Written evidence submitted by the Royal College of Midwives (CLL0073)
We welcome the opportunity to submit written evidence to this inquiry, into the lessons to be learnt from the COVID-19 pandemic.
The Royal College of Midwives (RCM) is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance and information, and learning opportunities with our broad range of events, conferences and online resources.
The impact on BAME communities and other at-risk groups
The pandemic has highlighted – and indeed exacerbated - many of the injustices experienced both by Black, Asian and minority ethnic (BAME) women who use maternity services and by BAME midwives and maternity support workers (MSWs). It is therefore incumbent on everyone involved in funding, planning, commissioning and providing maternity services to ensure that, rather than restoring the status quo, there is a collective commitment to tackle those underlying problems, which have always been there but for which there can no longer be any excuse to ignore.
This must include urgent action to address disparities in outcomes and experiences when it comes to maternal health and wellbeing. Black pregnant women are five times more likely, and Asian women twice as likely, to die during pregnancy and childbirth than white women. The experience, outcomes and access to services are also far worse for black and Asian women.
We support the action being taken by the Government, such as the four steps that the Chief Medical Officer and the National Clinical Director for Maternity and Women’s Health set out in June: a lower threshold for admission and referral for BAME women and their babies; better, more tailored communications; nutritional support; and more accurate ethnicity data.
But welcome as these initiatives are, we believe further action is necessary. In particular, the RCM supports an explicit target for the elimination of racial disparities in maternal mortality. Such targets focus minds and efforts on a problem, and this is something that must be addressed as a matter of urgency. This was recommended recently by Parliament’s Joint Committee on Human Rights and we would urge this inquiry to repeat and support that recommendation.
Urgent action is also needed to address the inequitable and discriminatory treatment of BAME midwives and MSWs. It is simply unacceptable, for example, that BAME maternity staff are more likely to experience bullying at work, face disciplinary processes and be less likely to advance in their careers. The most recent (2019) NHS staff survey found that 42% of midwives had experienced discrimination based on their ethnic background. This is something we must commit to tackle more aggressively than in the past. If we are to deliver an inclusive maternity service, racism in the NHS must be stamped out, and replaced with respect, dignity and compassion for everyone who works in it and for everyone it serves.
Whilst the focus of this inquiry is on the future and lessons to be learnt, the RCM would recommend that right now all BAME and other vulnerable staff should be risk-assessed. This could have big implications for the ability of services to ensure they have sufficient capacity to operate safely. This is particularly true for services with workforces that employ a significant proportion of staff who are BAME or otherwise potentially vulnerable. Looking further into the future, risk assessments like this need to take place as early as practicably possible and policies developed quickly to respond to the findings.
The lesson to be learnt here is that we need to drive down and seek to eliminate racial disparity. We want to see ambitious recommendations from this inquiry challenging the Government to get on with the job of eliminating disparities, which are wrong at any time but which in the pandemic have been shown to deliver even worse outcomes to BAME people.
Government communications and public health messaging
Advice to pregnant women in the early stages of the pandemic
In March, as the country entered the first national lockdown, the Government identified pregnant women as amongst those facing the highest risk from the virus. This announcement was made without any consultation with the RCM and without supporting evidence, particularly for women under 28 weeks pregnant.
The effect of this statement on pregnant women workers, especially those who continued to work in public facing roles – such as midwives and MSWs – was to leave them feeling exceptionally vulnerable in relation to whether they could carry on working at the front line. Unfortunately, the NHS was slow to give advice and support about the implications of this announcement for its pregnant workforce. In the absence of guidance from their employer, many pregnant women workers in maternity turned to the RCM, and we worked at pace with colleagues at the Royal College of Obstetricians and Gynaecologists (RCOG) to provide the advice and guidance pregnant women sought.
If the Government had given advance warning to the RCM and RCOG, we could have worked with them at speed to ensure that material and advice was in place while any announcement was made. This was a key opportunity to get the right message out straight away, but which was mishandled by the Government. There was of course a case for speed, but a little extra time to prepare for the inevitable would have been better.
