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.)

I wish there were more choices of stand alone birth centres, run by midwives. There are none which are close enough to me to attend.

I must say I would have to disagree with that. These units should be sited in hospitals and be physically close enough to the labour ward that a transfer can be made in seconds/minutes if something goes wrong. I've worked on labour ward and have seen plenty of healthy low risk women who have had sudden, unpredictable complications where being down the corridor from an operating theatre has saved the life of mother, baby or both.

I would like the following, thinking about it further:

• women don't get turned away from hospital just because they aren't dilated enough. Early labour an be incredibly painful and scary if you are alone, the health system has a duty of care not to brush women off with a suggestion to take paracetamol.

• hospital consolidation decisions set birth and maternity requirements as wholly separate. Yes, this may mean a lot of small maternity-only hospitals. But it's ridiculous to suggest that maternity (which will almost certainly happen to a large percentage of half the population at some point and is totally time critical) is the same as other medical services provision. It's not an illness.

I agree with much of what's already been said, but I would say that given that we (supposedly) have a national health system, I found it ridiculous that I couldn't opt to have antenatal care near my work and that all appointments were in the middle of the day and all made for the same time for everyone (so my school had to get cover each time even though I was never seen until after the end of the the school day).

DH was astonished by the basic and inaccurate methods that are used to establish due date. Given how much hangs on it, from induction to maternity leave dates, he felt more training in statistics was needed. We knew the date of conception to the minute (IVF) but no-one we saw would even take the info into account.

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

I think a birth debrief should be offered or booked after you have given birth. I didn't even know this was available until a few months ago (my son is three years old). I think it's important for every woman to understand what actually happened during her labour, especially if any sort of intervention was involved, decisions were made without her consent and if anything classed as an emergency occurred during her labour.
For me this simple option would have avoided a lot of distress, fear and years of anger. The NHS now has to pay for me to go through therapy and for a midwife to come and see me for a Birth Reflections appointment. Whether this is offered to some women afterwards, I don't know, but it was definitely not mentioned to me. You get told after an operation what happened, why is this any different? We get left in the dark.

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

Every woman makes a birth plan however a lot of women's plans are not adhered to due to unforeseen circumstances. Had I been kept more informed during the labour mine could have been followed. A lack of information on my progress resulted in an emergency situation, which I didn't know about at the time, meaning the plan had to be abandoned leaving me upset, disappointed and confused. I feel that had I been given the right information and support during my labour I could have taken steps to avoid an unpleasant outcome and the degradation of the birth I truly wanted.

The main issue with my birth experience was a lack of communication. The NHS needs to address the fact that what may seem ordinary to the midwife is new for the mother, especially first-time mothers. She needs to be listened to, encouraged and acknowledged; and not have procedures done to her without any sort of explanation or consent.

I was left alone a lot both during and after labour. It has left me with PTSD and anxiety that was undiagnosed for over 3 years.

I also agree with others about midwives attitudes to due dates. I was the only one who knew when I conceived. My son was born premature yet the midwives assumed my dates were wrong just by the appearance of my son.

My antenatal care was much better second time round - first time, I barely saw the same midwife twice and the number of available appointments with MWs at my local GP were so limited I ended up seeing the GP instead.

But postnatal was as bad as everyone else on this thread has said - in my case a very young midwife visitor me at home saying cheerfully 'Oh you should increase formula top ups, baby will be back to birth weight in no time'. I wanted to carry on breastfeeding but felt I was being discouraged from doing so. Baby getting back to birth weight was all they cared about.

Thankfully with amazing support from expert breastfeeding midwifes at drop-in cafes I was able to carry on BFing, but now my hospital trust is pulling the funding for them. How can such a short-sighted idea really be what is best for the parents and children? I predict BF continuation rates will plummet in our area, but all the hospital care about is the % initiating breastfeeding in hospital. No matter that most will stop after 2 weeks, probably, because of lack of support. The hospital only cares about what happens on its ward. The after care is SO important too, though!

