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by Rachel Boldero
For this issue, as we mark the 60th anniversary of AIMS, the AIMS Campaigns team were keen to invite Baroness Julia Cumberlege to introduce herself to our readers. For more than half of the time that AIMS has been in existence, Julia has been at the forefront of policy work on community, health and maternity service improvement. Julia remains on the Maternity Transformation Programme board and plays a key role in ensuring stakeholder voices are heard as the implementation programme proceeds. Most recently, Julia also led the review into medicines and medical devices safety1, and we will be reporting on the key messages from this review in our next issue, as it links to our work to seek improvements to the maternity services.
We invited Julia to tell us about what drives her interest in maternity policy, to share her reflections on her long-term involvement in this policy area, and to reflect on AIMS’ role in campaigning for maternity service.
1. Thank you for making the time and agreeing to be interviewed by AIMS. To start, can you tell us about your passion for maternity services and women’s health, and how this journey began?
It began when I gave birth to three sons. Two of those (the first two) I had at home, and the third in hospital. The difference between giving birth at home and hospital was so great. It was right that I had the third in hospital as I needed to be induced, but the difference in the care was significant.
At home I was in my territory, and that made such a difference. Indeed, with my first baby, I was 18 at the time, it was a very difficult birth and my midwife taught me how she being really skilled and confident can manage a difficult labour.
The professional partner at the time was my GP- he was very anxious because I was the daughter of his medical partner in the practice! During the birth, my husband took him to the kitchen and they shared a bottle of whiskey while the birth was taking place and overall I had a wonderful experience.
I am a farmer’s wife (my husband is now retired) so I got very involved with sheep and lambs and whilst of course this is very different from the birth of a human baby, there is this miracle of new birth and whether it is animals or humans, it is amazing to see.
2. You’ve been pivotal in two important maternity services reports, (Changing Childbirth 1993 and Better Births 2016)- How do you feel about the impact Changing Childbirth made?
Well I have talked to a lot of people since that report and they said it began to put women much more at the centre of care, and it did change some attitudes. We tried to introduce Continuity of Carer and unfortunately that withered. It was interesting with Changing Childbirth - I was a Minister in her Majesty’s government at the time so this was administered from the top. I learnt with Better Births years later that you have to drive things from the bottom up as much as top down. You have to make people in the service want to do it, and you have to ensure what they are doing is what women want.
I think the great difference between the two reports was that with Changing Childbirth I was only a Minister for a relatively short period of time and then a new government came in with different priorities, and maternity wasn’t one of them. With Better Births I was not a Minister and was appointed by Simon Stevens to lead the review of maternity services; NHS England were amazing because they gave us 8 years to implement and they gave us the people and resources to achieve this.
Now COVID has obviously intervened, some of the progress we were making has stood still or even gone back a bit and we now only have another 5 months to try to reinvigorate what we (and many maternity units) were trying to achieve.
3. There is a degree of overlap between some of the key points and recommendations in Changing Childbirth and Better Births, what do you see as the challenges and barriers as to why it has taken some time for particular initiatives to really embed into maternity services?
Well I think it is true of any major change- when I was Chair of the Brighton Health Authority (1986) I was asked to review Community Nursing and one of the 14 recommendations we made in neighbourhood nursing was that Nurses should be able to prescribe. I picked that up because I had been out with the Midwives and realised they could prescribe pethidine yet Nurses could prescribe nothing. We recommended that Community Nurses should be allowed to prescribe. It took 20 years for that to happen. It does take time to achieve your vision and what you want to see happen. You have to be persistent, determined and you have to inspire people who are giving the service in the community, the wards, labour wards, postnatally and throughout maternity services. You have to inspire them to want to do it. It is no good trying to introduce something nobody wants to do.
The other difference between the two reports is the wish of the women and the growth of women being more confident in knowing what they want, and on occasion insisting on what they want- that has been a major change in those 20 years.
4. Better Births put a lot of emphasis on Continuity of Care, why do you feel this is important?
Because it is safer. Because we only managed to get Jeremy Hunt (when he was Secretary of State for Health) to back this when he saw the results and research that had been carried out that evidenced it was safer. Of course, safety and making health services safer has been his great purpose in health. It does not necessarily depend on more interventions and more testing if you can provide the sort of services that Neighbourhood Midwives provided, and you can see what women want. We felt it was right with Changing Childbirth and then with Better Births we had the evidence. A lot more research had taken place and the results were obvious- the evidence showed this provided safer services. Equally important is that this is what women want.
5. Since you were Junior Health Minister in the House of Lords, what are the biggest changes you have observed in maternity services?
