A prioritisation framework for care in response to COVID-19
Version 2.1: Published Friday 26 June 2020
AIMS has welcomed the RCOG document Restoration and Recovery: priorities for obstetrics and gynaecology and made a number of suggestions which have been sent to RCOG. Our comment were as follows:
Thank you for the opportunity to comment on this document. We are very pleased to see this being discussed and shared, and especially the focus on ensuring that “women and girls have access to safe, personalised and effective care” and “that the risk of avoidable harm is limited as much as possible.” We hope that this will include consideration of how maternity service changes may have had a negative impact on the emotional and mental well-being of mothers and birthing people.
We also welcome the comment in the foreword that “Some of these transformations to clinical services may well be for the better and work now needs to start, alongside restoration, to research, audit and understand whether there are some changes that should remain.” However, we hope that changes which have been welcomed by maternity service users will not simply be abandoned pending such research.
In relation to the third bullet point on page 15 we are therefore concerned that in version 2.1 published on Friday 26th June the examples which were included in the previous version have been removed. Previously this said:
“Maternal medicine clinics may continue with some of the modernisations suggested during the pandemic but, overall, the aim should be to return to pre-pandemic levels until research identifies the safety and efficacy of these changes. A good example of change which should potentially be maintained is alternative testing for gestational diabetes given that glucose tolerance tests are difficult to deliver in a socially distanced fashion. Home blood pressure monitoring may also help to reduce contact where appropriate.”
We felt these were both examples of innovation which had been really appreciated by those using the service and had been pleased to see them highlighted. We are concerned that returning to pre-pandemic practices when there is no research to support one option or another makes little sense, and instead we would have hoped that both options of care could be offered, along with information that we don’t know whether one is more effective than the other, allowing service users to make an informed decision about what was best for them.
In this section we are pleased to see emphasis on considering the “Increasing levels of anxiety or perinatal mental health issues”. We are aware of many women contacting AIMS for whom this has been an issue., Sometimes this was exacerbated by the lack of flexibility from NHS Trusts or Boards, which demonstrated a failure to consider the need for personalised care. We hope that the restoration will include a focus on restoring support for choice for all maternity services users.
Another issue which has exacerbated anxiety and mental health issues for maternity service users has been a failure by some Trusts and Boards to be transparent about maternity service changes or their escalation/de-escalation plans. This lack of clear information has led to much anxiety over issues such as whether a planned home birth would be supported, or whether people would be able to have support from their chosen birth partners. Some Trusts and Boards have provided this information very well, so we would like to see these examples of good practice being shared through MVP networks, the LMS structure and the Royal Colleges with a recommendation for others to follow.
This lack of information has highlighted an issue that we have been concerned about for some time, in that some Trusts and Boards provide very clear information about the Maternity services they provide, but others do not. This would include making it clear who to contact in various circumstances, including contact details for PMAs or others who can provide support when additional support is required. Again we would hope that good practice for making such information available could be shared in order to raise the standard of information being provided.
In relation to point 3 “Consistency and variation* we welcome the comment that “By focusing on safe care, positive experiences for girls, women and their families, good clinical outcomes and co-produced prioritisation frameworks, variation can be limited.” We are aware that the degree of co-production has been extremely variable, and again would like to suggest that there is a recommendation for all to follow these examples of good practice.
We are aware that this was a very challenging time for maternity services but we do not believe that in all cases the reduction or removal of midwife-led birth options was genuinely due to staff restrictions. It seems that many Trusts that have been making good progress with women centred midwifery care as per Better Births continued to be innovative and found new ways to support the continuation or expansion of these services. In contrast, Trusts who have been reluctant to make the changes required by the Maternity Transformation Process took the opportunity to further reduce options such as out-of-hospital care and home birth. For example, we know that some immediately closed their birth centres, removed support for all home births and continue to resist reinstating these services, without any consideration of other ways of supporting them, such as those set out in the RCOG guidance “Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic.”
In relation to point 3 “Greater use of technology” we know that the opportunity for remote consultations has been welcomed by many maternity service users. There are benefits for those who find attending physical appointments more challenging, however there are some issues with this approach. For example, not everyone has access to the necessary technology, or to a private space in which to have confidential conversations. Some people may also prefer to have personal contact. We therefore welcome the suggestion under “Innovation and good practice” for “Coproducing greater choices over virtual or face-to-face appointments with service user and patient groups, taking into account the needs of and accessibility for vulnerable women and girls, those with language difficulties, and those from a BAME background who may be more at risk from coronavirus”.
In relation to point 4 we also appreciated the collaboration and discussion that has taken place with patients and charity groups during ongoing development of guidance. We hope to see this continue not only during the restoration and recovery of services, but beyond that time as an important aspect in the ongoing development of maternity services.
Third bullet point - We would be very please to see the “Adoption of more ‘one stop’ services that can reduce the need for repeat appointments” and would hope to see that happen within the context of the development of community hubs.
Fourth bullet point - We were very concerned by the apparent lack of understanding of the principle of informed consent in the statement that “ Women should be supported to choose their birthplace where the evidence supports this” (our emphasis). We trust that RCOG recognises the right of women to make decisions about their care in all circumstances and would urge you to amend this to say “Women should be provided with information to enable them to make an informed decision about their birthplace and to be supported in that decision.”
We were relieved to see the recommendation that “Midwifery staff redeployed from the community into the acute sector should be returned to community care to ensure the safe delivery of community services, including home births and community midwifery”. Indeed, we have questioned the wisdom of them being removed to the acute sector in the first place.
We hope that the suggestion that “Preparation for induction of labour and planned caesarean birth has also undergone efficiencies, many of which could continue into the post-pandemic period, especially during the transitional phase towards a full recovery, such as outpatient induction of labour.” will be subject to audit of the impact that these changes have had on outcomes, as well as consultation with a wide range of maternity service users to determine their care preferences. Again, we would hope that these would continue to be offered as options along with information about the currently limited knowledge about risk and benefits.
We are glad to see the comment that “birth partners should be welcomed in a more flexible fashion” but would suggest that this needs to go further and reflect the need for personalised care and case-by-case consideration of support needs. We heard from many women whose needs for support were completely disregarded and seen as unimportant, even when they had significant physical or psychological issues.
We are pleased to see the encouragement to local systems “to reaffirm their commitment to the principles of safe and personal care set out in Better Births”, but it would also be good to see reference to the similar initiatives in the other countries of the UK.
We hope that these comments are helpful, and look forward to seeing our suggestions reflected in the next version of the document.
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