Kathryn Gutteridge talks about what happens when women and midwives work together
As a midwife for some years now it is obvious to me that the greatest professional successes I have been involved in are because of the women who joined with me. If I reflect upon this then it is obvious that I have listened correctly to women's voices and joined with them in a journey to fulfil the work.
At the moment there appears to be a groundswell in maternity services supported by some key events that have raised issues around quality and safety. Morecambe Bay1 demonstrated how a service could lose sight of those important features by not listening in earnest to families and therefore failing the very people they were supposed to care for. The recent Maternity Review2 was commissioned to listen to families and to find out exactly what a high-class service should look like and how families should be at the heart of the process.
My view is that maternity care has suffered from many things, but one of the greatest failings is the lip service it pays to involving women and their families. For many years now there has been a requirement to involve patients and the public in health systems, this is no different in maternity with Maternity services Liaison Committees being an example. However, as with many health agendas, there is a lack of understanding andclarity of how and who should deal with this.
If we look at the origin of the 'person-centred' approach in healthcare back in the early 1990s a change in perspective emerged. The Patient's Charter3 then took this further and set out a number of rights for patients, including maximum waiting times and the right to have a complaint investigated. History has also highlighted the impact of not involving people in their own care. A successive number of reports commissioned, as a result of adverse events in health and social care, have concluded that in the majority of cases significant harm could have been prevented and financial cost saved if organisations had listened to those in their care.4,5
Maternity care is certainly considered to be a high risk area of health, as supported by the publication of Ten Years of Maternity Claims – An Analysis of NHS Litigation Authority Data.6 The report showed that litigation overall had increased and the commonest areas of deficiency had an underpinning thread of failing to listen or involve women in decision making. Therefore, if women are turning to lawyers to find a voice, it would make absolute sense to involve women right at the start of changes or service development.
Where women and midwives work together a strong foundation is made with a certainty around the philosophy of care. When developing any service provision a great deal of work should precede this, with a focus upon local women and families. If the service to be developed is a midwife unit in a busy urban city then research has to include significant elements that need to be addressed prior to any physical work.
To ensure that the service is bespoke, and fits the women it is intended for, a consultation should be started with a wide spectrum of reach. This should encompass all aspects of the service proposal and comprise detailed questions that are to be addressed. A consultation should begin with a project plan that has a time frame and key objectives to fulfil; there should also be a governance framework that monitors the progress of this work.
Using social media to both advertise the consultation and collect opinions is a very easy way today to engage with women's views. This method can produce a large volume of data. However, it is important not to rely purely on electronic opinion.
Example of some key questions:
There are many ways to conduct a survey or canvass opinion when a change is proposed, but the drivers should come from the women. If there is a steering group then this should include representatives from the women's community. This will ensure that throughout the development phase all of the information is validated by women. There should be a variety of events/methods to capture information which will inform the philosophy of a new service. This ensures the service is underpinned by systems and processes to suit local women. There are a few suggestions of how this may be done.
When women have given birth they will have a story to tell. This may have valuable information that can be fed back to midwives and doctors alike. In addition to this it gives women a voice and a platform in which they are heard. It is important to understand that many of the stories will include difficult narrative but the essence is facilitation that does not evoke emotion one way or the other. It may also be useful to video these stories, with the woman's permission, so that messages can be shared throughout the service.
Working with a specific group of women gives the consultation team opportunity to collect views from less representative groups. These target groups may be young parents, women with mental health illnesses or socially deprived women. As you can imagine all of the suggested groups will have their own needs and birth outcomes. For instance, if working with young parents, it is a good idea to engage with both parents. Using a specialist midwife to access these groups is an option. For example, when developing Serenity Birth Centre, a young mother's afternoon was held with a team of midwives. The young women used the opportunity to see a range of birthing equipment and environments. All of their comments and ideas were captured for use in planning the service. In addition to this a young father's evening event was held, supported by a project worker from the local community. This was a great success where the young men were able to state what was important to them at the time of birth and their involvement throughout the childbearing episode.
If there are specific ethnic communities then this has to be investigated as part of the consultancy plan. In Birmingham there are many such communities, one example is the Somalian community. It is essential that respectful enquiry is made through community organisations and that a key worker is involved. This makes access to community members easier and again is vital in establishing a relationship of trust. In the consultation work to develop the Serenity Birth Centre it became obvious that Somalian women did not want to book at the maternity unit. When meeting with the Somalian Women's Group it was discovered that they felt misunderstood, that they were afraid of having caesarean sections and that they were also not in favour of other birth interventions. Once again a listening event was organised, with women sharing their birth stories and experiences. It was clear that we had not met the needsof a significant group of women.
It proved very useful to engage with community elders. As project lead I can remember thinking that if we could show the elders of the community the benefits of midwife-led care then the job of convincing women would be so much easier. In this case I managed to be invited to several mosques and holy buildings. I met with both women and men in respected community roles. I asked them how I could reassure them about the benefits of a midwife for most women and I learnt some valuable information.
The elders told me that many families still upheld the traditions of their birth countries, even though on the face of it young women and men were living thoroughly westernised lives. I heard that families were keen to educate their children to achieve greater potential but that in itself became a conflict when the child challenged the family values. I gave the elders the principles of what safe midwife care could achieve and invited them to a tour of the unit to explain how interventions might cause problems. This small piece of work had boundless consequences. The elders generally influenced every family within their religious community and they were able to reinforce the new pathways we were hoping to introduce.
It is fair to say that there is no prescription to this process. It is repetitive and region specific. However, there are some rule of thumb principles that should be applied.
In the overall development of both Serenity and Halcyon Birth Centres the consultative work led to a model of care that was designed to meet our families' needs. This was derived from women and families at different stages of their childbearing and life course. The main themes to emerge were that women wanted to have a clean, safe environment, a midwife who was kind and that their family was cared for too. Not a great deal to ask for.
Consultant Midwife, Clinical Lead for Low Risk Care, Doctoral
Student, RCOG Undermining Champion for West Midlands
1.Kirkup B (2015) The Report of the Morecombe Bay Investigation. www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
2.National Maternity Review (2016) Better Births: Improving outcomes of maternity services in England. A Five Year Forward View for maternity care. NHS England. www.england.nhs.uk/ourwork/futurenhs/mat-review/
3.Department of Health (1991) The Patients Charter. DOH London.~
4.Department of Health (2012) Transforming care: A National response to Winterbourne View Hospital. Department of Health Review: Final Report. DOH London.
5.Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive summary. The Stationery Office. London.
6.NHS Litigation Authority (2012) Ten Years of Maternity Claims – An Analysis of NHS Litigation Authority Data. NHS Litigation Authority. London.
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