MNHQ here: after your thoughts on a possible campaign on postnatal care

[RowanMumsnet]

Hello all

As lots of you will hopefully know, we at MNHQ run campaigns every now and then on issues that really matter to MNers. Ongoing campaigns include better miscarriage care (keep an eye out for developments on that in the next month or so), support for families caring for children with disabilities and additional needs (MNHQ has signed up to a new campaigning alliance on that and we'll fill you in on what's happening soon), and rape myths.

We've been thinking for a while, though, that many of the most urgent and upsetting things our users talk about fall under the heading of - frankly - inadequate postnatal care.

MNHQ was involved in the National Maternity Review recently, and even among the senior NHS professionals there it was evident that there's a consensus that postnatal is the 'Cinderalla' of maternity services: underfunded, poorly resourced and rarely thought about - except when it goes horribly wrong.

Obviously this is a huge area and a very complex issue to address - so we'd like to hear from you:

• is this something you'd like to see MNHQ get into?
• which aspects of postnatal care need to be improved? We're already thinking about things like: breastfeeding support; perinatal mental health; staffing and conditions on postnatal wards; partners on postnatal wards (we know most of you aren't in favour ); care in the community from health visitors and community midwives; injury care for women post-birth, and longer-term care for pelvic floors; the six-week check and whether it really works for women and babies... but we're sure there are more.
• what solutions would you like to see? What's needed (up to and including money) to improve postnatal services for women and their families?

The aim of this thread is to find out whether you think this is a good idea overall, and to get a sense of which issues and which problems you think need attention - so please fire away and let us know your thoughts. When we've got something to work with we'll put together a survey for all our users so that we can get a bit of data to help us make some decisions.

Thanks
MNHQ

Would someone like to tell me how the CQC can give a rating of 'Good' for maternity care, when the report also states that the midwife to birth ratio at the time of the review was 36 to 1. It also acknowledges the RCM recommended level of 28 to 1. (Apparently the London Safety Standards recommend a minimum of 30 to 1)

Other trusts appear to have been given must harder times in their reports over staffing levels too. There really does appear to be a lack of consistency.

Whilst I appreciate its not just about raw numbers (agency staff and specialisation seem to be reoccurring themes) surely 36 to 1 birth is outrageous.

I'd also like to know how a hospital which was last reviewed in Jan 2015, had a rating of good when its midwife ratio was 33 to 1, and in the previous August had a month where 20% of the friends and family responses stated that they would NOT recommend postnatal services to a friend.

The would not recommend was 5% or over between August 2014 and March 2016 as follows:
March 2016 - 6%, Sept 2015 - 5%, Aug 2015 - 14%, June 2015 - 13%, May 2015 - 6 %, Apr 2015 - 7% , Sept 2014 - 8%, Aug 2014 - 20%
So hardly unusual by the look of it.
(Funny how its holiday time isn't it? For reference the national average for not recommending post natal care seems to be about 2%)

Why is this not really being reflected in what the CQC are saying?

When you look at the family friendly scores for ante-natal, birth and postnatal, postnatal is considerably lower every time.
Is this being reflected in the CQCs reviews fairly? I'm not convinced they are.

I actually think that the CQC survey which was carried out, which asked women in England who had a live birth in February 2015 about their experiences of NHS maternity services starts to make the friends and family responses look quite charitable and forgiving rather than demanding at all. Which makes me wonder whether women actually have low expectations in the first place anyway.

Why are ratios about midwives to births not more freely available and easily accessible anyway?

I've been hunting these down - they appear on CQC reports. I can not find for the life of me anything that comes this or is easy to find for women. I am currently going through all these report to try and make a list of these ratios. The ratio of 36 to 1 is the highest I've found (it also says that earlier in the year at the same hospital it was actually 37 but it had been improved). The lowest I've found is 23 to 1. At a hospital also rated as 'good'.

Looking through these CQC reports which are all 2014, 2015 or 2016, compared with the data from 2011 I have about midwife ratios it does look like they have improved.

