overview of maternity care in the uk jane sandall, professsor of womens health department of public...

Overview of Maternity care in the UK

Jane Sandall, Professsor of Womens HealthDepartment of Public Health

King’s College, London School of MedicineKing’s College, London

jane.sandall@kcl.ac.uk

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Maternity Care Is Different From Other Forms of Health Care Because

Latent in the care of women are ideas about motherhood, Latent in the care of women are ideas about motherhood, the role of women, families and sexualitythe 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

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• 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.

European Union Activities of a Midwife

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The Nursing and Midwifery Council (NMC)

All midwives must be registered with the NMCRegister for midwives and a register for nursesCurrently 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 practicesThe NMC sets standards for practice, education and supervision of midwivesThe NMC also investigates any allegations that a midwife (or a nurse) has not followed their code of practice

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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 months55 UK universities currently offer midwifery education programmes (not all offer the 18 month option)Training takes place at a university and at least half of the programme is based in clinical practice in direct contact with women, their babies and familiesThis can include the home, community and hospitals, as well as in other maternity services such as midwife-led units and birth centres.

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Midwifery EducationEU Directive 2005100 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

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Having a baby in EnglandAbout 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 hospitalafter delivery, women with instrumental deliveries one or two days andwomen with caesarean deliveries between two and four days

NHS Maternity Statistics, England: 2004-5 and 2007-08

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Current Policy

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Maternity Care Pathway

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Policy background on place of birth -NSF

Choice of most appropriate place and professional based on wishes, preferences and needsSpecific inclusion of home birth with risk assessment and adequate local supportMaternity 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

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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

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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

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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%

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Home births 2001-2007

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Birth Centres/midwife-led units

Trusts with: OUs AMUs

FMUs

No. %

84

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OUs only 1

65.8

17 OUs and AMUs

3

13.2

2

1

1

OUs, AMUs and FMUs

1

3.3

10

2

2

6

1

OUs and FMUs

2

15.1

FMUs only

3 2.6

HCC Data 2007 www.npeu.ox.ac.uk/birthplace

25 AMU54 FMU

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Birth Centre activity levels in England 05/06

Birth Centre Activity 2005-2006

0 100 200 300 400 500 600

GilchristRobert Jones*

WhitbyMalton

OkehamptonBridgnorth*

RomseyLudlow*

GranthamHarwich

Clacton*Braintree*

Bridlington*Lymington

Grange***Corbar

Wantage*Penrith**

Blackbrook^Devizes*Paulton*

HytheWakefield

Shepton MalletMaldon*

Andover*Wallingford

Frome*Chorley*St Mary's

GosportHexham

St AustellWestmorland

Jubilee*Weston-Supermare

Crowborough*StroudDover

Trowbridge*Royal Bournemouth

Shrewsbury*Hemel Hempstead*

Edgware

bir

th c

en

tre

deliveries

Tyler 2007

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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

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Defining normal birth

Women who:Started labour without induction. Did not have any anaesthesia. Did not have a caesarean. Did not have an instrumental deliveryDid not have an episiotomy

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Trend in ‘Normal’ Birth Rates

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Childbirth interventions 2007-08An 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 episiotomyNHS Maternity Statistics, England: 2004-5 and 2007-08

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Normality – priorities for implementation from NICEOne 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.

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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

Women’s experiences

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Current policy concerns UK 2008

Choice in place of birthSafety of out of hospital birth and midwife led careRising caesarean ratesReducing InequalitiesSystem safety

New in 2009 What models of care are cost-effectiveMaternity workforce and skillmix

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Implementation – what will it take?Dissemination and discussion at Trust/PCT level on

current practice and where it deviates from guidelineMidwife as first point of contact (NSF) (13% only in NPEU 2007 cf 12% in 1995)PSA Delivery Agreement – first contact before 12 weeksStrategy 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 placeSignificant changes in the ways midwives work to enable one to one support – admin, support roles, role at CSReview of models of midwifery care and skillmixTargets - see 10% home birth in WalesWill to change

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Evidence, Professions, the public and policy

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Research AgendaWhat are the outcomes for women at low risk in different birth settings? - BirthplaceCan 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?

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jane.sandall@kcl.ac.uk