AIMS Journal, 2023, Vol 35, No 3
By the AIMS Campaigns Team
In this article members of the AIMS Campaigns Team summarise some of the documents that we have been reading that we think will be of interest to other birth activists. Do let us know if you find this type of summary useful or have suggestions for what we should cover in future issues campaigns@aims.org.uk
What is it: This is NHS England’s response to the issues raised by the recent independent reports by Donna Ockenden on maternity services in Shrewsbury and Telford and by Dr Bill Kirkup on maternity and neonatal services in East Kent. It sets out “how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families.”
Who published it: NHS England
Publication date: 30 March 2023
Where can you find a copy: www.england.nhs.uk/publication/three-year-delivery-plan-for-maternity-and-neonatal-services/
Key points:
The plan lists four themes:
Under each theme there is a short explanation and then a list of ‘key commitments for women and families’ followed by three detailed objectives.
For each objective, the document sets out the responsibilities of Trusts, Integrated Care Boards (the bodies that have replaced clinical commissioning groups), and NHS England for the actions required to deliver the objective, and the measures and methods to be used to determine success.
Theme 1 objectives are Care that is personalised; Improve equity for mothers and babies; Work with service users to improve care
Theme 2 objectives are Grow our workforce; Value and retain our workforce; Invest in skills
Theme 3 objectives are Develop a positive safety culture; Learning and improving; Support and oversight
Theme 4 objectives are Standards to ensure best practice; Data to inform learning; Make better use of digital technology in maternity and neonatal services.
Many of the actions seem to relate to initiatives and tools that are already in place, and AIMS questions whether this plan is sufficiently radical to bring about the fundamental changes that are needed.
We are also disappointed not to see a recommitment to the full Better Births vision national-maternity-review-report.pdf (england.nhs.uk) and in particular that Trusts now only have a responsibility to “Consider {our emphasis} the roll out of midwifery continuity of carer in line with the principles around safe staffing” set out by NHS England, rather than a responsibility to implement this way of working as soon as safe staffing levels are achieved.
AIMS plans to comment further on the plan, and will continue to scrutinise how implementation is being monitored.
What is it: The document sets out the measures for determining success of the implementation of the four themes of the three year delivery plan.
Who published it: NHS England
Publication date: 20 June 2023
Where can you find a copy: https://www.england.nhs.uk/long-read/three-year-delivery-plan-for-maternity-and-neonatal-care-technical-guidance
Key points:
The four themes as detailed above, have a number of measures that will contribute to determining success:
15 measures for Listening to and working with women and families with compassion
9 points for Growing, retaining and supporting our workforce.
8 measures for Developing and sustaining a culture of safety, learning and support.
9 points for Standards and structures that underpin safer, more personalised, and more equitable care.
There will be a wide range of data sources used to measure success, these will include:
Regional management information returns
National Neonatal Research Database/ Neonatal Data Analysis Unit Reports
There are a few data sources that are still in development or the source of the data still to be confirmed
There is detailed information not only about which data will be used, but how it will be used to measure the outcome item. For example, from the percentages giving certain answers to specific questions in the CQC survey. AIMS has some concerns about this approach of using existing data to answer different questions.
In addition, we are concerned that using the proportion of women who answered ‘Yes, always’ in response to a question (such as ‘Thinking about your care during labour and birth, were you involved in decisions about your care?‘) but excluding from the calculation those that answered ‘Don’t know /can’t remember’ or ‘I did not want/need to be involved‘ will lead to a misleadingly high positive rate. AIMS also has concerns about the wording of this and other questions in the CQC survey. Being ‘involved’ in decisions is potentially very different from being supported to make fully informed decisions.
AIMS is pleased to see this clear documentation of how success will be measured, but we are left concerned that these indicators of success are not sufficient to provide clear success measures of the stated aspirations in many cases. We hope that when reports are published on successes of this plan, it will be made clear what the underlying data reported actually said.
What is it: A care bundle listing a number of elements aimed at reducing perinatal mortality. This is intended to guide practice and the care that is offered.