I think it has been the establishment of Local Maternity Systems (LMSs)2. Where they work well, these can make a real difference to the local services that are provided. These weren’t in existence until the NHS started to get them established. They are important as they attain the data and should then be looking at this very carefully to see how they can do better, and how other people/services may be doing better, and what they can put into practice in order to achieve the best. It is holding up a mirror on what is going on in different areas, in the different LMSs.
The second thing is community hubs3. These are equally important. We have 28 recommendations and wanted all of them implemented. We have much more information now, as to what women want. One of the difficulties with COVID has been that where we were collecting data, this has not been possible during COVID so we are lacking up to date information. Also of course, some of the services have had to be very differently organised and provided in order to accommodate the virus, so some of that information is going to be a bit skewed.
6. How do you think you have been able to make a difference to the maternity services - and ultimately the experiences of maternity service users - in the role that you have played?
I think what I have tried to do is put out a consistent message. I have tried to meet as many Midwives and women receiving services as I possibly could. You learn so much when you go and visit people. They tell you things you would never find on a piece of paper. In one area we met women who were very upset with what was happening to their service (closure of Freestanding Maternity Units), and you pick up the anger, energy, the determination to fight, when face to face. The thing is with maternity services- it is always changing. I get very upset when women’s choices are reduced. I think they should have the four choices we mention in the report- Home birth, Freestanding Maternity units/Midwife led units, Alongside Midwifery Units and also Obstetric Units. Women should have these four choices, and I think that is really important. The beginning of life is the most precious thing, that many women achieve and they are very conscious of how they give birth. The way they are treated during this time really makes a difference to the bonding with their baby and the longer term of the child into adulthood.
That leads to one of my worries about neonatal care- some babies at the moment [during the Covid19 pandemic] don’t have contact with a human face, only someone with a mask and there is the current great difficulty assuring parents they will get access to their babies and will be able to hold them. You cannot dismiss what has been going on since the world began in terms of bonding and ensuring that the future for your newborn is going to be a good one. It starts at the beginning. I do not underestimate the tremendous difficulty that units are currently going through where they are keeping everyone safe. I understand this. Some units have really gone out to ensure access is available 24/7 through technology or other means. Often it is reassurance that women want.
7. What particularly excites you about what is happening in maternity services currently?
When I see women being given real choices. When I see really high quality care that is given unstintingly to the women who need it, the commitment, dedication and even the love that midwives provide. A huge challenge now is how we address the health inequalities that have become so evident within the data we collect about maternity outcomes, especially those that relate to race and ethnicity. But I am sure that there will be an increasingly effective focus on that, now that we have the data.
8. How far will we have achieved the objectives of Maternity Transformation programme within the timescale of the NHS long term plan?
I think we will have gone a long way. It is very good that the long term plan is written in a way that incorporates all that we wanted in Better Births. It is not a full stop; it is a going forward view. It is right that we were given the time and now it has been taken forward in a wider context. This has been hugely encouraging.
9. AIMS is celebrating its 60th birthday this year. We believe we have contributed to improvement in Maternity Services and the Better Births agenda. How might Birth activists and AIMS in particular, help to progress the Better Births agenda?
First of all I would like to congratulate AIMS on achieving 60 years. There are an awful lot of Organisations (voluntary and not) who don’t survive that long. AIMS have kept up the momentum, understood the changing world and how they can contribute- AIMS has been outstanding in this field. I hope AIMS will keep momentum in achieving what you can against the 28 recommended improvements.
The other area I want to reference is Maternity Voices Partnerships (MVPs). We had Maternity Services Liaison Committees previously and some were very effective (and some less so), but out of that has grown the MVPs and what I want to ensure is much more co-production between users of these services and charities like AIMS, which will ensure that women’s voices are really heard and acted upon. There is still a bit of a way to go on that.
2 Local Maternity Systems (LMSs) Better Births recommendation (6.1) said that "Providers and commissioners should come together in local maternity systems covering populations of 500,000 to 1.5 million, with shared standards and protocols agreed by all.
3 The community hub concept, as described in the Better Births report, represents a recommendation to radically transform the way that maternity services are organised, to shift away from the current bias of a hospital-based services. Better Births stated that 'the NHS needs to organise its services around women and families. Community hubs should be identified to help every woman access the services she needs, with obstetric units providing care if she needs more specialised services. Hubs, hospitals and other services will need to work together to wrap the care around each woman' (4.28). Thus 'the concept of a community hub is that it is a local centre where women can access various elements of their maternity care' (4.29). www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: firstname.lastname@example.org
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