Step this way to help shape the future of maternity services in England

[RowanMumsnet]

Hello

As some of you will know, Mumsnet is on the panel of the National Maternity Review, which is an NHS England initiative set up in the wake of the report into the deaths of mothers and babies at the Morecambe Bay hospitals trust.

The remit of the review is to 'assess current maternity care provision and consider how services should be developed to meet the changing needs of women and babies'.

So we'd be really grateful if you could give us your feedback on the following two very broad themes:

Which choices do you wish to be able to make about the maternity care you receive?

What are the key barriers preventing women from making the choices that they wish to?

Thanks - any and all thoughts welcome. (And just FYI, this won't be your only opportunity to feed in, and more detailed feedback systems are going to be launched soon - we'll flag these up as they happen.)

Stop perpetuating the "nipple confusion" lie- there is very little evidence (versus opinion) on this and what does exist is of a very poor quality yet it is preached as gospel to mums antenatally Yes milk supply needs to be established but there is no such thing as a "lazy baby" and for some mothers mixed feeding or nipple shields help them to carry on breast feeding and the failure to apply the WHO exclusive breastfeeding evidence to the context of the UK (as opposed to developing countries where there may be issues of availability of clean water etc for formula where breast is clearly best).

Better postnatal care for mums of premature babies. Fortunately the post natal ward at my local hospital were great at doing my checks on the ward that should have been done by the community midwife as I was in NICU with my son but this is not the case for all. Better transitional care units for mums of premature babies- where dads can stay too- before dischage from NICU to home to support parents and help mums make the shift from expressing to breast feeding if they want to.
Sadly as an NHS employee I don't think the funding exists for any of this and what women will get is what interested parties think they want or should want, rather than what they really do want.

What women will get is what interested parties think they want or should want, rather than what they really do want.

Yes. For example it's no great coincidence that unmedicated vaginal delivery is being promoted as the most desirable outcome, despite the fact that even low risk women often have no interest in it whatsoever. Nothing wrong in NCB for those who want it, hence I'm supportive of other posters desire for more FMLUs etc, but there's a great deal of interested parties deciding this is what we should want and what's best for us. Equally, the partners overnight thing is clearly the way it's going in order to be able to further reduce staffing levels, despite the HUGE issues a lot of women have with it. It gets advocated for a lot on the basis of one pretty small survey of patient experience.

And yes, percentage targets for eg sections, numbers of women exclusively breastfeeding etc are not ok at all. The very concept of aiming for a certain number of women doing X just has a great big shit all over the right to choose.

Which choices do you wish to be able to make about the maternity care you receive?
-More balanced information on birth options.
-Being told that ELCS is a valid option
-Being given proper data about different options (eg not getting EMCS outcomes mixed up with ELCS ones)

• right to opt out of any contact with Bounty whatsoever, from moment one of your first AN appointment.
• proper consultation with an actual doctor re tongue tie if child is not breastfeeding by time you leave hospital

What are the key barriers preventing women from making the choices that they wish to?

• Targets, such as "we must get our CS rate down below X%"
• The Royal College of Midwives, whose main interest in ensuring its members have plenty of work and run the show
• not enough consultant obstetricians on actual, physical, present, duty at the weekends (our hospital= ZERO)
• A generally patronising attitude widespread in the NHS that they always know what's best for you and you don't. As demonstrated in hospital near us, where they warn you that if you dare ask for an ELCS (a perfectly rational and reasonable request, and one supported by NICE guidelines) they will automatically refer you to mental health.

Which choices do you wish to be able to make about the maternity care you receive?
I don't see you should have choose between a nice birthing center and Dr led care. I liked the idea of all the facilities they had in a birthing unit. Why should wanting the back up of a Dr stop you from having these?

I was stuck on an antenatal ward with three other labouring women and visitors coming too and fro over 12 hours before I went to the delivery suite. I don't think you should have to deal with that in any part of your labour - I found it extremely stressful. I just wanted to be on my own.

I wish there wasn't such a bad attitude to C-sections in this country. No where else in the world do they push so hard for V-backs after traumatic deliveries. They do not take into account the long term costs such as incontinence especially postmenopausal problems.

What are the key barriers preventing women from making the choices that they wish to?
Obviously money.
Thing is there are plenty of people who have the money to improve their surroundings (that don't live in London) and want to top up their care. I have private health insurance and it is frustrating that if i want a simple op I can get luxurious care but when it comes to having a baby there is no private option for me. I would quite happily have paid money for a private room for instance it the facilities were there. It's a shame more trusts don't take the initiative and be more business like - have add on/optional extras. (doesn't help they are always selling off every last scrap of land with no forethought for the future).

Better (or indeed any) breast feeding support from staff with expert up to date knowledge. All of the expert help I (eventually) got was from volunteers or private. It felt like the NHS only paid lip service to breast feeding then the minute you had a problem they wanted you to bottle feed as it was less hassle for them and they didn't know how to help.