This should not happen again. The Government has at times relied heavily on organisations such as the RCM, the RCOG and others to do much of the heavy lifting. It should have included them in discussions earlier than it did. Doing so would have served the interests of the public better. In any future equivalent situation, the Government must bring in key stakeholders as early as possible.
Visits to maternity units
Despite positive news on vaccines and the development of clinical interventions to assist those badly affected by the virus, we remain largely reliant on non-clinical practices to contain the speed and spread of the pandemic.
Fundamental to this is social distancing: limiting in-person interactions in which people may unwittingly pass on the virus. The need for social distancing extends to hospitals and other healthcare settings, where the virus could easily spread to vulnerable people and the NHS staff who care for them.
In maternity, that has meant that the NHS has sought to reduce the number of people coming into units. In some places that has meant shorter visiting times or partners having to attend scans virtually rather than physically. This has meant that for some women, their experience of maternity care may not have been what they will have anticipated. It is not the experience that midwives will have wanted for them either.
However, the NHS has at the same time sought to balance this with the need to ensure that all women are supported by at least one partner during labour, birth and for the period immediately after the birth. This applies in all but an extremely limited number of circumstances.
We have seen recently however a growing pressure on those running maternity services to abandon the balance that has been struck between openness and safety. These calls seek, more or less, to lift the restrictions that exist in maternity. But, while midwives understand that current arrangements are far from ideal, they are designed to maximum the safety of women, their partners and visitors, other users of maternity facilities and maternity staff. It also needs to be acknowledged that maternity services entered the pandemic with many units stretched near to breaking point.
Midwives understand that the current arrangements are far from ideal. They are not the experience of pregnancy many will have anticipated. It is not the experience midwives want for them either. But the pandemic has changed temporarily the way the NHS is able to provide care, and the service entered the pandemic with units already stretched near to breaking point.
Midwives understand that women and families will be feeling anxious about how the current arrangements will impact on their pregnancy and birth, but a big problem is the misinformation circulating online and in local communities and how that may stop pregnant women from accessing the care and support they need, or raising anxiety levels unnecessarily.
We have been particularly concerned that the impression is being given that that women are being denied support during labour and birth. Such stories are misleading and irresponsible. The overwhelming majority of women will continue to have their partner with them during labour and birth. Even in the extremely small number of cases where this is not possible, it remains the case that no woman ever gives birth alone – the very role of the midwife is to be there as emotional and psychological support as well as ensuring safe clinical care.
The coverage of this issue may also have contributed to the fact that, in a recent RCM member survey we found that seven out of 10 midwives had experienced abuse from pregnant women, their partners and families due to changes to attendance rules during the pandemic.
There was an opportunity for the Government to get this right. A framework agreement developed by the RCM, the RCOG and the Society & College of Radiographers was finalised at the beginning of August and yet it took NHS England (NHSE) an entire month to agree to publish it. Had they acted quicker it is likely that visiting would have become less of an issue because the message would have been out there earlier and before it became apparent that we were heading into a second wave.
The whole experience of this issue demonstrates just how important communication from the Government is. Should the UK go through this experience again, the Government must be more willing to explain why certain actions are being taken (for example, on rules around maternity unit visits) rather than acting simply as a channel for understandable frustration.
Expectation of a return to normal NHS services
The pressure that NHS maternity services have been under to lift their safety measures forms part of a wider problem that we are seeing arise across the health service.
Even whilst the virus continued to spread and well before any positive news had broken about vaccines there was much talk about getting NHS services back up to normal. But while we do need to restore services, we need to be mindful too of the huge physical and mental toll the pandemic has had on the NHS workforce.
It is in this light, for example. that Directors (DOMs) and Heads of Midwifery (HOMs) have raised concerns with the RCM about how they are meant to focus on delivering on a target that 35% of women are on a continuity of carer pathway, by March 2021, when they have so many other pressures to contend with. We are not aware of another part of the NHS that has been expected to continue with such as fundamental service change, while in the middle of a pandemic, and with chronic staff shortages. To date the NHS has been deaf to protestations from the NHS and our members that this is not the time to be introducing new ways of working and imposing targets.
