Webchat with Dr Gwyneth Lewis
Dr Gwyneth Lewis, a leading expert on maternity care and maternity adviser to the Department of Health, joined us for a webchat on 27 April 2009. This is an edited transcript of the discussion.
Before the chat, lots of Mumsnetters posted questions about antenatal care, including pregnancy loss, and postnatal care, so Dr Lewis began by explaining what she does and then answering the pre-chat questions.
GwynethLewis: Morning Mumsnetters. First off, I thought you'd like to know a bit about me and what I do. I am what is known as the maternity czar, in charge of advising the government on maternity policy. I am not a politician but a doctor with a passion for improving maternal and newborn health. Although I can answer and will try to answer many of your questions I can't do the overt political ones, nor can I comment on individual clinical issues.
So I will do my best to group the questions that I've seen so far and update you on what is currently happening, but I would also really like it if you could give me your considered views on what we should be doing next. The Maternity Matters policy has already done a lot of improve maternity care, and Lord Darzi's review, but we know that things aren't perfect and we're currently asking women and their partners where we should be improving services next. So I would like to leave the end of the session with a list of your top priorities to take back to ministers.
We're going to put up some answers to your early questions and then we can get started on the chat. You can read the questions in full here.
GwynethLewis: A number of posts asked about management of early miscarriage and access to early pregnancy assessment units. I have to say that I completely sympathise with the comments that you've made and understand the real devastation that not only a miscarriage can cause but also trying to find services that are friendly nearby and available when you need them. Although it's not in Maternity Matters as such, the treatment of early miscarriage and access to EPUs has already been raised as a very important issue in our overarching blueprint for maternity services, the National Service Framework for Maternity Services, available on the Department of Health website. The Secretary of State has already said that miscarriage is an important issue for him and we hope that the next stage of our maternity strategy will include this as a priority. I'm taking away the Mumsnet miscarriage standard code of practice to look at and pass on to everyone involved.
GwynethLewis: This is a hot topic and I quite accept many of the comments you've raised and I do understand the postnatal care immediately after birth in hospital scores least well on user satisfaction surveys. We are actively recruiting and training another 4,000 midwives but they won't be available until the end of 2012. These should make a great difference in addition to the 1,000 that we will have on stream by the end of 2009. The Healthcare Commission surveys have also pointed out poor standards of hygiene and staffing. Hygiene is a top priority for the NHS, and the Care Quality Commission who will now inspect hospitals will be looking at this closely. Hospital trusts have been asked to ensure that staffing levels are appropriate and safe, and I know that many have already reached acceptable staffing levels on postnatal wards and we expect progress in other hospitals very shortly.
In terms of reaching midwives after you've gone home, the Department of Health is very clear that all women should be able to access their midwives at places and times that suit them best. Every woman has the right to have an individual postnatal care plan, discussed with their midwife, which takes account of their needs and wishes.
In future, you will see midwives far more visible in the community, particularly in children's centres, where they can provide antenatal and postnatal care on a regular ad hoc basis.
In answer to the question on whether it is policy to cover postnatal wards at night, it certainly isn't government policy. Staffing is determined by local trusts and I know that they make every effort to use their own staff as much as possible and are working to provide continuity of midwifery care.
GwynethLewis: In regards to the questions from sambo303, hunkermunker and rachyrachyrach on breastfeeding, I can assure you that although breastfeeding support services may be rather patchy at present, there is a huge push to improve this and the DH is encouraging trusts to adopt Unicef Baby Friendly Initiative so that all staff in contact with mother's are trained to help mothers establish breast feeding and continue for longer. It's a government aim to improve breast feeding rates by 10% and 4 million pounds has been given by the department of health to kicks tart this. As our children's services develop, we expect to see easy access to breastfeeding support counsellors and and breastfeeding cafes. I am particularly concerned to improve breast feeding amougst teenage and more vulnerable mothers as it improves their physical and mental health, their attachment to their baby, and has significant health benefits for the baby as well.