Who published it: NHS England
Publication date: 1 June 2023
Where can you find a copy: www.england.nhs.uk/publication/saving-babies-lives-version-three/
Key points:
This version includes a refresh of the existing key elements and has added a new one. The six elements of the bundle are now:
Reducing smoking in pregnancy
Fetal growth – risk assessment, surveillance, and management
Raising awareness of reduced fetal movement
Effective fetal monitoring during labour
Reducing preterm birth
Management of pre-existing diabetes (NEW)
This new version has been produced despite the evaluation of version 2 not having been completed yet, as it was felt that “improvements to best practice couldn’t be delayed when evidence is readily available for improvements to several elements.” However, without the evaluation it is not clear how much the care bundle has contributed to reducing perinatal mortality, nor what contribution the different elements might have made. We are still awaiting publication of the evaluation.
There was a 25% reduction in stillbirths between 2010 and 2020 from 5.1 to 3.8 per thousand births but it increased to 4.1 per thousand in 2021, probably from both the direct and indirect effects of the Covid pandemic. (Note that the downward trend began before the first version of the care bundle was launched in 2016, decreasing from 5.1 per thousand births in 2010 to 4.5 per thousand births in 2015.)
AIMS is pleased to see a new section on “Informing women of the long-term outcomes of early term birth” and the inclusion of information about the risks and benefits of birth before 39 weeks.
We are concerned that despite references to the importance of pregnant women having “choice and control over the way their care is planned and delivered” the language in most places remains prescriptive, for example “In fetuses with an EFW (estimated fetal weight) between the 3rd and <10th centile, delivery should be considered at 39+0 weeks. Birth should be achieved by 39+6 weeks.”
The Reduced fetal movements (RFM) element comments on the AFFIRM study, which found no benefit from offering a package of assessments to all women with RFM after 26 weeks’ gestation and induction for recurrent episodes of RFM after 37 weeks’ gestation. This did not significantly reduce stillbirths but was associated with an increase in induction of labour and caesarean births. However the guidance does say that the option of induction “could be discussed” with women who experience a single episode of RFM after 38+6 weeks gestation, and that “women presenting with recurrent RFM are additionally informed of the association with an increased risk of stillbirth and given the option of expediting birth (by the most appropriate route for them) for RFM alone after 39+0 weeks.”
The new section “Management of pre-existing diabetes in pregnancy” focuses on the importance of care being offered “in a one stop clinic, providing care to pre-existing diabetes only, which routinely offers multidisciplinary review and has the resource and skill set to address all antenatal care requirements.” It also recommends “an intensified focus on glucose management.”
What is it: Update of the framework published in December 2020. It “sets out clear expectations for all trusts, aiming to address known variation in training and competency assessment across England.”
Who published it: NHS England’s Maternity Transformation Programme
Publication date: 31st May 2023
Where can you find a copy: https://www.england.nhs.uk/publication/core-competency-framework-version-two
Key points:
There are six modules. Each sets out the minimum standards for training and a “stretch target – ambition/aspiration.”
The focus is on “training to address significant areas of harm.”
Module 1 covers the training required to deliver each of the elements of the Saving Babies' Lives Care Bundle version 3.
Other modules cover fetal monitoring during pregnancy and labour; maternity emergencies and multi-professional training; equality, equity, and personalised care; care during labour and immediate postnatal period; and neonatal basic life support.
Modules 2, 3 and 6 (on fetal monitoring, maternity emergencies and neonatal basic life support) all include as part of the minimum standard “the principles of psychological safety and upholding civility in the workplace, ensuring staff are enabled to escalate clinical concerns.” This is an important requirement, as in many of the cases identified by the Ockended and East Kent reports, a bullying culture resulting in a failure to escalate - or respond to - concerns played a part.
It is also encouraging that module 4 (equality, equity, and personalised care) requires that as a minimum one topic from each of the following lists is covered:
List A: ongoing antenatal and intrapartum risk assessment and risk communication; maternal mental health; bereavement care.