The CQC said in one report that a particular hospital was scoring particularly badly in the family and friends test but responses were between 3 and 4%. The CQ stated that 'These data are still experimental so should be treated with extreme caution. However, the trust did achieve a response rate of 34% of the question on post natal care, though only managed a score of 38 out of 100, which is well below the England average of 66.' This was May 2014.

Even so, in later reports I'm not sure that the CQC's attitude to Family and Friends is particularly good. A response rate of 34% is huge! How many women have to report on their experience and give their opinions before someone deems them to be of value? (Note here that 34% turnout at an election is currently not that unusual)

These CQC reports rate maternity units on five elements: 'Safe', 'Effective', 'Caring', 'Responsive' and 'Well Led'. Of those I'm looked through (just done London so far) everyone scores 'Good' or 'Outstanding' for the Caring element bar one. Again, I'm struggling with this. On what criteria is the caring element assessed on? I'm not terribly convinced that this is matching what is being said on MN.

I will endeavour to finish putting together the data that I have and will get it to MNHQ in due course.

However, I already think from what I've seen there is a big hole that a big Mumsnet bus can be driven through and some very searching questions asked about. I really do think that some big questions need asking - the Maternity Review from earlier this year will achieve nothing if I'm right about the above...

My post natal care was inadequate for a number of reasons and I believe it directly contributed to PND.

Firstly, the staff were run off their feet and even the kind, understanding midwives had little time to meet the needs of their patients. I had a failed induction (Friday evening to Monday afternoon) and an EMCS. I was in shock and bewildered at what I had been through l, I'd lost a lot of blood and was completely at a loss of how to care for my baby. I felt I couldn't ask for help because staff were so busy.

Secondly, the ward was boiling hot, over crowded, uncomfortable and airless. Like others it was a nightmare to try to get any meaningful rest let alone sleep.

Thirdly, some midwives were awful. Rude, intolerant and plain nasty. I was told I should be "doing that by myself" when I physically couldn't get to my baby's cot, I was refused pain relief despite being written up for it and in agony by one midwife - I kicked up a huge fuss about that and one of the cleaners got the ward manager for me because she was so horrified by the midwife's attitude.

Bounty woman was an intrusive bitch and laughed at my husband setting up my lunch for me and informed me that after her c section she couldn't wait to be up and dressed and why was I still lying about? She was also subject to a complaint.

Some of the support staff and student midwives were amazingly supportive and kind but a couple were horrendous. One member of the support staff laughed and commented every time she saw me feeding my baby "you can't be feeding that baby again" as though establishing BF isn't hard enough, some twat had to pass comment!

Like others I was made to feel a nuisance more than once and on my final day the midwife blatantly used is to bed block - she didn't need to do anything for us and we were packed up at 9 ready to be discharged - this didn't take place until 6pm - I wish we had just left.

Candy please don't think that. I have tremendous pity for anybody who ends up with a CS. I burst my appendix so know how it feels to be cut open I would not have wanted to deal with a baby after it. I only had very bad bruising & 2nd degree tear but care just lacking. We are all in it together.

I am expecting again and am seriously considering signing myself out as soon as I can.

Breastfeeding support, especially 'out of hours'. DS was born at 2pm on a Friday, I had to go straight into surgery for a bad year, so didn't get to try a feed until about 5pm on the Friday. He struggled, i struggled, the midwife shouted at me that I needed to feed him, I cried and said I was trying, over and over. We were discharged on Sunday at 6pm and didn't get a community visit until the Tuesday. The community midwife was trained in breastfeeding support but by then I had struggled for five days and DS had lost lots of weight. The irony was the hospital where he was born has breastfeeding awards and great trained supporters but they're only on Mon to Fri 9 to 5 - unlike babies!

I was left alone for most of my labour with DS and that was frightening - they didn't believe I was progressing as fast as I was so they kept leaving me to it.

In contrast with DD I was at the MLU at the same hospital and it was great. The midwives there really buy into their role of supporting the woman and never left my side until she was born and we were fine and they offered to give us some time alone as a family. Still NHS, same trust, but the philosophy so different and that really mattered.