I'd like to see more homebirth midwives available who don't just call an ambulance at the slightest thing & are trained in actually supporting a labouring woman in her choices rather than spending all the labour either writing notes or on the phone. Both my labours could've been a lot easier if I'd had more supportive midwives. I wanted it to be as un-medical-ised as possible. I'd have been better off without any midwives there, they just added stress to the situation.

Women want choices but not everyone wants to give birth in midwife led units. I personally wanted the highest level of professional care possible in a hospital. Don't assume all women do not want intervention. Some do - we want pain relief, we want to be induced if we go over to prevent the risk of stillbirth. Those are our choices but some midwives refuse to accept we wish those levels of care.
I echo the sentiment about breastfeeding - women need much more information about where to go for help when things go wrong. Maybe a 24/7 helpline?
And postnatal care is dreadful in hospital - women are extremely vulnerable at this time and many feel left alone with the care of a newborn.
Barriers to making choices include entrenched NHS attitudes, paternalism and a postcode lottery of available services.

Agree with Oly4 a MW led unit would have had me running the other way! My anxiety meant I wanted 24/7 obstetric led unit care! With anaesthetists, theatres, NICU etc on tap!!!

I would like more private rooms on postnatal wards, the few at my local hospital were full so I had to stay on a 4 bedded ward after a very traumatic delivery.

...Too many visitors, partners staying overnight (although my own DH was a godsend as tbh the staff basically left you to it) but I understand that he was a stranger to the other women. Although they let you keep the curtains closed for privacy, it just made you feel hemmed in with no fresh air. A private room with a window and own bathroom(!) would have been lovey....instead of having to shuffle down the hall, barely able to walk, bleeding heavily, stared at by relatives and partners....!!

No actual practical breastfeedimg support from the nhs. I asked countless MWs , HVs etc to check my latch because DD had a tongue tie. Was told, yeh it looks about right from a cursory glance. I wanted someone to sit with me help me latch her on, actually watch her have a feed!! Tried to access NCT BF support in the community but everyone was so busy they just said, come to group! Not remotely practical when you can't walk, drive, or leave the house with a colicky, refluxy, tongue tied newborn!!!

Also, the same MW throughout would be lovely. So you didn't keep having to tell your 'story' at every single appointment!

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

I would like the midwife appointments to be available throughout the day, as are doctors appointments, so that I can actually have an appointment at 9, or 9:15 or 4, so that I can minimise disruption to my work. I know that I am entitled to time off for the appointments, but that doesn't mean that I don't want to minimise disruption to my colleagues and clients.

I would have liked some discussion of the options for birth, or some literature, explaining the options (but I do take the point that round here it's just one hospital or a home birth).

As a single mother (the first time I was pregnant/gave birth) I think that there needs to be some thought given to the needs of women in that position. I was left alone to labour and completely ignored. I waddled out to ask for some paracetamol, was ignored. Second time (c1/2 hour later) went to ask again and was ignored again. I then went out (I have been left alone for 2 hours at this point, after initial assessment showed me to be in early stages) and asked to be examined...which revealed me to be 9 cms. Too late for any pain relief (I had wanted an epidural) and straight to the labour ward. If I hadn't gone out and demanded attention I honestly think that I would have given birth alone. I also believe that this was because I had no one with me to advocate for me.

Whilst we're at it-also antenatal classes specifically for single mothers would be good. There is nothing so isolating during pregnancy as sitting in those classes without a partner. Depressing as hell.

I would also have liked to see the same midwife for most of the pregnancy (at the clinic I went to I saw I think 4-5).

Also, it would be good to have some baby clinics in the evening. Where I used to live our surgery had one a month in the evening, which was great. however, when I moved and ds was 4 months there was nothing in the evening. As I was wohm full time, and a single mother with no support it was impossible to attend, so I had no support or feedback regarding development etc.

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

lack of information.

Lack of staffing.

