Read the answers to your questions about pregnancy and maternity services from Rona McCandlish, the National Professional Maternity Advisor for the Care Quality Commission

[KathrynMumsnet]

Rona McCandlish, National Professional Maternity Advisor for the Care Quality Commission CQC, is here to answer any questions you may have about maternity services, pregnancy, birth or the postnatal period.

The CQC say “We ensure hospitals, care homes, dental and general practices and other care services in England provide people with safe, effective and high-quality care, and encourage the services to improve.”

Rona began her health care career started in health care as a nursing assistant in Edinburgh forty years ago. She went on to train as a general nurse, and then as a mental health nurse, and finally as a midwife. She has practised continuously as a registered midwife since 1985.

As a registered practicing midwife, Rona advises the CQC about a range of issues relating to maternity. Her varied work includes regularly being part of a team inspecting maternity services; advising CQC’s expert analysts; and meeting parents to talk about care they’ve experienced. Her feedback is then used by the CQC to improve maternity services inspections.

Post your questions for Rona on this thread by 21 June. We’ll then pick 20 questions for Rona to answer. Check the thread again on 30 June, when Rona’s responses will be posted.

This Q&A is sponsored by the CQC.

Thanks,

MNHQ

[AbbeyRoadCrossing]

Cop out answer to the mixed ward question too, very disappointing

[VivaLeBeaver]

I'm disappointed as well. I wish Id seen that there was a Q&A session but never did.

Id have loved to have known if she agreed that the decision to get rid of Supervisors of Midwives is quite probably political to save face for the CQC. Who after all had done a glowing inspection of Morcombe Bay inc maternity services while all the shit which has now been exposed there was ongoing.

Which surely has got to raise the question how effective are CQC inspections if they don't uncover such serious cultural problems.

[Guyropes]

She didn't answer my question either. I asked why home birth was encouraged in some areas and not in others. She points to guidance about individuals making choices. I know individuals make choices, I want to know why some localities encourage it while others don't!

[MrsHathaway]

Isn't it nice when you learn something new in a Q&A? [sarcasm]

A link to the website would have been quicker and no more informative.

The CQC doesn't think Bounty is a problem? Really?!

Disappointed is right.

[WellErrr]

Well what a load of cop outs.

Genuinely disappointed in those answers. Particularly regarding bounty reps and partners staying on the wards.

It's ALWAYS an invasiom of privacy and it's ALWAYS wrong.

[JinglyJanglyJungleBigGameTours]

Thanks viva, that explains it better!

[VivaLeBeaver]

A 1000ml pph is a trigger for a Datix or ir1 report rather than a big serious incident investigation. 99.9% of the time a woman wouldn't be informed this was taking place. Any ir1 which is completed by a member of staff is looked at by a group of senior staff. So the notes will be reviewed to see if there were any failings, if someone needs talking to about their practice, any lessons to be learnt, etc.

Duty of candor is a fairly recent thing so women are getting told more if an incident is being looked at but these still tend to be incidents where it's felt it either shouldn't have happened or incidents which have had a big impact, so if a pph resulted in icu admission or days of hdu care.

Most PPHs just happen rather than it been someone's fault. If it's been stopped fairly quickly then it will be a quick look at the notes to make sure everyone did everything they should have done.

[JinglyJanglyJungleBigGameTours]

I am genuinely stunned to read Rona's reply to lentilpot. My DH had the same experience and despite a massive pph no-one actually ever told us anything about why it happened and to my knowledge no incident investigation was carried out. It was never mentioned again once my blood transfusions were finished.

[Bovnydazzler]

Thank you for taking the time to answer some tough questions.

I also agree that there is no reasonable justification for allowing bounty reps on the ward, they serve no sensible, public duty purpose other than for commercial reasons. The child benefit form excuse is awful, any community midwife can give it out and howany mothers are incapable of going onto gov.uk.

You advise of patients having to give informed consent. I'd say this is impossible when you are allowing seemingly official people walk round the wards whilst they are often in pain, emotional, and exhausted, how can you genuinely talk of informed consent?

[RonaMcCandlish]

@Lailai84

i also work as a HCA (Healthcare Assistant) i would like to know, why are the NHS pressuring staff in regards of service user care but in the same breath taking away resources that help staff to give the care that is required??

Hello Lailai84,
When we inspect maternity services we see the vast majority of NHS frontline staff working hard to deliver safe and high quality care in the tough public sector economic climate.