List B: personalised care and support planning; informed decision making, enabling choice, consent, and human rights; equality and diversity with cultural competence.
AIMS hopes that over time this will lead to all maternity staff having a proper understanding of informed decision-making and consent, as well the importance of respecting individuals, taking account of cultural differences and acknowledging human diversity.
It is a pity that “Involving MNVPs/Service Users in co-producing and/or delivering training based on lived experiences,” is only part of the stretch target for this module, rather than being considered part of the minimum standard.
AIMS also regrets that module 5, on care during labour and immediate postnatal period, only talks about training having “a focus on deviation from the norm and escalating concerns.” There is no mention of what we consider the equally important aspect of knowing how to support and promote physiology in order to reduce the chance of such “deviations” occurring.
What is it: A report on common themes identified from complaints to the ombudsman about maternity care.
Who published it: The Parliamentary and Health Service Ombudsman
Publication date: Undated but early 2023
Where can you find a copy: https://www.ombudsman.org.uk/publications/spotlight-maternity-care-your-stories-your-rights-report
Key points:
Between 2020 and 2022 twenty seven complaints relating to maternity care were upheld or partly upheld by the ombudsman. The report does not say how many other complaints there were.
Almost two thirds (65%) of these complaints involved communication issues.
Three out of five of the case studies included relate to failures of support and/or follow-up care for women who suffered a miscarriage.
It emphasises the importance of “listening to families” and encourages people to exercise their right to complain.
It includes details of the process for making a complaint.
What is it: In 2014, the UK Chief Medical Officer recommended a review of pregnancy research needs and expenditure, with recommendations for future research priorities. This report sets out the findings of this review. It is principally aimed at research funders and policymakers.
Who published it: RAND Europe, a not-for-profit think tank. The report was commissioned by the UK Clinical Research Collaboration and funded by National Institute for Health and Care Research and The Wellcome Trust.
Publication date: 2020
Where can you find a copy: https://www.rand.org/randeurope/research/projects/uk-pregnancy-research-needs.html
Key points:
The study aimed to find out the answers to four main questions :
How much is currently spent on pregnancy research in the UK?
What this is spent on (topics and type of research)
How does spending on pregnancy-related research compare with spending on other areas of health research?
What should be the main priorities for future pregnancy research?
The review found that £51m is spent annually on pregnancy research in the UK, the equivalent of only 1% of health research funding and significantly less than the NHS spends on pregnancy-related litigation. The authors urge caution in comparing pregnancy-related research funding with other disease areas, as clearly pregnancy differs. Some outcomes which funders use to compare health research funding applications may also not apply to pregnancy, for example reducing the burden of ill health, given that most pregnancies are healthy.
For every £1 spent on NHS pregnancy care, about 1p is spent on research.
The recommendations in this report are based on feedback from an online survey which was open to members of the public and workshops held with researchers, healthcare professionals, charities and funders. However, out of 592 online survey responses, only 250 were from members of the public, a pretty small sample. The authors also don’t mention if they recorded any characteristics of the respondents, so the findings may not be representative of the whole of the UK. In addition, members of the public had slightly different priorities to the other groups asked.
The authors recommend mental health research as the top priority for research funding, given that perinatal mental health currently receives only 4% of all pregnancy research funding, despite affecting up to 20% of pregnant women. It also prioritises research into stillbirth as, depending on the classification system used, between 10% and 50% of stillbirths remain unexplained.
The authors go on to recommend a range of topics which should be prioritised for further research, including preterm birth, health inequalities, birth experiences and medication during pregnancy.
AIMS is pleased that “improving the experience of care” was listed as an aim of research as well as making birth safer and more equitable and that the authors acknowledge that experiences during pregnancy can have long-lasting impacts.
Overall, it is good that this report makes the case for increased investment in pregnancy research. However, the authors recommend policymakers consider the “potential for return on investment” in directing where research funding should go, which may not prioritise research topics in an equitable way. AIMS hopes that birthing women and people’s voices will continue to be listened to and put centre-stage in designing and carrying out future research. As they say – “Nothing about us, without us”!
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