CMOTdibbler: What do you think can be done to ensure that women get the support to continue to breastfeed? It seems that HCPs 'talk the talk' about initiating breastfeeding, but as soon as there is the least problem (baby too small, baby 'too big', not going 'long enough' between feeds, going too long, not feeding for long enough, feeding too long are all genuine statements from HCPs of women on MN) it is recommended to 'top up' with formula, or to introduce complementary foods before 26 weeks. It seems that breastfeeding is only a tangential part of HCP training, and that there is no requirement to keep up to date with developments. Nor is there any obvious way of dealing with an HCP who gives out of date or erroneous advice
GwynethLewis: First off, all health professionals must undergo regular updated training and the implementation of the Unicef Baby Friendly Initiative includes mandatory updated training for all staff. As I understand it, and I am not the world expert on Unicef Baby Friendly, all staff working in a baby-friendly trust have to undergo this extra training but as I said, I would need to check my understanding on this point.
CMOTdibbler: I think that there lies the problem - the maternity unit may have baby-friendly status, but the community midwives and health visitors are not going to be employed by the trust but by the primary care trust, so don't get updated training. I think the idea of a personalised postnatal care plan is great, but when will it be drawn up? In my case I went straight from SCBU to home, and had no idea at all what was going on. Neither did the midwife I think, as she didn't see me for four days afterwards. And this was a baby who had been jaundiced, in breathing problems and had a tube for feedings until 24 hours before discharge.
LeninGrad: How will the extra midwives work? I'd like a lead and back-up throughout my antenatal care, during labour and birth, and postnatally. A personal doula if you like. By the way, I need this now and for the next three months when my baby is due. Is that completely unrealistic?
GwynethLewis: Most of the posts are about type and place of birth and support of labour but I also think that antenatal care is important at helping women arrive at choices that are important for them. Although we have choice guarantees about place of birth, we have to accept that total choice isn't currently available to everyone around the country, as many of you have pointed out. The extra 4,000 midwives that I've already mentioned will go an enormous way to helping provide as many options as possible, as well as innovative and imaginative use of midwifery support work. This last group of really important people have an enormous amount to offer in supporting midwives and freeing up midwives' time to do what they do best. Every maternity trust has got plans, if not already implemented, to offer all mothers appropriate choices. And we know that in many parts of the country that satisfaction rates are rising accordingly, but we know that we have much to do.
In answer to LeninGrad's question about personal doulas, yes it would be a great thing I agree, but the funding of them proposes huge problems as they are very expensive to provide for everybody and other services will have to suffer as a result if we don't have unlimited funding. So being realistic, I don't think think a personal doula is possible, but we are working very hard to provide individualised care for everybody and extra support for those who need it most.
Dalyrymps: I've heard that although there are lots of midwifes being trained at the moment, there aren't the jobs there once they have been trained. I've heard that the governement are not providing the money needed to be able to offer the extra jobs even though the midwives are desperately needed. There have been newly trained midwives on here complaining that they are really frustrated as they have trained but can't get a job due to this reason. Is this true? Are the governement trying to sound good by saying they're training extra midwives but then not funding the jobs?
GwynethLewis: I can understand where you are coming from because in some parts of the country midwives are currently finding it hard to get jobs, although the extra money that has been given to maternity services will help free these posts in the future. Additionally, changes to the way the government is providing payment for maternity services should provide 10% more funding this year for such posts. This is on top of £330m already committed to supporting this. The 4,000 figure was developed in response to what the DH was told was needed by the Strategic Health Authorities.
Kopparbergkate: If these extra midwives appear on the wards, that will be great but is anything being done to try and enforce the continuity of care that "one woman, 1 midwife" implies or will health authorities be free to just make the existing midwife teams larger so you have even less chance of being cared for by the same midwife before, during and after birth?
GwynethLewis: Kopparbergkate has asked about continuity of care, and the Maternity Matters policy is not just about one woman one midwife, but about reorganising as necessary so that women have a known lead midwife during their antenatal period and postnatal period as well.
