within the Saving Babies’ Lives care bundle, so it is a matter of expanding that team to include other members. However, just having people on paper as the preterm birth lead team does not mean the care will improve unless we liberate their time and afford them efforts to make an impact.
Clare Livingstone: I absolutely agree with what the professor has just said. It may exist on paper but, in reality, it often does not, or it does not operate the way it should do to make a difference on the ground. Continuity of care is an example of that, and we know the evidence supports that continuity of midwifery care makes a real difference to outcomes. There are studies; there is a local study in Lambeth that has—
The Chair: We are coming to a question related to that later on.
Clare Livingstone: Oh, I am sorry. Okay.
Baroness Hughes of Stretford: Can we get a final comment from you, Róisín?
Róisín McKeon-Carter: I agree. The theory is there, but the execution is not because the priority will be given to the cot-side work and the infrastructure around that which is imperative for the outcomes. The recruitment and retention are not there.
The Chair: Thank you very much. You referred to the attrition rate of training midwives as 56%. Is that what I heard?
Clare Livingstone: That is correct, yes.[2]
The Chair: That seems extremely high.
Lord Winston: It does.
Baroness Thornhill: It is really staggering.
The Chair: Have you explored why that is so?
Clare Livingstone: Yes, we have, and the Royal College of Midwives published a report called State of Midwifery Education 2023 which covers all this, and the reasons why these student midwives feel unable to stay. As I said before, it is for financial reasons, but there are other reasons as well such as a lack of flexibility: a lot of student midwives may have childcare responsibilities or other caring responsibilities that they find very difficult to juggle with an inflexible shift system, which it very often is. There are lots of reasons why there is such a high attrition rate but, again, it is around student experience and if they are not feeling very well supported in their education then they might leave.
The Chair: When you talk about neonatal nurses, I presume you are including neonatal nurses, specialist neonatal nurses, advanced neonatal nurses, all together?
Róisín McKeon-Carter: The only thing we are benchmarked against is the qualified in speciality, the specialist neonatal nurse. When the Neonatal Critical Care Transformation Review was published, it was about all nurses because, for example, you do not need a QIS nurse to look after a special care baby. The only benchmarking is against the QIS—qualified in speciality—and there are national standards coming out. Health Education England, or what is now called NHS England Workforce, Training and Education, is just about to publish standards for the QIS because we know that nationally there is no equity among the training of these nurses. At the Neonatal Nurses Association, we want to ensure nurses who are employed in the north-east are as well educated as in the north-west. At the moment, there is a variance in their training and education and the impact on the outcomes is significant.
Q182 Baroness Owen of Alderley Edge: I wanted to touch upon apprenticeships. What is the difference in what someone who is qualified and is an apprentice can do versus a student attending university to train in midwifery? What is the percentage of people who go down the apprenticeship path versus the student midwife university path?
Clare Livingstone: The qualification is the same. They are drawn from the workforce and they very often have had previous experience of working on a maternity ward—they might be a healthcare assistant or a maternity support worker—so they already have a lot of practical experience under their belt. They know what they are going into and the attrition rate is virtually nothing, so they know it does work. We are very supportive of that. The number of apprentices is very low at the moment, I think it is 3%; it is a very low number.
The Chair: So you want to go back to the older model?
Clare Livingstone: No. There are advantages with that model, but a lot of it comes down to finance as well. Sadly, a lot of student midwives are saddled with around £60,000 worth of debt. So, when they qualify, they are—
The Chair: Do you think the problem will be solved if we convert all to an apprenticeship scheme, but give them degrees?
Clare Livingstone: I am not sure it would solve all the problems, but the apprenticeship programme definitely needs to be expanded.
The Chair: Lord Winston, did you have a question?
Lord Winston: No, not at this stage, Chairman. Thank you.
Baroness Blackstone: If student midwives or, indeed students at the beginning of their careers, are not being adequately supported, who is failing? I am not just trying to point the finger; I am trying to think of how you resolve these problems. Support is obviously needed in any professional role when people are starting out in it so why are those in more senior positions not giving these younger or more recently qualified midwives the support they need?
I have a second question about neonatal nurses. The shortage of neonatal nurses is very long-standing. Is it partly to do with a lack of interest or confidence or desire to take up this particular specialism in nursing or is it, again, dropout? It is something to do with the first rather than the second, is it not?
Róisín McKeon-Carter: I need to go back with a little history. When the neonatal services were redesigned in 2003, every one of the 200 hospital units in the country looked after each level of child. The evidence showed that the expert areas—like neonatal intensive care—were all commissioned, as were medical staff and medical consultants. However, there was no front-loading of nurses to increase the qualified in speciality nurses in any of the services, and we have never caught up. As the Neonatal Nurses Association, we court undergraduate nurses, we are working with the chief nurses for all countries and we are raising the profile of neonatal nursing because it is a Cinderella service. When we get nurses to join us, they stay, but we have never really achieved the benchmark because we were not front-loaded. That is still an issue. We need to front-load; we need to give the matrons more nurses than they actually need to run the service because the pathways to enhanced nurse, advanced nurse, and consultant nurse are there and they are all necessary.