Ah to the kind posters who replied about me saying about those people who think CSers have had it easy - I didn't mean you lovely lot. I haven't personally seen that attitude in MN. But in real life I have, quite a lot - those who joke about "too posh to push" and say a CS is easier. I wouldn't wish a CS on anybody.

Sorry to keep going on but reading the stories on this thread and remembering my own experience of post natal care has made me very sad.

I think one of the things that needs to change is the attitude of staff on post natal wards. I realise that staff are overworked, stressed and probably doing the job of at least three people but sometimes staff need to have a bit of humanity and remember that the women they are caring for have just been through a physically and mentally exhausting experience (often for the first time) and in the majority of cases are not trying to be annoying or waste their time when they ring their buzzer to ask a question that you have heard hundreds of times before. In addition to the serious stuff about not being listened too, things being done without consent, etc., a lot of women's negative experience of post natal care is down to the attitude (or perceived attitude, which is actually what really matters) of staff. Women are reporting being made to feel like a nuisance or being spoken to harshly when they are at their most vulnerable. I think staff who see labour, birth and the complications that go with it every day become desensitised to what a significant event it is for their patients and how distressing it is to be in pain/hungry/sleep deprived/caring for a baby post surgery or any of the other elements of being a new mother in hospital. In my view, more kindness, compassion and empathy from staff would go a long way to improving womens' experience of post natal care.

I'm sure many midwives and other post natal staff would be horrified to read this thread as I can't believe there are many who are deliberately harsh to their patients and I'm sure most go into the job because they want to help women at a very special time in their lives but it seems that staffing levels and funding cuts has meant that this important element of care has been lost.

Yes, do it do it please - another vote for breastfeeding support. It has been slashed to smithereens round here: breastfeeding cafés, specialists and drop ins at my local hospital have all disappeared and nowadays you have to get yourself miles to the next town if you want help. Tough luck if you've just had a caesarean and don't have anyone to drive you, worse still if you don't drive, yeah right a new mum struggling on the bus to get urgent make or break help with BFing. Can't see that happening somehow.

I've now gone through London, North East, North West & South West CQC.

On the 'caring' rating. There is ONE hospital in all those regions that scored less than good. ONE.

I still have to go through South East, East of England, West Mids and East Midlands.

I think we have a problem with the way the CQC is reporting. A fairly big one.

I've also got some concerns over a few other things going on with the few elements I've focused on.

Given that the National Maternity Review is relying on the CQC to audit and pick up on problems for its proposed changes to Maternity Care across the board I am VERY concerned.

If the CQC is not picking up on things that seem to be apparent from threads and threads of feedback on MN then there is a real issue with the CQC.

Sadly, its not the first time I think issues about the CQC and maternity have been raised.

I think the phrase 'can of worms' springs to mind here.

Will keep digging, but 'having the weekend off' from this.

How weirdly cathartic to read this! So much of my experience at a big city teaching hospital with amazing neonatal facilities.

Incredibly dismissive midwives, terrible breastfeeding 'support', a surgical team who refused to allow me to hold my EMCS baby for nearly an hour and that...woman from Bounty - is that still going on?

The breastfeeding support was probably worst. I don't think any of them had had training - certainly not the same training anyway, so conflicting advice, they were rude and clearly didn't have time for me and they kept insisting I needed to give my dd formula when what we needed was help. Again, apparently there were supporters in the week but not at the weekend.

I had paracetamol and ibuprofen and was pretty comfortable (as long as I didn't overdo it) so for some people it works.

Three cheers for you...does that mean those of us who need something stronger or maybe went home earlier than you shouldn't be given the pain relief we need? The fact is that for most surgery you are offered something stronger in case you need it. If you don't need it you just don't take it. Still can't understand why it needs to be any different for CS.

redtooth when thinking about ratios they often only hold relevance during birth - as the focus is on safety
Not on postnatal
The NICE guidance around maternity staffing highlighted how little evidence there is around this and particularly what the right level of staffing might even be outside of birth

Redtooth you are amazing

Reading these I now feel pretty lucky. I had lots of pain relief because I refused to shut up until they gave more. I refused to leave on discharge day for 5 hours because pharmacy hadn't sorted my dihydrocodeine
The MWs were nice too, it was a doctor who was horrible about bf. The support was lacking though.
MN definitely needs a campaign about this. I got decent care because I'm a health professional and I was able to be assertive with them, not everyone can be though.