I was particularly struck by the lack of assistance re:breastfeeding. I breastfed both of mine, and really struggled the first day with with ds1, basically with knowing what to do. Help was not forthcoming. I saw f/f mothers being brought warmed bottles in the middle of the night, but when I wanted a bit of advice as to how ds was doing I was made to feel like I was being a pain (I only asked the once...believe me). If I could have had 5 minutes of advice I would have been so much less stressed. I was never given any encouragement to breastfeed and I wonder how much impact that has on the takeup figures. It's really the harder option in hospital.

Lack of choice. My friend was adamant she wanted an elective c-section. She was clear this was not for strictly medical reasons-it was her choice. She ended up going private for it, because she was basically told she could not on the NHS. There are many stories of women being refused epidurals when they ask for them. It's really as if women are not allowed to make these choices over their birth.

A lack of realisation that mothers also have a life independent of their children. There is an assumption (tbh this carries on into school) that facilities can/will be attended in the middle of the day. There is nothing at the weekends or in the evening. For example I had PND with ds1, but was unable to access any support or help-sessions were all during the day.

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

I think shared wards are outdated and not conducive to the physical and mental rest women need after giving birth, especially if the birth has been traumatic. My hospital had some private rooms you could pay for, which we were happy to do, but they were all occupied. So, even if you are eligible for one, if they are all taken, you still have to stay on a shared ward. I know it's a matter of space and finding but perhaps midwife led units and more support for home births would free up space in hospital so private rooms would be more of a possibility for those that have to give birth in hospital.

I echo others' who mention breastfeeding support. The 'breast is best' message is pushed by the NHS but from one area to another support and information differs. And his follows on in post natal care too.

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

Lack of funding and resources: In some areas, people can request a home birth but if the home birth team are dealing with a birth/s elsewhere then someone planning a home birth may have to go into hospital.

Inconsistency in training and knowledge amongst health care practitioners: I was given different information and advice from midwives and consultants during and after (RE breastfeeding) pregnancy.

Another benefit to private rooms is that partners could stay and support the woman who has just a given brith. Particularly in the case of c section recovery, this would save time for hospital staff as the partner could help with getting baby in and out of the crib for feeding/ preparing bottles for bottle feeding.

PamBagnall that is, even if the hospital staff are prepared to help! With my DC1 I had a very grumpy night time nurse who was furious when I asked her to help change a nappy 'you should be doing this by yourself now!' - I was on night 2 after a CS!

Second time, I was very clear to the night time staff and made sure I explained myself properly - 'I've had a CS, I can't turn or lift the baby easily, but if you pass the baby to me I can change her.' Luckily second time round they were much more understanding.

There needs to be far more clinical supervision and continuous professional development, managed by leaders who are committed to ensure that abuse does not happen on their watch.

And yet the govt have decided to dismantle midwifery supervision. Which was a bizarre decision if ever there was one.

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

The language used by HCPs.

There is no such thing as 'failure to progress', 'incompetent cervix', 'poor maternal effort'. They all focus on the woman as a failure and the woman's body as something that needs to be handed over submissively.

Also,

'if your baby is still in there at 41 weeks we'll need to do something about it'.

'If you go over 42 weeks you'll have to be induced'

'you can't get in the pool until you are 4cm dilated'

'we need to break your waters'

All terrible, terrible ways of communicating with a woman as they imply she has no autonomy or choice.

This is entirely from my own experience. dc1 and only was a home birth but had to transfer to hospital afterwards as I had a retained placenta.

antenatal:

• every woman to be guaranteed to see the same midwife (or team of 2 or 3 midwives - so that each others annual leaves are covered) at every appointment and ideally these should be the midwives who assist during a woman's labour. I unfortunately never saw the same midwife twice antenatally and only a cursory read of my notes was given.

• midwives to be more linked into the gp/nhs online record system (I realise that nhs computer issues are somewhat of a hot potato!) however at my booking in appointment, I sat with a midwife in a room in my gp's surgery giving her all my medical history (which my gp would have had on computer) for her to write by hand in my maternity notes. This just strikes me as completely inefficient.