I would also like to see support for the midwifery teams, the undergraduate midwives, and the newly graduated midwives. We do not have, for example, enough psychology services. We do not have enough support for these quality roles in any of the services to support undergraduate nurses and the newly qualified. They have to hit the shop floor and hit it hard. There is no practice development commissioned. The back-office staff, matrons and managers are often out clinically as well. We need to get these quality roles and allied health professional roles in place to support the infrastructure, and, if we do so, I am confident the outcomes will improve.
Clare Livingstone: There are some excellent examples of preceptorship programmes that support newly qualified midwives extremely well, but this is not the case everywhere and it is vital that, once midwives qualify, they are supported properly for the first year or two so they do not just hit the ground running. It can be quite terrifying, particularly on a short-staffed ward or a ward that is a delivery suite staffed almost entirely by agency staff. We know of examples where they are fully staffed by agency staff and that is not a student experience we would want to see at all. It is not because there is not the will to support: senior midwives want to do it, but they cannot. They are not able to, because often a co-ordinator of a delivery suite, who should be supernumerary and not actually caring for anyone in labour, very often is. There are all sorts of safety reasons why it is not happening.
Lord Winston: I do not quite understand. Are you arguing that this is a matter of insufficient cash, or is it a question of no proper organisation and structure to the way midwives are trained, managed and regulated?
Clare Livingstone: The midwifery workforce has been depleted over a number of years. From extrapolating NHS digital data, we know the proportion of midwives relative to other disciplines within the NHS has, quite significantly, not grown to the same extent. I would be very happy to provide the committee with the details of those figures in our written submission. However, that has been the case, and it clearly illustrates that the number of midwives has not increased as it should have done. Although we have this figure that we are short by 2,500 midwives, it may well be more than that, because, as you know, the complexity of birth has increased over time.
Lord Winston: The birth rate has decreased though, has it not?
Clare Livingstone: The birth rate has decreased, but the complexity has not.
Q183 Baroness Seccombe: The committee has heard that there is significant variation nationally in the implementation of clinical guidance relating to preterm birth. What is driving that variation, and how can it be reduced?
Professor Basky Thilaganathan: There are two problems that lead to that significant variation. There is a report from the RCOG called Each Baby Counts, which came out in 2022. It reviewed over 1,000 adverse outcomes, of which about 25% were stillbirths and neonatal deaths, and 75% were brain injury. Fundamentally, it showed the variation is based around improper or inadequate risk assessment 75% of the time, and two-thirds of the time, despite the correct diagnosis being made, the guidelines for management were not followed.
Currently, there are 107 NICE guidance documents in pregnancy care alone. Each of those contains between 10 and 20 recommendations and, therefore, any given midwife or doctor has to remember somewhere around 1,500 recommendations and be able to deliver it in a context-specific manner at any time of the day. It does not help to have an encyclopaedia on the ward. A trust may have implemented the guidance but it is not lack of guidance, it is not lack of evidence, it is delivery of the guidance at the right time, at the right place, by the right person, which fails.
Let us deal with how the RCOG is tackling that. About three years ago, with the help of the charity Tommy’s, both the RCM and the RCOG developed the Tommy’s National Centre for Maternity Improvement, which created an application, a software tool; actually, a medical device because it helps deliver care. What this software tool does is that, at five key points in pregnancy—all related to both preterm birth and stillbirth—it delivers the right recommendations for the doctor or the midwife to follow. It does not give them an encyclopaedia. More importantly, this software tool shares the recommendations with the woman. You have it on faith when you go to your doctor or your GP that he or she is doing the right thing for you, but you do not know. What this tool does is it tells the woman, “Dr Basky should now be organising for you to have a scan and transfer you to a tertiary neonatal unit”. So there is nowhere to hide: the women are empowered to make sure they get the right care, and the doctors and midwives are empowered to ensure they deliver the right care.
That software tool is just starting a trial here in 26 hospitals in the UK. It has been funded in Australia in a seven-hospital trial, and a lower and middle-income country version of it is being used in Africa in a Gates Foundation project in 52 hospitals in three countries. We use devices to look at our bank, to book our holidays, and to see how to get to the Houses of Parliament, yet, when it comes to delivering care to these women, we have books and guidance documents sitting on a chair, and it is not quite right.
The Chair: Sorry to interrupt, but, as a retired obstetrician, I sit here worrying slightly. It cannot be right to say, “I am overburdened by the guidance that comes; I cannot cope with it. I need a very simplified version, which may or may not do the job, and that is what we are developing”. It cannot be right.
Professor Basky Thilaganathan: It is an absolutely appropriate point to make. Lord Patel, you are an eminent obstetrician.
The Chair: Was.
Professor Basky Thilaganathan: You are not a newly qualified obstetrician.
The Chair: I might have been.