Yes, this is a really important campaign. When I talk to other Mums I am inevitably the only one who has had a nice post-natal experience.

What made it good?
I gave birth in a small standalone midwife-led unit, meaning that:

• Staffing ratios were much higher overall. Midwives were busy but still had time to come and spend time with us
• Breastfeeding was regularly observed, and extra help was available if we needed it
• We stayed in the same private room during and after delivery, meaning that we had a quiet place to actually rest
• Partners could stay over too, meaning that practical help and emotional support was immediately available. It didn't feel so lonely or overwhelming when we were tackling things together
• Co-sleeper cots were the norm which made it massively easier to breastfeed with a painful tear
• A kitchen was available with frozen food so you could eat anytime (we had nice fresh ready meals from the Tesco down the road which were properly heartening)
• We were encouraged to stay a second night (1 night labour, 1 night post-natal) and benefitted from this

Some small things could have been improved:

• Pain relief, not offered and I didn't think to ask so suffered through until getting home
• Some midwives are still pretty brusque / patronising. Issues like incontinence are trivial for them but profoundly intimate, personal and reshaping for women and their sense of self
• Poor wound care guidance overall, learned much more from MNers

• Standalone MLUs at least are only available to ultra low-risk pregnancies, meaning that those with relatively straightforward labours are benefitting from this post-natal care rather than those requiring hospital admission

After discharge:

• We had good in person follow-up from MWs and HV team
• Most importantly we had breastfeeding clinics every day of the week somewhere in the borough, which we went to when having problems
• Plus the breastfeeding co-ordinator phones everyone personally to ask if they need a home visit

Pitterpatterrain, yes very much noted. I looked at it for a lot of reasons. You would expect if the number of staff was one of the biggest issues that the hospitals with the highest ratio would be the worst. This is not the case.

I think it is important to really understand a problem before looking for solutions. If the evidence isn't there to support the theory then you need to dig a bit deeper. Therefore being able to say in themselves are not really the issue (unless the are stupidly high)

I think looking at the reports is throwing up things over staffing , how staffing levels are recorded and reported ( including is 30 to 1 in one area isnt the same as the next and the cqc don't seem to be reporting in a way that is consistent)

Then there is the issue over what weight they give themselves. One report I've seen talks about the atmosphere of caring based on interviews with about 25 patients whilst the cqc are there whilst dismissing feedback forms as unreliable as the response rate is too low. Quite how they can assess the responses of 25 woman in hospital at the same time as inspectors being on site as more representative and reliable is quite beyond me.

There are issues where ratios are high from what I can see, but this is to do with other issues such as whether staff are being shunted around a lot, agency staff, sickness issues, balance of staff experience and specialities and management. It does seem to be a management issue rather than a staffing one but I need to dig a bit deeper I think.

You need to get the angle bang on to take on who ever is failing women.

At the moment what seems to be striking me is hospital management running rings around inspectors and the cqc methodology and reporting to be total arse.

Proving this and making the case needs to be done and needs to be robust but I think its there. Its the devil in the detail but when you start picking at it becomes a lot more obvious.

As I say, questions to ask and examples to find.... Its just spectulation without that. You have to build a case to be answered... And hopefully if you get that right that's how you get change.

Easier said than done though. But I think if anyone can do it, its with the help of mn.

Yes please. To all you mentioned

There has to be a massive overhaul of breastfeeding support. Midwives do not as standard know more than a very basic level of how it works...They don't understand the science behind it and both times when I was sobbing in agony they had no idea how to help.

I got help with my mastitis and dc2 tongue tie from am independent lactation consultant. She came to my house and massaged my breasts for an hour stopping my mastitis and giving me strength and ability to carry on.