I gave birth to my first in a consultant led unit and second in a midwife led unit in the same hospital. I love the option of mlu in a hospital with that safety net, this wasn't available in my more local hospital where the mlu was 20 mins drive from the hospital. It did occur to me after the birth in mlu why is the care not similar in consultant led? In consultant led I had a rubbish birthing pool and none of the other equipment which could have made it comfortable. And afterwards I was transfered to a horrible crowded ward. I had had a spinal block and was literally stuck in bed with no call button and didn't see a member of staff for ages. Then they kept fobbing me off about having a shower. I wasn't 'allowed' one until about 10hrs after birth. I felt so vulnerable and humiliated. I assume that cost is the reason the consultant led unit did not let me and dp stay in a private room with double bed and ensuite as the mlu did but I think it is such a shame that having a slightly riskier birth means you miss out on that additional comfort which helps whole family bond and breastfeeding get established.

I also think that midwives and health visitors should maybe be trained a bit more in asking difficult questions. At my midwife booking appointment she asked 'so there is no domestic violence, is there?' Luckily there wasn't as it would take amazing courage to answer 'actually there is' to that. And I had a similar experience with a health visitor when mentioning an emotional problem I had. 'But you feel fine now, don't you?' I didn't actually but 'oh yes, if course' was the only answer I felt able to give.

That all said I have hdlad fantastic care over all. Thank you NHS!

The changes in Supervison of Midwifery will have huge impact on women accessing choices.
At the moment a SOM will be available to discuss, sdvise and care plan. Without that independent advocacy role women who want care outside the norm will be scuppered. Managers of maternity services have to focus on the policies and guidelines of the institution. Supervisors are independent of that. If/when Supervision is scrapped there will be no support for this.

Also Supervision is massively important for midwives. SOMs are there to support and encourage professional development. Without that midwifery morale will be even lower.

Also...

What developments or improvements can realistically happen with the NHS virtually bankrupt?

Really?

At what point will women/service users/staff just have to accept that there is nothing they can do because the money has run out.?

Can I ask a question? Is it normal for delivery rooms to have a private loo? Mine didn't and I found putting on my clothes and walking down the corridor for a wee too much bother. I ended up being catheterised as I wasn't going enough and in hindsight a private loo might have stopped this from happening.

Wanted to feed into this because something MUST be done to improve postnatal care. I have heard so many horror stories from women about their time on postnatal wards. - no care, no privacy , no compassion, no sleep. My own experience with my first child was dreadful. A time that should have been joyful was full of fear, exhaustion and stress. I've never felt so alone. Postnatal wards need more midwives & more walls!!

Saying that inductions cause complications that cost money is a generalisation and not necessarily accurate. For example, induction at 41 weeks reduces the chance of emcs on average. So please don't go in making that argument HQ. Also, stillbirth rates do increase after term and it should be for every woman to make the call about what level of risk is acceptable to her. Someone else's ideas about what constitutes defensive medicine shouldn't even come into it, indeed this is detrimental to women's right to choose.

Which choices do you wish to be able to make about the maternity care you receive?

I was quite lucky - there is a good amount of choice in my trust, including a well-established and well-resources home birth team. This should be available everywhere - the place of birth study showed that for low risk multiparous women home birth is just as safe for mother and baby. And cheaper for the NHS incidentally.

The choice that was not available to me, and I wish it had been, was one-to-one continuity of care from a midwife. I paid for this privately and I genuinely believe it's one of the reasons I had such a good birth outcome (not the only reason obviously).

What are the key barriers preventing women from making the choices that they wish to?

Well obviously the NHS machine - you get what you're given.

But underlying that is an attitude.

I genuinely believe that there is a view that women should take what they're given with birth and just shut up - it's romanticised as necessarily difficult ("wimmin's issues" and things like hormones which, you know, cause problems, albeit unspecified most of the time). A pain-relief free birth is also mythologised as ideal which is utter bollocks. If men so much as stub their toe there is a generous view on the need for pain relief.

Things that no one else in the health system would put up with are inflicted on birthing women. Overlooking normal consent standards when it comes to internals and interventions during brith. Allowing Bounty ladies and their notoriously aggressive ways and inappropriate access. Failure to prevent visitors on the ward at all hours including partners overnight, despite this discomforting other patients. Dire after care and a belief that a 5-month pregnant-sized stomach for life is "normal" when it's really not. I could go on and on.

More birth centres and MLUs

More continuity of care during pregnancy and birth - not the current 'you get who you get' system

1. a free choice in what happens to your body - i.e. being able to choose a c-section, pain relief, natural birth.

No partners staying over night in pn wards

No Bounty reps on pn wards.

2. the barriers are paternalism and greed. Putting money before women's health and bodily autonomy.

Whatare, your post about the underlying attitudes around childbirth is spot on. Even if it's not intentional on the part of some hpc's. I was admitted to the labour ward in established labour, in agony (back to back baby, came in by ambulance as I couldn't sit in the car for more than 10 seconds) and I was given the overriding impression by the first couple of midwives (intentionally or not) that I was being a bit of a wuss as I was "only" 4cm dilated. Told no-one would be free to give me an epidural for at least 90 minutes. 2.5 hours later, midwife starts talking about pethidine, I state I don't want it, I want an epidural! Her answer "well we'll just examine how far along you are, and then discuss it!" Turns out by then I was 10cm and had been transitioning while they hadn't noticed. Must confess to feeling a bit smug but there is a patronising attitude, especially for first timers - "There, there dear. It's childbirth, of course it's going to hurt" and to make you feel like you're making a fuss about nothing rather than actually listening to what you're saying.