Professor Basky Thilaganathan: You are not a newly qualified young doctor at 3 am on a Sunday morning trying to deal with the issues at hand. First, there is a difference between experience and knowledge and delivering that. Secondly, it is not delivering a simplified version at all; it is picking out of the 2,500 recommendations that exist. It says, “For this woman”, because the tool knows her personal history and is able to deliver precisely what that woman requires at that time. Too often, we do too much too late.
Baroness Seccombe: May we hear from the two ladies with us? Can we hear from Clare first, and then Róisín?
Clare Livingstone: I concur with what the professor has already said about the volume of guidance and the accessibility of that guidance, but there is another point I would like to make. There is the Saving Babies’ Lives care bundle, version 3. Element 1 is smoking, and smoking cessation is vital in pregnancy. It advises that smoking cessation services should be embedded within maternity services. That has not happened fully. There is a whole mixture of commissioning arrangements whereby smoking services are delivered: some sit within maternity, but others are commissioned externally by other providers; some are with local authorities. We are told attrition rates for referrals that go outside of services are far higher, and that women like to be cared for and supported by someone they know. It really depends so much on trust, on building a trusting relationship, so having a midwife.
Smoking is a stigmatised activity. It is sometimes very difficult for women to admit to it, so they find it difficult to go outside and engage with a different service, with somebody they do not know. Our experience is that they will find it easier if there is good continuity and they are cared for by a trusted professional midwife.
Róisín McKeon-Carter: I will bring it back to the baby. It is imperative that a preterm baby is born in the right place. The Saving Babies’ Lives audit and the changes in the demographic of women having babies has resulted in a paucity of antenatal beds in tertiary services for preterm mothers who are at risk of having preterm babies.
At the NNA, we are driving to find a pathway to get the right baby in the right cot at the right time; to get babies who are blocking cots in neonatal units home as quickly as we can. This will support antenatal beds as well because we have women who come in and maybe sit for two weeks in an antenatal bed. We have developed a programme of transitional care and outreach to include—it is a perinatal workforce—midwives and neonatal nurses, and we get babies to transitional care very early. There is guidance from the maternity incentive scheme, and BAPM has produced a transitional care framework. We know we can safely look after babies born seven weeks premature—33 weeks gestation—in the transitional care. It is about having the quality roles, transitional care nurses outreach nurses, to take these babies home.
My experience in the south-west in Derriford Hospital is that we can reduce the length of separation of babies from the mother to one day compared to a regional average of seven if we have this pathway in place. Along with the director of midwifery, I strive to empty the transitional care cots, because we can put antenatal women in those cots; it is a hybrid ward. That pathway is really important, but it has changed with the Saving Babies’ Lives audit. Women are directed into hospital much more than they were and, of course, the 2007 document, Maternity Matters, closed a lot of the maternity hospital beds. Having a pathway to transitional care and outreach will empty neonatal cots for the most sick and preterm babies, and transitional care will facilitate other postnatal women to be in hospital and get them out quicker.
Baroness Seccombe: Do you see the variation reducing, and that eventually we will get the same guidance throughout the country?
Róisín McKeon-Carter: Transitional care and outreach services are not commissioned. Even though we have a benchmark from the maternity incentive scheme, from NHS Resolution, it is not commissioned. The NNA is really calling for commissioning of transitional care and outreach. It is cheap because the mother is the primary caregiver and our evidence shows these babies do not come back into hospital; once they go home, they are looked after very safely.
Professor Basky Thilaganathan: We specifically asked about guidance, but also about variation in care. The majority of variation in care, according to RCOG’s Each Baby Counts report, is down to improper or inadequate risk assessment. I know this inquiry has heard a lot about risk assessment at pregnancy and how critical and vital it is. The reality is it is not fit for purpose. In fact, the risk assessment tools we use now actually drive and worsen inequity of care in the UK. We have a checklist-based system to assess risk of preterm birth in pregnancy. That checklist-based system is heavily favouring women with a legacy effect; if you have had a preterm birth before, you are heightened and sped into a preterm birth clinical service. However, only 15% of preterm births will occur in women who have had one before. The vast majority of preterm births occur in women who have never had a preterm birth before and, therefore, the current system leaves that out.
The second issue, and the one that really drives the inequity of care here, is the fact that—this committee is fully aware—during Covid it became incredibly apparent that ethnicity and socioeconomic deprivation are the strongest drivers of adverse health outcomes in this country. Nowhere in this checklist does the woman’s ethnicity nor her socioeconomic deprivation feature. So a woman who is socioeconomically deprived or black is automatically two to three times more likely to have a preterm birth but is not afforded those specialist services. Therefore, in the UK now, black and socioeconomically deprived women with the same risk factors are three times less likely to be referred to a preterm birth specialist service.