Wavertree: Do you reckon that all the choices pregnant women are supposedly offered actually sets some of them up for disappointment when they don't get the birth they've planned or envisaged, particularly first time around? Do you think midwives should be emphasising that, to an extent, you get the birth that your baby gives you? And do you agree that what women need is a clear explanation afterwards, so they don't go away feeling they somehow 'failed' if they had a caesarean, failed to have a water birth or whatever?
GwynethLewis: Poorly prepared mums have less satisfying labours and are more likely to have interventions, which is why we support the introduction of active management of labour initiatives during the antenatal period. I know only too well how ending up with a caesarian section may lead to a sense of failure and I do accept your point that perhaps we ought to make sure that mothers that don't get the births that they had set their hearts on get the opportunity to discuss this afterwards.
hunkermunker: Please can you define "vulnerable"? Aren't we all vulnerable in some way after we've had babies? Isn't providing community support for ALL women, rather than targeting specific "hard-to-reach" groups a better way forward? I'm interested in parity of service - decent provision for all. How is the £4m being spent? Has that been given to hospitals direct, perhaps to gain accreditation with Baby Friendly? Isn't a large part of the problem that chief execs don't see maternity services as a priority? Is more education for those in control of the purse strings an option? As I said below, it seems to be that the standard is "you're not dead, your baby's not dead, what are you bleating about?".
I welcome the introduction of Maternity Matters, but I really do think we have a long way to go if women really are given true choice in their care - especially in London hospitals, where there is huge pressure on labour wards. I'd also like to say that, from where I stand, things are getting better. When I started to contact people in my borough (councillors, MPs, health professionals, etc) five years ago, there was little notice paid to it. Five years on, exciting things are happening with regard to maternity services and particularly with breastfeeding support. I'm sure it's a combination of top-down policy and pressure from the women who've been through the service that's changing things within - but there still needs to be somewhat of a culture change within the service - and more needs to be done about hearing from the women who've been through the service. I'm working on that though!
GwynethLewis: hunkermunker asks for my definition of vulnerable and I take her point that we are all vulnerable in some way, especially at such a critical time in our lives. The term is generally used, however, when discussing those women who need services most and who access them least, such as the hard-to-reach groups that you talk about. Some of these face a ten times higher risk of death or problems during childbirth, as do their babies and young children. But I do agree that all women should have access to universally high-quality services, it's just that we have to work extra hard to get these other mothers into services.
martha7731: I wanted to ask what your views are on the issue of elective caesarean by maternal request (ie when there's no medical need). This is something that is standard practice in many countries but still not the case in the UK. Do you think this is for financial reasons only and do you think it's ever likely to change? I feel strongly that every woman should be able to choose the birth she wants - assuming she fully understands the risks and benefits of course. I had very personal reasons for wanting an elective caesarean for my first pregnancy, and actually went private because I couldn't face the additional anxiety and trauma of having to 'persuade' possibly hostile midwives/consultants of my case. We're not rich, and so this cost is a stretch for us, and I feel it's very wrong that intelligent and informed women should be denied this choice.
GwynethLewis: I'd like to point out that there is no blanket ban as some people think, however, as more evidence emerges from my own work, in particular about the risks of caesarian section, the advice from the National Institute for Clinical Excellence is that it is far more beneficial to have a caesarian section only for clinical reasons. But the guidance also understands the real difficulties some mothers face having had previous traumatic births and recommend in this situation that they have a chat with the obstetrician and decide which is the best course of action for them and seek a second opinion if necessary. The work I've recently done with mothers has now definitively proved that caesarian section proposes significant risks to subsequent pregnancies. For example, if you've had two previous sections, you are 18 more times likely to suffer a major bleed.
hunkermunker: What do you think of Bounty packs?