While CQC understands that many trusts are experiencing budget cuts, inspectors must ensure that a service continues to meet the fundamental standards:

• Is care or treatment tailored to a patient’s needs and preferences
  
• Are patients treated with dignity and respect at all times while they're receiving care and treatment
  
• Has the patient (or anybody legally acting on the patient’s behalf) given consent before any care or treatment is given to them
  
• The patient must not be given unsafe care or treatment or be put at risk of harm that could be avoided
  
• The patient must not suffer any form of abuse or improper treatment while receiving care

[RonaMcCandlish]

@MrsHathaway

For my most recent pregnancy (DC3) I had excellent patient-centred pregnancy, home delivery and post-natal care with One 2 One Midwives (here) who are a private company offering NHS services. They appear to be pioneers in areas such as hypnobirthing, delayed cord clamping, physiological third stage, etc.

The quality of care available with a familiar face in one's own home and very frequent contact (more than double what I would have had under my local hospital) was fantastic. I am evangelical about the benefits to the pregnant/post-natal woman and her child. Without going into detail, it's quite possible the relationship I had with my assigned midwife saved my life.

However I understand there are issues regarding the funding of such services - although on paper a One2One pregnancy is cheaper to the NHS than a hospital-led birth, the complications of when payments are made to service providers can mean a Trust provides maternity services without getting paid for them.

Anyway, tl;dr version:

I had a home birth with a midwife from a private company paid for by the NHS and I thought it was great.

(1) What is the future of home birthing in the UK?

(2) What place will private companies have in driving innovation and improvement in maternity services within the NHS?

Hello Mrs Hathaway,
As you know, choice of home birth is national policy and I’m looking forward to the report from NHS England’s National Maternity Review and its contribution to this debate
(www.england.nhs.uk/2015/04/24/julia-cumberlege/).

CQC regulates providers of maternity services whether they operate privately or in the NHS, and when we inspect any provider we are keen to recognise innovation and improvements in our reports.

[RonaMcCandlish]

@cherryade8

Hi, what is being done to improve breastfeeding support and advice on maternity units and in the community? In my experience the midwives had a really poor and basic understanding of breastfeeding and were very unsupportive. Conversely the NCT had excellent breastfeeding counsellors who were really encouraging and had a brilliant knowledge and it was as a result of them that I breastfed for two years. If I'd stuck with the midwives then I'd have been lucky to breastfeed for two weeks!

Thanks!

Hi Cherryade8,

I'm really sorry to know you didn't have a good experience of breastfeeding support from midwives. Would you feel able to e-mail the Head of Midwifery at the trust where you had your baby to let them know about your experience? I would expect them to be interested in what you have to say so that they can use your complaint to make improvements in the service and to make it more likely that every woman can have the best start as a new mother.

[RonaMcCandlish]

@Thurlow

Is the CQC involved in any way in ensuring that it is easier to transfer from maternity services in one area/PCT to another area?

When pregnant I found this a huge difficulty. I knew I would be moving late in my pregnancy to a completely different county. This meant that the community midwives where I lived for the first 30+w of my pregnancy didn't discuss birth choices or anything like that, but by the time I was "booked in" with my new maternity team after moving, at 34w it was considered too late to discuss choices.

The maternity team from the first place said they were not able in anyway to contact the maternity team where we were moving to, or help me find contact numbers, or in anyway make the process just a tiny bit less stressful and worrying.

It all worked out fine in the end but I did miss out on a lot - discussion of birth choices, hospital tours and all that - and I feel it isn't that unusual a circumstance. I'd be interested to know if the CQC are involved or have any thoughts on assisting maternity services throughout the UK communicating with each other and working together to deliver useful maternity services to women who may either be moving or know they will be travelling to be with family (for support) to give birth.

Hi Thurlow,
I’m sorry you had such an unhappy experience when you transferred from one maternity service to another during your pregnancy. I know it’s not unheard of for women to move home when they’re pregnant.

At the moment, this is not something that CQC is involved in. However, I encourage you to share your experience with CQC at www.cqc.org.uk/share-your-experience-finder, as we will use the information you give us to help us assess the quality and safety of the service.

[RonaMcCandlish]

@gallicgirl

What are you doing to promote informed consent from mothers?

I often hear "I wasn't allowed. .." or "the midwives wouldn't let me....." or even " i don't know what happened ".

Midwives should be fully advising of all benefits and risks and making sure mothers understand the decision to consent or not is theirs (mother).

Hi Gallicgirl,
CQC is concerned with whether people’s consent to care and treatment is sought in line with legislation and guidance.

When we inspect a maternity service, we look to find out whether women have been offered information to help them make the decisions that are right for them about their care, and whether they feel they’ve been supported in the decisions they make.