There are additional problems with it: this checklist uses categorical factors. So if your BMI gets to 40, you are suddenly at risk. However, if your BMI is 39, you are not. If your age is 40, you are at risk; if your age is 39 years and 11 months, you are not. We use these continuous variables in a categorical fashion. A checklist does not take proportion and perspective. So you may be at high risk because you smoke, but you may be at low risk because you have had three babies at term, you are young, you are fit, you are white, you do not have any comorbidities, and you have never had a caesarean section. In a way, this checklist works to stigmatise women, not to reassure them that everything is okay. We cannot use the absence of risk factors to lower their risk because what happens then is we have a very high false positive rate. We tell lots of women they are at high risk of preterm birth and we flood an inadequately staffed service with women who do not need to be seen.
It is for that reason that the Tommy’s app contains a risk algorithm that takes all these factors and uses them to produce a numerical risk in order to triage women. In the current system, if I were to tell a woman she is high risk, and she turns round to me and says, “Prof, what is the risk?” I will have to shrug my shoulders. Therefore, it is really unethical of us to think we are providing a risk assessment system when we are unable to provide the woman with an actual numerical risk. It is not a risk assessment system at all; it is an arbitrary 60 year-old checklist that we have failed to progress from. There is nothing wrong with being 60, but it is the age of the checklist.
The Chair: I think you realised in time that there is nothing wrong with being 60.
Professor Basky Thilaganathan: No, Sir.
Q184 Lord Winston: Maybe we can get away from digital information a little and think about the patient a bit more. We are hearing that a very large number of women are not being seen after they have had a preterm birth, which is a real issue. Basky, you are representing an organisation responsible for training, assessment, and examination of people who are practising: in your impression, how many consultant obstetricians follow up on a woman who has had a preterm birth, let us say at three to four months after the delivery?
Professor Basky Thilaganathan: Very few. Whether women who have had a previous preterm birth are seen when they attend for their next pregnancy would depend on whether the service has a preterm birth specialist service. It would also depend on the 100 to 150 midwives who work in any individual trust and how good they are at using the 60-year-old checklist and affecting their care.
There is robust evidence to show that a woman who is of an ethnic minority or socially deprived is far less likely to be afforded the same access to care than a woman not from those two groups. The key issues here are about access, equity and variability in care and a system that is driving inequity.
Lord Winston: Are you saying access does not necessarily mean they are not given an appointment?
Professor Basky Thilaganathan: Indeed.
Lord Winston: That they just do not turn up?
Professor Basky Thilaganathan: No; they do not get referred.
Lord Winston: I do not accept the issue about the 15% who have a recurrent problem, because a lot of these women have fertility problems following a preterm birth or are very concerned about something happening again; they are clearly very anxious. We have heard people do not feel they were properly assessed afterwards.
As you will be aware, a number of things can occur such as clearly defined abnormalities of the uterus, risk of infection after a preterm birth or manipulation, which is not uncommon because of the risk of bacteria and that may delay childbearing, and there are the issues of trauma. Above all, there is the issue of the psychological status of women. From the evidence we have heard, we do not feel that is dealt with nearly adequately enough, and that is primarily a medical problem.
Professor Basky Thilaganathan: You make two important points there. One may be a misinterpretation or misunderstanding. Of preterm births that occur, 15% currently occur in women who have had a previous preterm birth. The key point I was making was that 85% of women who have a preterm birth do not have a legacy effect.
In terms of postpartum follow-up, I completely agree with you. For example, 55% of women who have preterm pre-eclampsia never have a baby again because of the trauma of going into intensive care and having drips in what they thought was a normal situation, not a disease. Pregnancy is not a disease. It is not just preterm birth; it is stillbirth, pre-eclampsia, and all the above.
We have the services and we have the staffing across the board to deal with what we have right now. Once the cord is cut, our colleges have very limited powers, ability and resources to continue to care for these women postpartum. That is in progress, and the college is very keen to ensure there is postpartum care, but without resources or staffing, that is not going to happen.
Lord Winston: Is it in the college guidelines?
Professor Basky Thilaganathan: There are college guidelines, for example, with pre-eclampsia and preterm birth.
The Chair: Thank you.
Q185 Baroness Owen of Alderley Edge: We have heard a lot about the variation impacting the outcomes of preterm birth, but is the current education and training in relation to preterm birth sufficient to ensure care can be delivered consistently? If not, how could this be improved?
Professor Basky Thilaganathan: The RCOG is an educational institution, so we have a core curriculum, an MRCOG syllabus, subspecialty training, CPD and e-learning, as well as our own green-top guidelines to add to what NICE produced—because there are not enough guidelines available already.
There is more than enough material and a pathway of training but, as I said before, the issue is not about the training. You may know everything, but the key issue is whether you deliver that at the right time and the right place for the right woman.
We are one of the last professions to adopt digital technology. I do not mean digital information repositories, which is what we have now; we have 35 different maternity information systems in the UK embedded in 110 hospitals, with the data stored in 110 different servers. They only serve to provide information to the local trusts about what they are doing; they do not serve me, my junior doctors or midwives to help us deliver better care. That is why the RCOG and the RCM are very keen to implement a tool like the Tommy’s app, which helps inform women and helps us deliver better care.
