Written evidence submitted by the National Childbirth Trust (EPE0014)
Introduction
NCT is a charity whose mission is to support parents through the ‘first 1,000 days’, i.e. pregnancy and the child’s first two years, and to help them have the best possible experience of pregnancy, birth and early parenthood. We do this through: sharing knowledge to inform and support parents' decision-making; creating networks for and among new and expectant parents; and harnessing voices to advance public policy and attitudes around key issues for parents.
We were made aware of the government’s ambitions in maternity outcomes from the time of their first launch in 2015 and have been following progress toward their achievement.
Commitment 1: By 2025, halve the rates of: stillbirths; neonatal deaths; maternal deaths; brain injuries to the baby that occur during or soon after birth.
We work alongside charities including Sands, Bliss, Tommy’s and Twins Trust within the Pregnancy & Baby Charity Network and we support the campaigns and calls from these organisations who work specifically with parents who have lost babies or whose babies are at high risk of mortality or morbidity. Our understanding of data from the Office for National Statistics (ONS) and from the Mothers & Babies: Reducing Risk through Audit & Confidential Enquiry (MBRRACE) reports indicates that, although considerable progress has been made towards all the targets since 2015, none is confidently on track for meeting the ambition and the trends in neonatal and maternal deaths are plateau-ing, i.e. progress has slowed so the graph gradient is almost flat.
NCT has a major role in preparing expectant parents for childbirth and therefore we monitor closely changes in midwifery and obstetric practice that may affect the choices that pregnant women and their partners wish to make. An example is the rapidly increasing frequency of induction of labour (IoL) being recommended to women who are told that their unborn baby may be at risk if the birth does not take place swiftly. The Care Quality Commission in 2019 (CQC Maternity Survey) found 44% of women reported having accepted IoL, compared with 29.4% in 2017 and 31.6% in 2018 (NHS Maternity Statistics 2017-18). It is understood that one cause of this increase is a commendable desire to achieve a reduction in late-pregnancy stillbirths, which is now near its target. However, the rate of births complicated by a need for intervention also increased over the same period and it appears the neonatal death rate slightly increased. We are concerned that IoL rates have risen so sharply without a strong evidence-base for the change and we trust that research into the outcomes of birth after IoL will be carried out robustly, that findings will be disseminated and that parents can be assured there are not unintended negative consequences of the high IoL rate.
As a charity for parents, we are profoundly aware of the impact on a family when a mother dies. Therefore, although we acknowledge that the numbers of maternal deaths in the UK remain low and slowly diminishing, we read each relevant MBRRACE report and help disseminate the findings. It has been widely documented that there are stark inequalities in outcome when deaths of white women are compared to those of Black, Asian or mixed heritage mothers, as well as the contrast between women from the least and most deprived areas. Some extra help has been included in the NHS Long Term Plan for these mothers, but there are still numerous accounts from individuals affected who describe an NHS culture where Black women, in particular, do not have their expressed concerns addressed, leaving them feeling ignored and marginalised from mainstream services. This loss of trust can create a cycle of missed appointments by women who feel the service is not for them and poorer care due to the lack of continuity in the relationship. As well as the emphasis on continuity of carer for women from BAME groups, there needs to be more work on NHS culture and expansion of cultural competence training.
Repeated analyses of the annual MBRRACE data show more maternal deaths occurring in the postnatal period than at other stages. This is a serious concern. We gain a strong impression that health planners aiming to improve outcomes tend to focus on late pregnancy and in-labour interventions – such as IoL, fetal surveillance, assisted and surgical modes of birth - in the hope of rapid progress within the same system. Unfortunately this cannot happen in postnatal care as the service is stretched - and over-stretched - across hospital, community, public health and primary care. There is a worrying lack of co-ordination, leadership and accountability, leading to women ‘falling through the gaps’ and unable to find the right professional to address their issues as they navigate a labyrinth of different health organisations, locations and booking systems. It must be remembered that many of these women are already experiencing volatile levels of mental health, and virtually all of them are caring for a newborn baby.
Commitment 2: By 2024, 75% of women from BAME communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period
NCT works with the ‘FiveXMore’ movement and others to highlight the gross inequalities of maternity outcome for women from Black, Asian and other minority ethnic communities. We acknowledge the accelerated commitment to providing a continuity-of-carer model of practice for these and other women – and their babies - who are at greater risk of mortality and serious morbidity. However, this move is unlikely to be successful unless it is embedded in a wider culture change across the NHS and other statutory agencies, as well as within the voluntary and community sector where support to parents is offered.
Commitment 4: All women to have a personalised care and support plan by 2021
Responding to the panel’s question ‘Is the commitment likely to achieve meaningful improvement for service users?’, it is a matter of regret to NCT that many women now express some cynicism about any approach to personalised plans, whether these are specific ‘birth plans’; other preferences recorded in their notes; or conclusions based on decision aids (DAs) such as the NHS ‘Where to have your baby?’ or Birthrights’ ‘IDECIDE’ which promotes informed consent. DAs have become more popular since the ‘Montgomery judgement’ (UK Supreme Court, 2015) which changed the basis on which women must be given relevant information before they accept or decline an offered intervention. However, anecdotal feedback suggests that creating a plan or using a decision aid may raise women’s expectations but cause disproportionate disappointment if the plan is not – or cannot be – carried through.
Any kind of plan suggested or recommended to pregnant women must be both realistic and flexible, while at the same time demonstrating a genuine understanding of their individual wishes and an ability of the caregiver both to explain the evidence underpinning the benefits and disadvantages of a course of action and to acknowledge when this evidence is too sparse to be useful.
The stage of the maternity journey at which plans can be most useful is the postnatal period: unfortunately this is often a time that a plan fails because of the fragmented nature of the service and the poor co-ordination of the care provided by hospital, community, local authority and primary care. Postnatal care plans must cover the period from birth until at least the 6-8 week GP check-up, and ensure the mother and baby have a source of support they can contact at all times, as this period can be an extremely vulnerable time for both.
NCT therefore supports the commitment for all women to have ‘a personalised care and support plan’ but with the caveat that these must be used as an opportunity for open discussion when women can feel comfortable to disclose their, sometimes intimate, concerns. One comment from our March 2021 postnatal care survey said: “Postnatal care has been awful. I said [to HV on phone] I had been deeply anxious … and she completed a meaningless questionnaire … it felt entirely pointless and bureaucratic. I have not felt supported by any postnatal care … I do not feel listened to and do not feel that there is any real support in place, just questionnaires and tick-box checklists.”
Above all, any care plan MUST avoid both the perception and the actuality of being a ‘tick-box’ exercise.
May 2021