• procedures such as induction to be discussed with the woman and consent explicitly asked for. my waters broke before labour started and I was told that if I hadn't delivered by x time then I needed to come into hospital to be induced. Fortunately I did deliver well before the time limit so the situation didn't arise, but hcp cannot mandate that a woman be induced. All they can do is recommended the procedure and it is up to the woman to accept or not.

post natally

• ideally women to be given a private room so that they and their partners can stay to establish time as a family without the presence of a male partner embarrassing other new mums on the ward. In particular, if a mother has had surgery (a c section or other surgery) then it is often vital that they have a partner staying to help them as they are unable to get out of bed/even lift the baby and very often the ward midwives are too busy to help (speaking from personal experience).

• no matter what time a mother arrives on the ward, a proper meal to be offered to her. it is likely that it has been several hours since she has last eaten and babies arrivals do not always coincide with meal times!

• bounty to be banned. There is no reason for sales people to be on a ward when new mums are at their most vulnerable. There is no other hospital ward where sales people are allowed so why maternity? This practice needs to stop now.

• instead of bounty, a breastfeeding lactation consultant should personally visit each woman and ask if they would like any advice/support. Obviously if a woman declines they should respect this decision. but it seems ridiculous that the bounty woman has direct access to each woman but not necessarily the breastfeeding consultant. In my hospital, I had an announcement made that the breastfeeding consultant would be available in the family room if anyone would like to see her. All well and good you might think, but I had had a spinal a few hours earlier and couldn't even get out of bed much less walk down the corridor to the family room!

• discharges to be speeded up. I know that sometimes women need to stay in hospital longer, but for those who have been given the all clear to go home, keeping them in hospital longer than necessary is not conducive to their mental wellbeing and they are blocking a bed in hospital which could be used for another patient. I was given the all clear in the morning but didn't actually leave until 7.30pm at night. I was getting the bus home with my baby and could have done so much earlier in daylight hours and had more time at home with my baby if the discharge process had been speeded up.

• do not make a woman feel like a prisoner on the ward. If a woman wishes to leave the ward temporarily with her baby for whatever reason before she has been discharged (or god forbid, discharge herself and the baby early) then she should be free to do so without having to do battle with security at the main ward door and being made to feel like a criminal. No other ward has security on it so why maternity?

absolutely agree with non-judgemental access to pain relief mentioned earlier. elsewhere throughout the nhs analgesia is considered a normal and positive part of care and healing for all sorts of major and minor body parts and procedures... only labour has such weightiness added to the decision! this is probably for historical reasons or due to erroneous misconception of what women are perceived to feel or desire about the process of giving birth (whole other thread). we are not all the same and in the 21st century epidural should be easy and freely available if the woman wants it (and needless to say as soon as she wants it, barring medical contraindication).

regarding partners sleeping in the wards i disagree this should be ruled out and continuing the line of questioning above there should be a choice about this. it does not have to be complicated - perhaps a simple remodelling of wards to allow partner only areas and partner free areas so everyone can have what they need. you need only browse a few of the threads here on this topic to read vivid and heart wrenching descriptions of women who required their partners present round the clock in absolute terms - usually due to a combination of extreme fatigue and very real physical disability after traumatic births and absent/poor after-care on the post-natal ward, two things about which unfortunately we have no choice. in which case at least let us choose how we can help ourselves with our personal resources, albeit without it impinging on others personal choices either.

The same midwife sounds good in theory but I had the same absolutely awful midwife for my appointments. Her advice was so outdated and she was so poor at listening to what I was saying I actually changed gps to get away from her.

Luckily I had a pregnant friend at another surgery who said hers was great so I switched to there.