If you had a magic money tree, I am sure you would give us all the money, we would have all the staff, and we would all be better off. Given that is not going to happen immediately, our solutions have to be the limited staff working cleverer, reducing the false positive rate by using a good screening tool, and therefore reducing the amount of work we do and working more efficiently. It is inappropriate not to think about it.
Clare Livingstone: Although student midwives spend time on neonatal units as part of their placements, it is often just a week or two. So they will see preterm babies, but their exposure and experience are pretty limited, and no standards are stipulated by the NMC in pre-registration.
Róisín McKeon-Carter: When a preterm baby or a term baby needing resuscitation is born, it is imperative that the staff attending that delivery—midwives, junior doctors, advanced practice nurses—have the skills. There is a standard in place: the Resuscitation Council UK’s Newborn Life Support course, which is a one-day course. Sadly, that is not commissioned either; a benchmark has been set for nurses, midwives and junior doctors that nobody is meeting because there is no backfill for staff to attend those courses.
The Resuscitation Council UK relies on a faculty of medical, nursing and midwifery staff. The medical staff get study time and are possibly paid for that, but the midwives and nurses do not get any backfill or time to undertake the additional training to become faculty. Consequently, we cannot run these Newborn Life Support courses, so nobody is meeting that benchmark. It is a huge risk to both the preterm and term baby being born.
Lord Hampton: When you say backfill, are you talking about cover when they are out?
Róisín McKeon-Carter: Yes.
Q186 Baroness Owen of Alderley Edge: What education and training does your organisation provide to improve care for mothers and preterm babies?
Clare Livingstone: The Royal College of Midwives does not provide education. We have education resources to support students and our members, but we do not run courses ourselves; those are provided by universities.
Baroness Owen of Alderley Edge: Is a mother given any guidance before she takes her baby home?
Clare Livingstone: Yes, midwives are fully involved in the discharge of a preterm baby. The mother will be prepared with all the information and support she needs and then will be seen at her home in the community as a follow-up.
Róisín McKeon-Carter: The Bliss charity has developed a charter specifically to support parents of preterm babies to take their babies home safely. It is very clear, and around 12 intensive care units in the country are benchmarked against that charter. It includes education, breastfeeding support, and psychology, and is a really good tool to benchmark services against.
Lord Winston talked about the trauma. Every family who has a baby in intensive care will suffer post-traumatic stress, regardless of how ill that child is. They need allied health professional support going forward, and the women need physiotherapy, dieticians, psychology and nursing support to enable them to take their baby home.
Getting back to the pathway from neonatal intensive care through to high dependency, special care, transitional care and outreach services: intensive care, high dependency and special care are commissioned. Historically, there was a disincentive to keep babies apart from their mothers because you got money for them in an intensive care bed. The NNA is calling for that to change; we want these transitional care beds and a virtual neonatal outreach ward commissioned. We have examples of extremely preterm, small babies being discharged home at maybe 1.5 kilograms, but you have to send them home with staff and an infrastructure in place to enable these women to look after their babies.
Transitional care absolutely supports that. They get tooled up and get skills to be able to look after their baby, and these babies continue out to the community and do not come back, which is the significant thing: they are not readmitted unless they are extremely preterm and have other services to go to. Bliss has asked parents about that pathway, and 100% of parents need that support in the hospital, in a transitional care model and in the community. It is critical.
Q187 Baroness Cumberlege: I do not know whether they still do it, but when I was having children, a lot of us had our babies born at home and the community midwife was just fantastic and gave us huge support. Are those people still in existence or is it now so hospital-driven that it is much less about having babies in the community, and more about having them born in hospital and having support at home when they take the babies home? I just wonder what the picture is now.
Clare Livingstone: We often feel postnatal care is a Cinderella service; that it is not as well-resourced as other parts of the pathway, which is very sad because postnatal care is vital. It comes back to the continuity, because if a midwife has seen a woman and her family throughout pregnancy and is the same person who comes to see them at home—whether the baby is born at home or not—it really joins up those services and enables that support to continue.
Whatever issues arise in pregnancy, it is vital that women do not have to repeat their story to somebody new, or not tell it at all; it helps to have that trusting relationship already established in pregnancy. So it is happening, and it is a variable picture around the country; some places have excellent home birth services that are carrying on, but it comes back to the shortage of staff.
The Chair: It is not just about home births. It is about the community care.
Clare Livingstone: It is exactly about the community care and running community clinics; women are often seen antenatally in clinics, children’s centres or family hubs, which is ideal because it establishes that relationship and engages women with all the other services they will rely on once they have been discharged from our care.
Q188 Baroness Owen of Alderley Edge: I have one more question, and we know what the answer is going to be, but it is useful for the record. What are the main barriers to not undertaking further training? Why are people not undertaking further training in their role?
The Chair: To clarify, is there no opportunity for continuing training in any of the three professions, and what are the barriers?
Professor Basky Thilaganathan: There are very few barriers; there are lots of training opportunities, but we just do not have enough people entering the speciality, and we would urge people to enter the speciality in order to do so. It is about numbers coming through.