It’s sad that you’ve often heard women saying they ‘weren’t allowed’ or ‘the midwives wouldn’t let me’ or that they ‘…don’t know what happened’. Complaints and suggestions from the people who use a service should be used to help improvement, so I’d encourage any women who has had the kind of experiences you describe to contact the Head of Midwifery in the trust where she’d had her maternity care in order to discuss the care she received.

Every NHS trust should have a pathway for complaints see:
www.nhs.uk/choiceintheNHS/Rightsandpledges/complaints/Pages/NHScomplaints.aspx And of course, please contact CQC at www.cqc.org.uk/share-your-experience-finder if you feel that you have not had a satisfactory response.

[RonaMcCandlish]

@Sparky888

What does the CQC do to check/audit that patients are informed of their right to choose a c-section, and that the risks associated with vaginal birth are also explained during the consent process?

Does the CQC require a target for reducing the number of c-sections. If so, on what clinical evidence?

Hi Sparky88,

When we inspect a service, CQC gathers evidence using a range of methods to determine whether people’s consent to care and treatment is always sought in line with legislation and guidance. For example, when I inspect a maternity unit I often spend time with women waiting to be seen in the antenatal clinic and ask them about discussions they’ve had with maternity staff and whether they feel happy that they’ve had the right information, at the right time, to make their choices about things like screening tests and options for where to have their baby.

Some services are innovative about the way they offer information and support for women with particular needs, such as people who don’t speak or read English, or who have learning disabilities, and we take note of this in our assessment of the quality of the service.
We always look at the way consent has been recorded in maternity notes and make a judgement about whether staff are doing it correctly – because if they are not, that’s something that has to be pointed out to the provider and we expect them to take action to ensure that the legal requirement for informed consent is met.

We also talk with women about their experiences of being approached for consent to find out whether they feel that they were part of the decision making process. We don’t just look at the quality of consent for a caesarean section, we also look at consent surrounding having an episiotomy, perineal suturing also requires informed consent.

CQC doesn’t have a required target for caesarean section in a trust, but we do monitor and investigate the rate of caesarean section to make a judgement about whether care is being delivered safely and effectively.

[RonaMcCandlish]

@Changenamechange

On the postnatal ward after the birth of my third child I witnessed the following:

A first time, very young mum, after a traumatic, fast and early birth (with no birthing partner present) asking the bounty lady to hurry up and finish the photos on three separate occasions so that she could breastfeed her baby ( the second feed of the baby's life). Each time the bounty lady bought for more time to finish the photos ( taking an additional 10 minutes). The young woman had not even passed urine after the birth yet.

This young woman was in absolutely not fit mental or physical state to deal with a bounty rep, as I imagine is the case for the vast majority of women on post natal ward.

Why are they allowed in the ward at all? When will women's and baby's needs come first in this issue?

And with all due respect, please don't give me the standard answer of; we have few complaints, and women like the service being offered.

@MissTwister

I would echo concerns about the Bounty Reps. Post Natal wards are no place for private marketing companies to be hawking their wares to vulnerable women. My local hospital has a sign up telling women to 'look out for their friendly rep' after they've given birth. This is hugely inappropriate as the service provides little to nothing of use for women and is solely a cash making exercise for the NHS yet I know several people with, frankly, horror stories about the hassle they have received from the reps at what should be a private and personal time. What is your organisation doing to look into this?

Hi Changenamechange & MissTwister,

Please see my response above to PenguinsAreAce regarding the presence and practices of commercial representatives in maternity services.

[RonaMcCandlish]

@RugBugs

My maternity hospital has historically been understaffed and this was flagged as a concern at their last inspection. After a recruitment drive they're now staffed to the CQC advised safe ratios but the local commissioning group are refusing to fund at that level creating a budget deficit. Why are the commissioning group allowed to choose to only fund below what the CQC has determined to be a safe amount of midwives?

Hello RugBugs,

When CQC inspects a registered maternity provider we consider whether the service is safe, effective, caring, responsive and well-led for all the women and families it serves.

We expect registered providers to meet safe staffing levels, and in maternity care this would mean using evidence-based guidance such as NICE NG4 Safe midwifery staffing in maternity care settings (www.nice.org.uk/guidance/ng4) and RCOG guidance about medical staffing in maternity services
(RCOG 2012 Reconfiguration of Women’s Services in the UK)

[RonaMcCandlish]

@Duckstar

I would repeat AbbeyRoadCrossing question. Encouraging partners to stay 24 hrs appears to be an attempt to deal with staff shortages on maternity wards. I spent 11 days on a postnatal ward. Partners were allowed 12 hrs per day and to be honest that was bad enough. The ward was noisy and busy. How come if I was in an I growing toenail it would be unacceptable for me to be on a mixed ward, but post-birth, bleeding, catheterised, leaking milk it's fine for me to be sleeping on a ward with various men? What will the CQC do to ensure the feelings of all maternity patients are respected?

