January 2016. We’re awaiting the publication of the National Maternity Review report and recommendations. The work has been undertaken in less than a year. If you haven’t read the 1993 Changing Childbirth Report, which was also chaired by Julia Cumberledge, do borrow a copy and read it soon – lots has changed since then, but not enough. (Who would have thought that in 2015 22% of women* having a straightforward vaginal birth would give birth in stirrups?)
This is a very long post – you’ll see why. Best to say aloud now, I think, what my concerns were at the outset of the current review. I am hoping so very much to have been needlessly worried. I wish so very much for everything to turn out well – for the recommendations to be evidence-based and excitingly forward-looking. I know that all involved are sincere and well-intentioned. If bringing about changes in maternity care were a simple thing, though, Changing Childbirth would have changed the world more than it did.
Of course we already have national policy, national clinical guidance from NICE, and other well-known resources (for example this report and this report), that appear to me more than adequate to inform and support experience-based co-design and commissioning of local solutions in maternity, if the will to do the work exists locally. So will the expense of a national exercise prove to have been worthwhile? And what difference can it make? It will be interesting to see.
Looking back to 2015
Some reflections, then, on the context, and my concerns about the process.
On 7 April 2015 I wrote to Anna Bradley, Chair of Healthwatch England, about the National Maternity Review. I told her:
You will see from the attached correspondence that I am concerned that:
• the process of the review is not of an adequate standard given its significance
• the review is not framed in a manner that gives explicit assurance that women’s human rights in pregnancy, labour and birth are recognised and will be acknowledged and protected in the course of the review
• insufficient detail and assurance has been published to show the standards that will be observed as the review collects and works with research and other evidence, and makes recommendations.
After introducing the often poorly understood topic of women’s human rights in childbirth (legally mother and fetus are one), I continued:
Women may very easily find their autonomy and rights constrained – in law, or merely by social conditions, which can be equally effective. Not to bear in mind the history of maternity care in England and Wales going back to the 1960s (and indeed long before that) when considering this matter is to step out into the arena unprepared. I recommend to anyone trying to understand the complex politics, the issue of informed choice and something of the history, the following reference texts:
1. Birth and Power; a Savage Enquiry Revisited (2011 – reflections from retired obstetrician Wendy Savage, whose case is well-known, and contributions from other commentators)
2. The Politics of Maternity (2013 – concise; a particular view, of course, but outlining the issues clearly)
3.Informed Choice in Maternity Care (2004 – still highly relevant)
4.Birth – a history (by a US author, but still highly informative)
I tried to explain to her something of the background to the review, as I saw it:
The context for the proposed national review includes:
• the publication of the updated NICE Guideline Intrapartum Care: care of healthy women and their babies during childbirth in December 2014 (NICE IPC 2014)
• statements about planning maternity care made in the FIve Year Forward View from NHS England
• the report of the Morecambe Bay Investigation (Kirkup Report) published on 3 March 2015
• the proposal for the dismantling of the system of Supervision of Midvives, which is linked to the investigation of events at Morecambe Bay by the PHSO and others. Supervisors, in addition to their current role in regulation, have a very important role in advocating for women who exercise their right to decline advice and not to consent, and indeed in facilitating choices in birth planning that are ‘against local policy’ – women can find themselves under great pressure, notwithstanding their rights.
I think that the original impetus for the national review probably arose from the general situation in maternity care (see, for example, RCM’s State of Maternity Services Report 2013) and the fact that the findings of the Birthplace Study meant that the place of birth recommendations in NICE IPC 2014 were widely anticipated (the current system of care does not, in practical terms, reflect that guidance, in many areas.) There is no doubt, however, that the events that led to the Kirkup Report and recommendations have become increasingly significant.
I offered a few thoughts on a national maternity review being undertaken following the Kirkup Report:
The Kirkup Report makes very sad reading indeed. However, I am not sure, having read the whole report, how the leap is made in the conclusion from recommendations about the local situation to recommending a national maternity review to be conducted in the light of the situation at the Morecambe Bay Trust: no evidence or reasoning is given. […] Cumbria, which includes the Lake District, has a highly unusual physical geography (arguably unique in England and Wales) and high levels of socio-economic deprivation […] While birth culture is an issue across England and Wales (as recognised by NICE IPC 2014: see 1.1.12 and 1.1.13 – indeed all of section 1.1 and the key priorities for implementation), I would hesitate to suggest, without evidence, that the very particular local situation documented in the Kirkup Report exists in quite the same way elsewhere. The RCOG has just published a local maternity review for Cumbria.
I shared my concern about the harm that a national review might do if driven by the desire to be seen to ‘do something’ in response to the Kirkup Report, rather than by thoughtful and thorough consideration of all relevant evidence and factors:
It would be unfortunate if a rushed response (the national review is due to report by the end of the year – a short time for such work) to the particular and local in […] Cumbria were to do harm to the quality of the planning for the future of maternity provision that is undoubtedly needed across all of England and Wales.
My view is that planning should be local, involving women in understanding:
• that they have choices
• the best available research evidence, and
• examples of good practice in care elsewhere, including women’s experiences and outcomes in the broadest sense (including the impact of experiences of care and support on early family life, for example) as part of their involvement in the review and redesign of services.
If planning is to be national, then the stakes are such that the standards for the conduct of the review must surely be very high.