The Chair: Is it not enough people entering obstetrics, or not enough people entering obstetrics and gynaecology?
Professor Basky Thilaganathan: It is obstetrics and gynaecology; they are inseparable at entry.
The Chair: But we are talking about specialised preterm services. I am well aware everybody is the same at the entry point, but they become specialists.
Professor Basky Thilaganathan: We do not have a specialism in preterm birth, we have maternal-fetal medicine, which is a major subspecialty within obstetrics and gynaecology. There are more than enough people—the majority of the staff are obstetricians—our issue is with the lack of people entering the speciality of obstetrics and gynaecology.
There is a commitment from the NHS long-term workforce plan to place more people and get more medical degrees, but we need that converted into obstetrics and gynaecology specialists, otherwise we are going to get this bottleneck of having lots of doctors but not enough obstetricians and gynaecologists. That is the key bottleneck, not once you enter the speciality. There is an issue of burnout within the speciality. Our attrition rates have gone down. We are looking after them, but we are not able to protect them from the issues of resources and staffing levels, which is why burnout happens.
The Chair: It is the young blood, you see.
Baroness Cumberlege: When I was giving birth to babies at home, the most important person was the general practitioner, who was very experienced in home delivery and all the rest of it. Has that gone now?
Professor Basky Thilaganathan: Yes, that has gone.
Baroness Cumberlege: That is my answer.
Professor Basky Thilaganathan: It is a midwifery-based service, as it should be.
Baroness Cumberlege: It is a great pity, because it was all about building the family and about the community; it was about so much more than just the baby.
Professor Basky Thilaganathan: I respect your right to have that opinion, but pregnancy is not a disease, and midwives are more than capable of delivering babies at home and recognising when they are not suitable to deliver at home. I would support my colleagues in doing home births.
The Chair: Baroness Cumberlege would not agree with you, having done a lot of work in it. Anyway, we need to move on.
Q189 Baroness Thornhill: Part of my question has been addressed during the discourse, so I might stick a few random things in. In a sense, this is the round-up question, which gives you an opportunity to tell us the priority areas for intervention for our recommendations. How can women at risk of preterm birth be more effectively identified and triaged?
Professor, you have given us a devastating critique of the screening tool, which I found quite depressing and it bothered me a lot. Clare, I believe the midwives do the initial screening. Could you talk to us a little about that process please?
Clare Livingstone: Women will attend a booking-in appointment in the first trimester of their pregnancy where the midwife will get to know them and go through a lot of questions about their social, medical and obstetric history, and so on. Appropriate referrals are made at that point. As the professor has mentioned, a much bigger picture of relevant social determinants and ethnicity is often then clear, which will have an impact on that woman.
Professor Basky Thilaganathan: Can I help my colleague out here?
Baroness Thornhill: It would really help us. We are constantly being told ethnicity is relevant, so can we deal with the causation?
Professor Basky Thilaganathan: Baroness, my sincere apologies; I did not want to depress you at all.
Baroness Thornhill: Depress us in a good way.
Professor Basky Thilaganathan: I offered a solution at the same time as I identified the problem: there are tools that take all these risk factors from the checklist, put them into an algorithm, and come out with a numerical risk for the woman. We have the ability to take this rather inequitable checklist and turn it into an equitable risk assessment, which can then work to place women into various care pathways: very low risk, leave you alone; moderate risk, let us do some more tests; high risk, you need to go to the preterm birth service.
Tommy's National Centre for Maternity Improvement—in conjunction with the RCOG and RCM—implemented this tool in four hospitals during Covid and it is effectively being taken out. We are now doing the early audit, but a randomised control trial in 26 hospitals will be starting in a few months.
Q190 The Chair: You have mentioned this several times now. It is important to distinguish that checklists may not have worked, and I am well aware that checklists are used in other fields of medicine, not only in the field of obstetrics, such as with ethnicity in diabetes where you have scored higher before you have even stated your name. As Lord Winston pointed out, we should be thinking about the patient. If you say to somebody with a different ethnicity, "Your risk of preterm birth is higher because you are black, brown, green or yellow", what does that do to that patient?
Professor Basky Thilaganathan: That is a very good point and is precisely why we need to use the approach the RCOG is promoting. If you say, "You are poor, or black, and at high risk", that is racism or classism, and we cannot do that. Ethnicity in these tools is used in the same way as age or weight; as a way of modifying the a priori risk. A woman who enters your room at the moment may have a one in 100 risk of preterm birth. If she smokes and is black, that risk may go to one in 30, but her risk may drop to one in 500 if she has had five normal, term deliveries. It is used in a very continuous algorithm way, rather than in a categorical way to say, "You are black; your risk is high", or, "You are white and your risk is low".
Lord Winston: We have heard expert evidence that suggests these risks are pretty vague, and that is one of the problems. Can you tell us what the metrics show about the value of this algorithm?
Professor Basky Thilaganathan: The algorithm being used in the RCOG, RCM, and Tommy's clinical decision tool was developed in the UK.