GwynethLewis: I think it is important to know that Bounty packs are not assessed or endorsed by the Department of Health and their provision is negotiated by the local maternity trust. The DH does provide the maternity book, which is free of charge and we are very proud of our new pregnancy care planner, which you can find on the NHS website. This can also instantly be translated into 12 languages.
carriemumsnet: We've had a lot of discussion over the years on Mumsnet about Group B strep and the anxiety and in some cases devastation this can cause, yet it's rarely - if ever - mentioned by the maternity services and the test isn't offered routinely on the NHS. Is this something you have a view on?
GwynethLewis: I really appreciate the strength of feeling on this issue and have met Group B Strep Support and others to hear their views. Recommendations about screening for all mothers are made by the Royal College of Obstetricians and the National Screening Committee and these currently do not support its routine introduction because of the potential risks to mothers. However, this guidance is under review by the national screening committee and I suggest anyone who feels strongly about this should contact them directly.
slug: I have only had one child, possibly because the experience of having my first was so traumatic that I can't face childbirth again. A major factor in my experience was the lack of anaesthesia. Initially, I was refused access to anaesthesia because the attending midwife, who I had never met before, imposed her Christian beliefs on me telling me "God intended women to suffer as punishment for Eve's sin". I was later told there was neither an anaestheist availabe, so I could not have an epidural, nor was there any gas and air left. I was forced to have an episiotomy and deliver an 8lb baby via forceps, and be stiched up afterwards without any pain relief at all. I've later discovered that this is not an uncommon experience in the hospital in which I delivered (Evangelical Christians aside). What is being done, if anything, to ensure women aren't forced to give birth under such circumstances?
GwynethLewis: slug and others, I'm so sorry to read about your experiences and I understand the very lasting effects this has had on you. I can't comment on the particular circumstances or individual midwives, but in terms of pain relief, if you were in a hospital, you should have had access to both an epidural and gas and air. You midwife sounds dire and I would have wanted to complain, too. In the first instance, when I felt ready, I would have asked to speak to the head of midwifery and then the local supervisor of midwives. All hospitals have a PALS service who can advise you on how to complain.
coveredinsnot: Screening for postnatal depression is common, and everyone seems to know about it. But when I mentioned something about Post-Traumatic Stress Disorder (PTSD) following childbirth, my health visitor said, 'PTS what? What's that?'. PTSD following childbirth is a serious issue, and does affect a significant number of women, but its detection, let alone treatment, is patchy, negligible or non-existent. Are there plans to rectify this nationally, starting with recognition of the disorder?
mrssmoody: Please could you address the following - better postnatal care and recognition of postnatal traumatic stress and help to deal with it. Some measurement of how many women suffer it would be good. I had a very traumatic first birth - 24-hour labour followed by emergency caesarian. Matters made worse by some very unhelpful staff (possibly excused by the pressure they were facing due to overcrowding). Seven-day stay in hospital afterwards, again some great staff but some really awful ones (again, too busy to do anything more than hand out drugs). My mental health really suffered by the time I got out, very distressed by the whole thing. By the time I plucked up the courage to have another baby, it was three years later. Even so, I still cried every time I had to visit the hospital, the memories of the first time were so vivid. I only got through that pregnancy and successful VBAC thanks to my independent midwife, and a lot of hassling the hospital for the care I should have got first time round. The terrible thing is my story is not that unusual, and I've heard plenty worse. The UK's mothers deserve better than this.
GwynethLewis: The National Institute for Clinical Excellence guidelines on mental health and pregnancy, as well as all professionals working in the areas of maternal and newborn psychiatry, except PTS to be a recognised condition that causes considerable anxiety and disability. As the new mental health services develop for postnatal mums, I hope that everyone working in the area will eventually be trained and understand the importance of this condition.
GwynethLewis: Thanks everyone, wish I could stay longer. I am sorry if I didn't answer all your questions. I found it really helpful and have some strong messages to take back, including breast feeding support, continuity of care during pregnancy and birth, managing miscarriage sensitively, and quality of postnatal care. I shall catch up with the Mumsnet team in a week or two to see if there is anything else that I can do.