We know that the first wave of the pandemic took its toll on midwives and MSWs. While they remain determined to support the women in their care, energy levels have been sapped, self-isolation protocols have added to staff shortages, and the pressure to return to work-as-normal is causing real anxiety across the maternity workforce.
Some thought does need to be given to expectation management. Not that normal service will never return but that staff are not machines. They have been on the frontline of fighting this pandemic for most of a year and need time to deal with the impact of that. The service needs to assist them as they go through that, and at a higher political level we need some visible attempt to understand those pressures.
Axing of Public Health England
The axing of Public Health England (PHE) and its replacement by a new National Institute for Health Protection raises significant questions about the future of public health services in England.
In particular, with the virus yet to be defeated (with tens of millions facing severe restrictions for months to come, even after the end of the second national lockdown), is now really the right time to order a major restructuring of the bodies spearheading the pandemic response? Did taking this decision make it easier or harder for those involved in public health to focus solely on tackling the virus?
This is certainly an issue worthy of exploration by the inquiry. Aside from the pandemic response, it is important to note that PHE directly manages or commissions programmes of relevance to maternity care, such as immunisation and screening, infant feeding and smoking cessation. These all contribute to making us healthier as a nation and to significantly reducing the pressures on the NHS. We must of course ramp up our ability to fight the pandemic but in doing so we should not take our eye off the ball of endemic public health risks.
The UK’s prior preparedness for a pandemic
The RCM’s most up-to-date assessment is that the NHS in England is short of just over 3,000 midwives. The NHS has been short of midwives for decades despite repeated promises of more midwives for the NHS. In the runup to the 2010 UK General Election, for example, David Cameron promised to recruit 3,000 more midwives. A decade later we are still waiting for them all to arrive.
The most recent survey of HOMs illustrates well some of the pressures:
The RCM also conducted a survey of members in the summer that demonstrated the pressure on services and the workforce:
Running a service with insufficient resources means it can just about run OK most of the time, reliant upon the goodwill of those who staff the system. But such an approach leaves it much less likely to cope when placed under intense pressure. The lesson here is that we need to see proper, sustained investment in the NHS to ensure it recovers from the strain and impact that the pandemic has had, as well as putting it in better shape to cope with any potential future pandemic or crisis of a similar magnitude.
The use of student midwives
Student midwives make an invaluable contribution to the health of women and families, both during and after their training. Never has that been more apparent than during this current crisis, not only with those formally entering the workforce but also with many others who have volunteered in health and care settings.
That said, the utilisation of students (as well as returning midwives) has often been reactive, slow and poorly thought-out. This is perhaps to some extent understandable and excusable. The system was going to need resources, including people, so was provided with those resources to tackle what would come as the pandemic took hold.
The decision to suspend student midwives’ studies and deploy some of them into the workforce represented a massive disruption to their education and their preparation to become midwives. The RCM believes that if the system had been better prepared to deal with the pandemic then it may not have been necessary to use students in this way. This disruption was therefore a consequence of the under-resourcing of maternity care, leaving it needing staff from wherever it could get them.
In future we should seek to ensure that the education and training of future midwives and other healthcare staff can continue and be subject to as little disruption as possible.
To this end, there needs to be a thorough review of the deployment of healthcare students as well as returners. This needs to form part of a wider plan for how the NHS copes with any subsequent crises of this kind.
There can be no doubt however that women and their babies have benefited from the sacrifice and dedication of student midwives who have stepped up and supported maternity teams across the country. Those who helped in this way deserve praise for their commitment.
 “Seven out of 10 midwives experience abuse from women and partners during pandemic, says RCM”, Royal College of Midwives, 20 November 2020, https://www.rcm.org.uk/media-releases/2020/november/seven-out-of-10-midwives-experience-abuse-from-women-and-partners-during-pandemic-says-rcm/
 “Midwives missing meals and loo breaks to keep services running”, Royal College of Midwives, 20 August 2020, https://www.rcm.org.uk/media-releases/2020/august/midwives-missing-meals-and-loo-breaks-to-keep-services-running/