The Chair: It is in development.
Professor Basky Thilaganathan: It has been developed, is CE marked, is being used in four hospitals right now and is going to be rolled out into another 26.
Lord Winston: What do the metrics show?
Professor Basky Thilaganathan: First, the algorithms follow the NICE guidance for digital health technology tools, which means that they are developed and have been externally validated in another time and place to show they work as they are meant to work. It shows the risk assessment is accurate and has been calibrated for women with risks between 0% and 10% for preterm birth.
That is where the tool is used at the moment. Using a numerical risk assessment tool, we are able to halve the number of women identified as high risk, while at the same time improving the women at increased risk of preterm birth by about 20% or 30%, instead of having a checklist that overidentifies women as being at high risk of preterm birth, over-refers, and misses the majority of stillbirths because we do not catch them. We are therefore able to work more efficiently and equitably.
The solutions exist, but the NHS has not had the infrastructure to enable doctors and midwives to use these tools. Midwives are currently using this tool in four hospitals—Lewisham & Greenwich NHS Trust, Ashford & St Peter's NHS Foundation Trust, and Sheffield Teaching Hospital NHS Foundation Trust—at booking to assess and numerically assign a risk. The woman has access to that information, and they are then triaged into care services. This model of care is equitable and reduces inequity of care and poor care, and we have to consider that. I have a conflict of interest because I am leading this issue for the RCOG and the RCM, but we are leading it because the inequity and variability of care are intolerable.
Lord Winston: When do you think we might know whether we have reduced the actual incidence of preterm birth using this particular algorithm?
Professor Basky Thilaganathan: The data from the four early adopter sites, which is not a clinical trial but an interrupted time series analysis, will be available to tell us the impact on preterm birth and stillbirth by early next year. The trial in 26 NHS hospitals in England will be available in 2027. That is a randomised controlled trial, so that would be the highest level of evidence.
I will remind you this is not just about preterm birth and it contains five algorithms. There is a preterm birth risk assessment to ensure all women have equitable care at the beginning of pregnancy. Embedded in the tool is the QUiPP algorithm, which does two important things for women who present with threatened preterm labour: first, it reduces the unnecessary use of corticosteroids, admissions, and transfer of hospital in 90% of women who never go on to deliver, having presented with preterm labour. That is not only a cost saving, but it is good for the women because they can go home and for the staff because they have less work to do. At the moment, there is overtreatment, over-transfer, and a blocking of beds.
Secondly, it correctly identifies the 10% of women most likely to deliver within the next two weeks; those women can then be sent to our neonatal services by the preterm birth lead team. So there are multiple algorithms in this device to help us work better to reduce both preterm birth and stillbirth; it is a complex intervention.
Q191 Baroness Thornhill: Unless Clare and Róisín have anything further to say, can I shift us a little? I do feel a bit happier, because I can understand how using that would give a much more nuanced picture of a woman, and I feel better about the aspect of being black putting you more at risk; that bothered me. I find that encouraging, so thank you very much.
Several people have mentioned the phrase Cinderella service. Why is the delivery of our babies deemed to be a Cinderella service? Can you amplify a little on the wage structure? Are nurses paid more in other areas or is there a set rate? Why would it be the Cinderella service?
Róisín McKeon-Carter: For neonatal nursing, unless a member of their family has experience, the public is not aware of babies needing intensive care and treatment in addition to a midwife. Within hospital trusts, my experience is that neonatal services are a Cinderella service. For example, A&E departments get the focus in a hospital. The Neonatal Nurses Association is trying very hard to raise the profile of the neonatal nurse by meeting the chief nurses for the country.
Pay is an issue. Our specialist neonatal nurses come in as graduate nurses, are immediately put on a postgraduate course that takes two and a half years, and they are paid the same amount of money as before they undertook this course. The Neonatal Nurses Association is calling for equity with our midwifery colleagues to ensure they become postgraduates, undertake preceptorship training, and then get paid an Agenda for Change band 6. We know that will support our nurses to come into the service and to be recruited and retained within our service, so there is inequity in pay.
Clare Livingstone: Midwives see women and families postnatally for approximately 10 days, but sometimes up to about 28 days. We have been increasingly concerned about that and campaigning at the RCM for more resources in postnatal care, but it is sadly an area that seems to get pinched from; robbing Peter to pay Paul. There is just not enough to go around, and that is the reality.
I also speak up for our health-visiting colleagues because that service is very short-staffed and unable to work with us and support women. After the first birth visit, we transfer care from maternity services to health visits at around 10 days. There are a lot of issues, and postnatal care has really suffered for a number of years.
Baroness Thornhill: Let us do the continuity of care that you were going to mention earlier, but the Chair asked you not to. How significant is the continuity of care in relation to risk? What do we know statistically about continuity of care? One witness said it was a wonderfully ambitious aspiration, but basically watch the flying pigs. Why is that? It has obviously been neglected.