Hi Duckstar,

It can feel impossible to rest in a postnatal ward, amongst women (and men) you’ve never met before, with your newborn and surrounded by other babies’ crying.

When we carry out an inspection under our ‘Caring’ domain we particularly look at whether staff treat and involve people with compassion, kindness, dignity and respect.

For example we ask: “How do staff make sure that people’s privacy and dignity is always respected, including during physical or intimate care?”

We know some maternity units organise the environment and people’s competing demands a lot better than others. However where we have evidence that privacy and dignity are not being respected we can require that the provider takes steps to improve.

[RonaMcCandlish]

@Emrob86

Do you feel that there is a shortage of midwives?

Hello Emrob86,

We always look at midwifery and medical staffing when we inspect a maternity service and review whether the right level and number of staff are available, both 24 hours a day and though 7 days a week. We also review use of non-permanent staff, and the trust’s recruitment plans if their staffing levels are too low. We use this information to help make a judgement about the service. For some trusts, it is harder to recruit and retain staff.

[RonaMcCandlish]

@lauren222

I would repeat the question by PenguinsAreAce regarding bounty reps having access to wards. I have heard several accounts of these people invading parents' privacy post-birth and asking very inappropriate questions to parents who have had a traumatic birth experience or suffered a loss. Not to mention that they sell on your details to third parties resulting in lots of junk mail and often tell people that you can only get the child benefit form through them. I put in my birth plan that I didn't want to be approached by a bounty rep. My wishes were not respected.

My next question is around how CQC can look at the treatment of tongue-tie within its inspection methodology. My son was born with a severe tongue tie which meant that he could not breastfeed. We had to wait 2 weeks for the separation procedure to be carried out. Luckily we were able to get breastfeeding established after this, however, I suspect that if we had waited much longer it would not have been possible.

My last question relates to the training of midwives in relation to diagnosis of posterior positioned babies. Despite numerous examinations my baby was only diagnosed as being in posterior position until I reached 9cm after 30+ hours of labour. I ended up having an emergency c section. I know that he was in this position from the outset as my contractions started off so painfully that I was on my hand and knees from the beginning and couldn't speak during the contractions. There were other signs that I think the midwives should have picked up on such as turning up at hospital only 2cm dilated but unable to manage with the pain and clutching my back for the whole labour. I kept being told that the baby was head down but I don't think that the midwives had the skills to determine anything beyond that. To be honest, this has led to me losing confidence in midwifery care and I look forward to being under consultant-led care next time.

Hi Lauren222,

Please see my response above to PenguinsAreAce regarding the presence and practices of commercial representatives in maternity services.

Tongue-tie makes breastfeeding so much harder– congratulations on establishing lactation during the 2 weeks you waited for your son to be treated. Although recognising and treating it early is really important to breastfeeding, CQC looks it as part of care for newborns when we inspect a service. We would expect that a maternity service would be using a standard such as the NICE interventional guidance (www.nice.org.uk/guidance/IPG149) for treatment.

I’m so sorry to hear that your baby’s position was misdiagnosed in labour and that you feel you’ve lost confidence in midwifery care. Heads of Midwifery I know would want to hear when something has gone wrong with the care, or when care could have been better.

If you could bear to contact the Head of Midwifery where you gave birth and book a meeting to talk with her about your experience I would hope they would want to hear your story and use your experience to improve.

[RonaMcCandlish]

@Pico2

I had disappointingly poor care when I had my first child. We accepted the offer of attending a birth afterthoughts session with a midwife. I was disappointed with this - there was an attitude of "it isn't in your notes, so it didn't happen" with fairly sparce notes and that nothing went wrong except their communication with us. We haven't been alone in finding our local maternity services very resistant to acknowledging poor care. I understand that they don't want to end up with lots of legal claims for negligence. But shouldn't there be a way of maternity service providers learning from the experience of service users and being able to let those parents know that their feedback has been acted on?

Hello Pico2,

I’m sorry you felt you had poor care when you had your baby, and it’s such a shame you also had a disappointing experience at your birth afterthoughts session. It takes a lot of energy and emotional work to come to the point of having such a session and you sound as though you still would want to help the service to learn and improve.