Just to be clear, needing any form of pain relief at ANY stage of labour, does not make a woman a wimp/wuss. We are all different and have different labours. That is what hpc's need to remember, not just give the impression "well you can't be in that much pain already!"

I can already tell I'm going to be a lot more bolshy about stuff with DC2!

This is an interesting thread, I'm currently pregnant with my first so I am yet to experience the care you receive during labour and post birth. However I have been really frustrated with the lack of information about where I can give birth.

When I found out I was pregnant. I was interested in finding out more about the MLU in our area. However in my first midwife appointment I was only given the options of hospital or home birth. When I asked specifically about the MLU my midwife said she didn't know much about it and as the local hospital has just been done up it should be a similar experience but with doctors on hand if needed. She seemed quite insistent that I should put down the local hospital for now and I can always change it later which I agreed to.

Following that I have tried to find out more about the maternity ward at my local hospital but the only information online is a bit of text dated before the refurbishment was done. They also don't allow ward tours here so it is impossible to make an informed choice.

Still not convinced that it will be a similar experience to the MLU. I asked about changing my choice to the MLU again on my last appointment but the responses I got seemed odd. The midwife said she wouldn't change it on my notes but said I could have my baby anywhere I liked. She said I should call the unit if I wanted to have my baby their but she couldn't find a number. It also wasn't clear if I should be calling them now or just when I'm in labour to see if they have space.

It really sounded like she was saying no and yes at the same time which just left me and my husband confused. I'm also not sure what the point of specifying anything on my notes is if it's not really what I want!

I'd like to see the health of the mother (particularly mental health) taken more into account with feeding issues. I was kept in hospital for a week after an emergency c-section and was put into a routine of pumping and cup feeding which only allowed 20 minutes sleep every 3 hours, was forcibly woken, my son became seriously ill because there was not enough milk because the midwives kept dismissing me when I told them there was nothing coming out. The ward was a horrible environment with no privacy, it felt like prison. The prioritisation of breastfeeding over all other issues made the staff seem like warders who considered mothers to be merely milking machines. I felt pressured and harangued. I was told I was a bad parent and that I didn't care as much about my child as I should. I was just struggling to get enough milk out but was accused of being squeamish and precious.

It ruined what should have been a really happy time for me with a baby I'd waited over 10 years for. I was okay when I went home, but I firmly believe that other women would have been pushed over the edge into post natal depression.

I believe breastfeeding should only be promoted in positive terms, and not by making women feel guilty or like a bad parent if they can't or don't want to do it.

We are entitled to our own views baffled, but not our own facts. Which is what someone who is claiming that inductions cause complications and cost more money is doing: actually, some inductions do just the opposite. It's a fact that induction at 41 weeks makes EMCS less likely. I'm no advocate for reducing sections as a goal in itself, but clearly most women would prefer to avoid EMCS ideally. Just saying 'induction causes complications' is far too simplistic, and if MN go in saying that to a load of maternity experts, they're going to look silly and be taken less seriously. This is a separate issue entirely from women being pressured into induction, which of course is wrong. And it's no more or less wrong if it happens before or after the point at which induction makes EMCS less likely.

And sorry, but comments like 'the risk of stillbirth is still relatively low' are completely inappropriate- I will be the one to decide whether that risk is acceptable to me, nobody else. The post I was replying to highlighted 'excessive defensive medicine' as something that limits women's choices, which it certainly can. However, the post was also problematic in itself because of the minimisation of the greater stillbirth risk the further postdates a woman goes. MN can (and should) advocate for women to have the right to choose to refuse induction without minimising the increased stilbirth rates if a woman chooses expectant management instead. They shouldn't be mutually exclusive.

MN can (and should) advocate for women to have the right to choose to refuse induction

This. Absolutely this. When I went in to the day assessment unit for a check at 8 days overdue they told me they would book me in for an induction at 14 days overdue. I told them I wanted expectant monitoring and an appointment with the consultant to discuss that instead. The midwife told me she would check "if I was allowed".

Sorry? If I want to refuse a medical procedure I'll refuse a medical procedure, and if you think I need a medical procedure you will seek my consent not tell me I have to have it.

Yeah, that's worrying. You think to yourself, you presumably took a midwifery degree, was there no mention of CONSENT or were you just skiving the day they covered that?

Which choices do you wish to be able to make about the maternity care you receive?

Well, just choices, within reason, actually explained, without prejudice.

What are the key barriers preventing women from making the choices that they wish to?

Staffing levels, time available, training of staff who are available, attitudes and prejudices of some of the staff that are available (I'm looking at you, maternity assistant who told me I couldn't breast feed because my boobs were too big and Midwife who told me, with an eyeroll, that after five days of almost no sleep on the ward I was being defeatist to consider going home and mix feeding rather than staying in and struggling to exclusively breastfeed).