I noted that Anna Bradley serves on the Board of CQC and that Healthwatch England has (or will have) a Memorandum of Understanding with NHS England. I declared my relevant interests:
I am an MSLC member (and [then was] Chair)… an LSA Lay Reviewer (participating in annual audits of teams of Supervisors of Midwives, including discussing and reviewing complex care plans involving Supervisors advocating for women) – Lay Reviewers receive a fee for each audit they participate in…an NCT antenatal teacher…served as one of two lay members on the NICE IPC 2014 guideline development group…write to you in a private capacity (reflecting the above roles and interests) – in my working life, since January 2015 I have been a local Healthwatch officer…
I told her:
I write as an experienced and informed maternity lay advocate to ask you to join me in hearing and considering the response I await from NHS England to my questions about the proposed national maternity review.
And left it at that, after receiving a polite but brief reply, hoping I had at least highlighted some key points to be kept in mind as Healthwatch England continued, no doubt, to monitor the review process. I am pleased to see that in December Healthwatch England published some findings from local Healthwatch around the country (and a letter to the review). I am also pleased that Healthwatch England noted in its briefing the importance of sharing such feedback with multidisciplinary MSLCs – women, commissioners, healthcare professionals and others working together as equals – you can see examples MSLC reporting and analysis here.
So what was my correspondence with NHS England? I had emailed a contact at NHS England at the end of March, somewhat baffled by the lack of clarity in the review panel appointments process. My contact put me in touch with the relevant person at NHS England to hear my concerns, and I wrote in more detail – my concerns are summarised above – full text here: birthandbiology.wordpress.com to the National Maternity Review
NHS England replied, explaining that the review did not involve a public appointments process, and that it was not possible to answer my questions about methodology and approach at such an early stage in the process.
Some ‘wait and see’ necessary, then. The national maternity ‘conversation’ on Twitter – and to some extent in the press – was lively through the year. Although often enough I swapped notes with doctors and midwives who are not on Twitter, and were barely aware of the national review, if at all. So I wondered what difference the ‘national conversation’ makes. Hard to tell.
Looking ahead in 2016 – awaiting the recommendations
Will the recommendations be evidence-based?
Reflecting now on Julia Cumberledge’s most recent blog, one point jumped out at me: her reference to ‘the Health Secretary’s pledge to fund improvements to technology and equipment, which we hope will make maternity services safer’ Worrying. Because research evidence matters, and the pledge is arguably misguided, as we’ll see.
Mary Newburn wrote a powerful open letter (addressed to the Guardian) here in November, explaining that ‘Jeremy Hunt (Jeremy Hunt aims to cut number of stillbirths and neonatal deaths, 13 Nov) is strong on rhetoric but weak on detail. Evidence that ‘digital equipment’ saves lives is limited, so let’s not kid ourselves and get caught up in a technology race.’
Also in November, in an extraordinary moment of speaking truth to power, a group of well-known and respected researchers and doctors wrote this letter to the Guardian, explaining very clearly that public health is the key to cutting stillbirths: ‘We welcomed Jeremy Hunt’s recently announced ambition to halve England’s rate of stillbirth by 2030, but his proposed “maternity safety champions” and the provision of “high-tech digital equipment” offer no solution for the majority of stillbirths, which occur before labour.’
Perhaps the scene was set for this by the equally extraordinary and powerful letter from Birthrights and others to the review team back in August: the Birthrights letter to the National Maternity Review.
It’s encouraging that so many who are able to give an informed, expert view, whether about relevant human rights issues or about research evidence, spoke up and made their views known while the review was in progress.
Review recommendations – what to expect?
When Baroness Cumberledge spoke at the National Maternity Review Birth Tank 2 event in Birmingham, a process of ‘expectations’ management’ was in full swing. The ‘best practice’ examples we were shown – and encouraged to ‘go, implement now’ – were interesting. Some inspiring. But as regards the review itself, the message seemed to be, ‘Don’t expect too much,’ and we were clearly told, ‘There is no more money.’
Well this is what I expect of the review report and recommendations:
• Evidence – especially research evidence – demonstrably handled correctly
• NICE guidance respected, and used as it should be
• Respect for the NHS constitution
• My questions about methodology and the protection of human rights answered satisfactorily
• Evidence included from listening to vulnerable women where they are in the community, which the review team has promised during Twitter conversations (‘come to us’ drop-ins are not the best way to reach most women, vulnerable or otherwise)
• An approach to quality and safety of maternity care that adopts the definition used by the WHO, as outlined in the Birthrights letter to the review
• A commitment to care in labour and birth that is both woman-centred and based on best available research evidence, and accordingly a commitment to co-design processes that involves women in the way I outlined to Anna Bradley (the review itself has not been a co-design process in this sense – it has been a listening exercise, which is different.)
It still isn’t clear to me what the status of the review recommendations will be. Advisory only? National policy to replace Maternity Matters? And in either case, will it encourage and support hard-pressed commissioners to implement relevant NICE guidance including CG190 Intrapartum Care for healthy women and babies, or will it provide them with reasons for not doing so? Will key, evidence-based public health measures that women, their babies and families deserve to have implemented be a casualty? I do hope not.
We have seen recently that the multidisciplinary, collaborative community of people wanting to improve the quality of maternity care – women, commissioners, midwives, doctors, and others – can and will speak out about research evidence, and about public health (as noted above). I find that immensely encouraging.
Meanwhile, at local level, work continues. In particular, I wish #MSLC and #MatExp colleagues across the country – women, commissioners, midwives, doctors and others – a Happy New Year. The tough stuff – the difficult conversations; the daring to do things differently – depends on you and those like you, as it always has, and always will.
I hope the National Maternity Review recommendations will support your birth work, and uphold the values that we adhere to: recognising women’s human rights; being woman-centred, and supporting families; arguing for and creating care that is based on best available research evidence; providing women with real choices, and respecting and supporting their individual decisions, whatever they decide. If not, well, we know what to do. We’ll keep going.
*% of women reporting birthing in stirrups – unassisted vaginal birth – confirmed by writing to CQC survey team