Do you feel you could now raise your complaint though the trust’s complaints process? Every NHS trust should have such a pathway – see
www.nhs.uk/choiceintheNHS/Rightsandpledges/complaints/Pages/NHScomplaints.aspx

And of course , please contact CQC at www.cqc.org.uk/share-your-experience-finder if you feel that you have not had a satisfactory response.

[RonaMcCandlish]

@Guyropes

I have read on the antenatal pages on mn that in certain locations, home birth is being encouraged, yet it is clear that in other locations it isn't. I recognise that things have changed hugely with regard to the availability of home birth in the last 20 years, but can you explain why some localities encourage it while others don't?

Hello Guyropes,

NHS Choices (www.nhs.uk/conditions/pregnancy-and-baby/pages/where-can-i-give-birth.aspx) explains this saying ‘The choice you have about where to have your baby will depend on your needs and risks and, to some extent, on where you live’.

The Birthplace in England Research Programme (www.npeu.ox.ac.uk/birthplace) recently highlighted an expansion of midwifery-led settings (particularly midwifery units located alongside an obstetric unit) and this may be influencing variations in women choosing birth at home or accessing midwifery-led unit. The Which? website also includes Birth Choice pages with a tool to help a woman make choices that are right for her about place of birth (www.which.co.uk/birth-choice/find-and-compare)

[RonaMcCandlish]

@OliveCane

Hi Rona,

After a 12 hour labour and with stitches and completely exhausted, the midwife expected me to change the baby's nappy and put on baby's clothes! I didn't even know how to put a nappy on! Seriously, shouldn't there be more one to one help available during this time? How can women be expected to look after a tiny baby after a major operation/traumatic procedure?

Hello OliveCane,

Feeling exhaustion after giving birth would make any new task hard. I’m really sorry you didn’t get the kind of support you needed. Would you feel comfortable e-mailing the Head of Midwifery at the trust where you had you baby to let them know about this? Of course no maternity service gets it right all the time, but every service should want to continually improve so that people’s experiences are as positive as they can be. I would expect them to show an interest in your case as they can use your complaint to make improvements to the service, making it more likely that every woman can have the best start as a new mother.

To share your experience with the CQC, follow this link: www.cqc.org.uk/share-your-experience-finder

[RonaMcCandlish]

@ChickenLaVidaLoca

Hi Rona.

Many women on MN have posted about having to look after their new babies overnight soon after having had sections or difficult vaginal births, and how problematic this was for them. We are talking women with many stitches in either abdomen or perineum, sometimes a catheter, still woozy from anaesthesia, frightened of dropping their babies. Sometimes they even resort to having the baby in the bed with them, which poses obvious safety issues due to the impossibility of safe cosleeping in that situation. Given the wholesale abandonment of well baby nurseries, this is an increasingly common problem. Not all women want to room in with their babies or are capable of doing so safely, and there aren't always enough staff to assist them in caring for their babies overnight when they need help to do so. How do you see this problem being solved?

Please don't respond simply with something about rooming in encouraging breastfeeding, as there's nothing to prevent women who want to breastfeed but are unable to safely look after their babies immediately post-birth from leaving the baby in the nursery overnight and having the baby brought to them to feed. This issue is about a lot more than that, particularly since well over a quarter of new mothers do not breastfeed at all.

Hello ChickenLaVidaLoca,

I know it can be really hard to rest in a postnatal ward, amongst people you don’t know, with your newborn and surrounded by other babies’ crying. CQC sees that some maternity units organise the environment and people’s competing demands a lot better than others and we can comment about this when we’re reviewing a maternity unit.

We consider staffing levels on postnatal care when we inspect a maternity service against the standards in our inspection framework and we always ask women in postnatal care about their experiences. Our inspection framework includes NICE Guidance G37 on Postnatal care which recommends that parents should be informed about the risks of co-sleeping.

When we have evidence of concern such as the ones you are talking about we raise this with the provider as we expect them to provide safe, quality care for all women and babies throughout the whole of 24 hours and throughout the whole week.

Knowing about people’s experiences of maternity care is a vital part of CQC’s inspections and when we visit any maternity service we ask women and families about this.

This year we are also carrying out our national survey of women’s experiences of maternity services. At the moment, women who had their babies in February are being invited to take part in CQC’s 2015 national survey about women’s experiences of maternity care:
www.cqc.org.uk/content/surveys.

Findings from the survey will be used by trusts to benchmark themselves with similar maternity services and will highlight where they are getting things right and where there are problems which they should take action to improve on. CQC uses the results as part of the way we monitor the quality of a service.