Every local authority needs to see bf support as integral to child health. There need to be HOME VISITING bf experts.

In the nordic countries women are expected to stay in hospital until their milk comes in. Most women experience problems after they get home and thst is when they need specialist support.

My first baby was born in Hackney and a breast feeding expert midwife (ie. Someone who ran the local bf support group and was properly trained ) came to my house and said she would stay as long as I liked to watch me feed and help get the latch fixed.

This is the minimum level if support women need . Expecting women to drag themselves put of the house a few days after birth to a bf drop in is ludicrous. I went to a few but my dh drove me. Second time round there wasn't even one near enough to reach without a car.

On another note. I read recently about the very dangerous shortage in psychiatric ward placed for women with babies.

This means women suffering severe mental health problems often as a result of their birth are being separated from their babies...unsurprisingly exacerbating their problems.

This seems like third world brutality to me. UK mental health services have many problems but this is one Mumnset could campsign on.

Been stewing overnight. Wanted to clarify some of what I said yesterday.

I can't get away from this:
Mumsnet's essential remit is to speak for women (well for parents but in this case its definitely women) and to get their voice heard.

I believe that as part of this campaign to have any last effect mumsnet need to campaign on the following point:
For women's experiences of post natal care to be better recognised, acknowledged and acted upon where necessary

Which goes back to what I'm saying above.

You either believe one of the two following statements to be correct:
Statement A - The Noise
The level of complaints about post natal care on social media, mumsnet, family and friends, feedback on nhs choices and other sources indicates that there is a problem. There are reoccurring themes throughout. Amongst them is the word 'uncaring'.

Statement B
The Cqc are correct in saying that standards in maternity with regard to caring are 'good'

The two statements are mutually incompatible and it is impossible for both to be correct.

If you believe the Cqc you believe that all the voices using the word Uncaring (or similar) are isolated and unusual, women are exaggerating wildly (when they don't in other areas of care), women are simply lying, or women have unrealistic or unreasonable expectations.

if you believe you the noise then the cqc are failing massively and this fight whilst we want it to be about post natal care is not going to avoid being wider issues in maternity as a whole and indeed the nhs.

It also has to be put in the context of other cqc criticism in the last couple of years.

This scares the life out of out of me. I have to ask do MN have the stomach for this?

My experience stays with me almost 10 years on. Animal in a vets would have been treated better (not that they deserve anything less).

After a long drawn out labour to then being wheeled down for an emergency placenta removal, had general for this. Then being wheeled back to a side room, before being swiftly told, after about an hour that I was being wheeled back to the ward.

Had drips in arm and I was left with these empty drips and a newborn and a nightshirt still covered in blood with no-one coming to offer help and tell me where to go for a bath to clean up etc I honestly felt dreadful and what should have been a magical time quickly soured. Staff at my hospital lacked empathy, I was made to feel awful for asking someone to look after Ds while I tried to clean myself up.

It was, I'm sure what lead me into the land of PND. I came out of that hospital crying, couldn't stop the tears.

I mentioned this all to my HV afterwards who advised me to complain but I just didn't have the energy.

This whole thread is making me so angry. Is it any wonder pnd is so common? I was very sceptical of the 'it's your hormones dear' explanation at the time. Who wouldn't be depressed at home with a newborn after all of these experiences?

I honestly believe that my experience lead me down the PND road, it was one of the worse experiences.

The staff were so cold, almost felt how I imagine a prison to be like, I'm not exaggerating. It was an extremely busy time of year but still, no excuse to make a new mother feel so terrible. Not even basic care, I had to shuffle on my own to the nearest toilet, there was blood on the seats and the floor. I was scoffed at when I asked where the shower was, no showers just a bath. Again I had to ask where the bathroom was so I could clean myself up. I was made to feel awful for asking someone to look after Ds while I tried to sleep, I was just so exhausted and in pain.

I feel angry at the whole experience and I wish I had complained at the time.

ko

My post natal experience was overwhelmingly good, however I feel like I was in a minority. I would therefore absolutely back a campaign like this.