Pre natal care to be consistent- after first baby mw appt frequently the sporadic second pregnancy appt were a surprise - 12 weeks between them is too long to establish any form of care onto unity
During delivery- I'd like to be able to opt into pain relief and section: I strongly believe no man would have any stitches on his genitalia without out pain relief...
Post natal consistency- we are in an area with several brilliant maternity provisions but I hear horror stories elsewhere- post baby pre discharge no BF careno physio care and no home births entertained

I can see from the comments that services vary between different parts of the UK. Having moved a few times myself, I now definitely know that there is a massive difference. It could be due to a few things like the demand versus supply of healthcare professionals.
Whilst I was in the Midlands I saw the same midwife every time, had her work mobile and could text for things like blood result, she could text me back for simple things like prescription that I need. It felt like the perfect personalised care . Fast forward to London and there are so many different stages and different people to see. For example, measuring bump sizes; two people can measure the same size at the same time and get different numbers. Imagine if measuring at different times, you get sent for an unnecessary investigation either because you're too big or too small for dates. Waste of resources (which is already limited!)

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

Better choice on ease of moving where to give birth. Ie, a truly integrated service so that if for whatsoever reason you decide you need to change where you're giving birth, it does not mean a while new battery of information being collected again. The pregnancy book is meant to be universal so that if I do turn up here, you'd accept that a competent colleague of yours has already done the job especially if it's just a tick box exercise like is in the green book!
What are the key barriers preventing women from making the choices that they wish to?
NHS not truly integrated. Get the IT systems up to date so that patient history can be checked without having to jump loops or request paper copies. Yes, make it so a consent is needed but get with the times. It doesn't take a genius to figure out how much can be saved if between 2 hospitals down the road to each other can't view each other's investigations despite serving the same case load.

Also postnatally needs more to be done in the community. We complain about how much hospital stays cost but if a birth has just gone very smoothly with a low risk patient, they can be discharged immediately for community follow up (as long as they're equipped to deal with the few potential complications) . Waiting for a baby check for 8 hours, sometimes even more is a joke and we realise the person doing it is busy ( probably trying to get through the other 50 things they need to sort out). More care in community ( provided the funding is available and resources are out in to place for this).

I would have liked

Free choice between a vaginal birth or cesarean section.

Choice of when to come to hospital with women deciding when in their Labor they want to come in.

Any thing other than a minor tear reviewed and repaired by a senior doctor.

Proper followup and advice for women with childbirth injuries.

Having suffered a mmc and stillbirth the provision for women in this situation needs to be massively improved. Having to sit in the antenatal clinic waiting room for the scan to confirm what blood results had already told us (we had a mmc at 8 weeks), surrounded by happy, heavily pregnant women clutching scan photos did nothing for mine or my DH's emotional state at an already upsetting time.

DS1 was in Scbu for the first 3 weeks of life, and having to stay on the post natal ward alone, with my baby a good 10min walk away in another part of the hospital, while I recovered from a cs was also a million miles away from ideal.

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

I would have liked the ability to choose a c-section over an episiotomy and tear.
I would have liked a debrief on my first birth without spending 2 years, and getting to 30 weeks pregnant, absolutely terrified of giving birth vaginally again.

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

Lack of information surrounding what has happened during previous births. I think that anything other than a 'textbook' birth should be debriefed as communication may not be possible during an emergency but should always be fully discussed afterwards.
Often I think (and especially for first time mums) there is a fear of going against the medical professional's advice instead of doing what is best for the mother - additional information around vaginal birth / caesarian and the risks associated with each should be given early in pregnancy before any decisions have been made.

Thanks so much for your input - it's very helpful in focusing our thoughts

@sootballs

MN - this is a subject I'm passionate about, because due to poor care my dd1 was left with something called hypoxic ischemic encephalopathy. Her brain was irrevocably damaged during labour because of proven negligence and she is disabled with epilepsy.

and it was avoidable

Yup.

But I'm over the anger and rage and now just want to petition for better care. But the EoE NHS team have fobbed me off for over a year as patient liaison despite me travelling hundreds of miles to attend meetings.

Can I help?

Thanks Sootballs; do feel free to email us on [email protected] if there's anything particular you want us to look at or have a think about.