Clare Livingstone: It has been, and we will be putting a written submission into the committee that will give you all those figures, but there is a significant difference in terms of preventing preterm birth with continuity of care. There are studies that show this, and there is a Cochrane review showing evidence to support it.
It comes down to building a trusting relationship where women feel able to confide in their midwife, feel well supported; the family, context and background are all known, and they feel able to disclose sometimes very sensitive information to somebody they trust. There is a lot of shame and embarrassment in admitting to things such as smoking, substance misuse, and domestic abuse. These things are very difficult to admit to someone you do not know.
It may also be having somebody who is an advocate and speaking up on your behalf. If someone has chronic housing issues or is living in overcrowded accommodation, midwives will make referrals to local authorities—they now have a duty to refer under the Homelessness Reduction Act 2017—which will hopefully support them in getting some support from their housing department. These are factors that increase stress and stress causes rises in cortisol. It is not difficult or new to us.
Baroness Thornhill: Róisín, do you want to add anything to that from your experience?
Róisín McKeon-Carter: No. The Bliss baby charter that I was talking about earlier will support our cohort of families and their lower socioeconomic issues. In my service in Plymouth, we call it a wraparound; for example, if women are displaced from North Devon District Hospital into Derriford Hospital, we give them free accommodation, food and parking, psychology services as much as we can, and a hardship allowance because we know this admission into a neonatal service can increase family breakdown and adverse maternal mental health.
That is not bought. We had to create funds to get our family accommodation, and we rely heavily on the charity sector and on volunteers to support that. The group we look after is much smaller than the birth rate in the UK, but it is significant. The sequela of reaching neonatal services is significant for financial and psychological reasons, so we would like the Bliss baby charter to be adhered to in all units.
Q192 The Chair: Baroness Wyld led the Private Member’s Bill that now allows parents of preterm babies to be supported longer term.
We have heard evidence repeatedly that neonatal networks—neonatologists, nurses, clinical psychologists and others—are highly effective, including getting funding to provide and co-ordinate the care of the neonates and develop integrated care. Contrary to that, the evidence we heard is that fetal medicine networks are less developed. It may be because they are that much younger in starting, rather than the neonatal, and that time will allow them to develop. I would like to hear the view in the obstetric world about how fetal medicine networks could be developed and why they are not so effective.
Professor Basky Thilaganathan: You are absolutely right; fetal medicine networks are much newer in the game than neonatal networks. In my particular region in south-west Thames, our fetal medicine network has been developed over 15 years and is extremely mature and effective. But that is not the same in the other 24 areas where there are fetal medicine services and units, so there is variability in how they function or perform. Part of the reason is also funding; there is no dedicated funding to develop these fetal medicine networks. They are an addition to everything else we have to do at the same time, and most of us contribute towards the existing neonatal networks.
The Chair: We heard the neonatal network was not funded for 10 years, but it made the case as to how important it was in the delivery of care and improving care that made the funding available, so there may be a lesson to learn. Another important point is that we did not hear that midwives were included in the fetal medicine network. Is that a wrong impression?
Professor Basky Thilaganathan: I can only speak for my region, where midwives are integral to our fetal medicine network. That may not be the case in the rest of the country.
Q193 The Chair: I cannot ask the chief executive sitting in the audience, but what will be the role of the RCOG in developing stronger networks?
Professor Basky Thilaganathan: The RCOG and the RCM are in a new phase and a new relationship. We share a building and premises, and we have very good relationships.
The Chair: No, I mean developing fetal medicine networks.
Professor Basky Thilaganathan: It should be done in conjunction with the RCM. As you quite rightly say, this is not an isolated obstetric adventure. It should be in conjunction with our midwives, and we should have a focus on developing good fetal medicine networks.
The Chair: What will be the role of RCOG in developing strong fetal medicine networks that include midwives? What would be the role in developing stronger networks?
Professor Basky Thilaganathan: No more role than the Royal College of Paediatrics and Child Health had in developing the neonatal networks. It is very much a localised service provision development. It was not driven by the Royal College of Paediatrics and Child Health.
The Chair: Thank you very much indeed. I know we have been more challenging than we usually are, but that was to extract maximum information from you all, and it has been most helpful.
We will try to help as much as we can through this report, but we rely much on the evidence we hear, and for that evidence to be substantiated rather than hearsay. You suggested that you would have more material to send as written evidence; please do so, and figures would be helpful. Thank you very much for coming. We appreciate it very much.
[1] Note by the witness: The witness would like to clarify that the average attrition rate in 2021–22 was 13.8% (Royal College of Midwives, State of Midwifery Education 2023 p 15: https://www.rcm.org.uk/media/7001/rcm-state-of-midwifery-education-2023.pdf), and that in a 2022 survey of student midwives, conducted by Health Education England, 58.3% stated that they had considered leaving their course (NHS England, ‘You said, we listened’: https://www.hee.nhs.uk/our-work/quality/national-education-training-survey-nets/you-said-we-listened).
[2] Note by the witness: The witness would like to highlight the clarification provided in the footnote on page 4.