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By Nadia Higson
The Care Quality Commission (CQC) maternity care survey was first run in 2007, and has been conducted annually since 2017. It aims to capture the views of service users, to give ‘insight into their experiences and the quality of the care they receive’. This includes looking at key themes from the Maternity Transformation Programme, Safer Maternity Care and the NHS Long-Term Plan including:
The findings are used by a range of bodies: the CQC itself, the Department of Health and Social Care, NHS England, NHS Trusts and Clinical Commissioning Groups, and patients, their supporters and representative groups. There are both national results1 and results for individual NHS Trusts2.
The survey collects quantitative (numerical) data which enables many aspects of maternity care in different Trusts to be compared with national data and provides evidence for whether they are improving over time, at both local and national level. By its nature, it gives us little understanding of why respondents answered as they did, what lay behind good or bad experiences, or how they think their care could have been improved.
Paper surveys are sent by post to the home addresses of all those in England aged over 16 who gave birth during February 2019 (or, for smaller trusts, all or part of January 2019 as well), excluding those whose babies have died or been taken into care, those still in hospital during the sample period and those who used a private hospital or midwife. Using the post is intended to avoid the results being biased by a desire to please, which might happen if the surveys were completed in the presence of staff or on trust premises.
The survey is sent out in April, to ensure that all respondents will have experienced postnatal care up until at least 6 weeks after the birth. Two reminders are sent to those who have not responded, and assurances about confidentiality and data protection are given. Responses must be submitted by August.
The questions are developed with input from an external advisory group of stakeholders. In 2019, 11 new questions were added, 9 removed and 41 amended. Whilst it is good to keep improving and adapting a survey to changing needs, this will mean that the responses to some questions cannot be compared year on year.
The questions were tested for understanding and relevance with 22 recent mothers from different parts of the country and socio-demographic groups, and with different types of birth experience. There is a freephone language line offering a translation service, and contact details are provided for Mencap who can support those with learning difficulties. Nevertheless, the problem remains that people with poor literacy skills, those from socially-deprived groups and those for whom English is not their first language are still less likely than other groups to complete a written survey, as they need to have both the ability and the will to access support.
Perhaps in part because of this, those who responded are more likely to be older and to record their ethnicity as white than those who did not respond. It is likely that they are also less often socially deprived, but that data is not given.
With this kind of survey, it is not possible to check how well respondents have understood a question. In some cases, such as the questions about place of birth discussed below, it seems that lack of clear definitions has probably produced a misleading result. Also, with a limited choice of responses it is hard to know what to make of answers such as ‘Yes, some of the time’ which could mean anything from 5% to 95% of the time. In some cases, adding a definition or using a clearer range of possible responses (e.g. always – usually – rarely – never) would have been helpful.
The sample is substantial – over 17,000 participants across 126 NHS Trusts, representing a response rate of 36.5%. This is very high for a postal survey and is a good-sized sample for statistical analysis. The pooled data for England is weighted to take account of response rates in individual trusts as well as by the socio-demographics of the sample.
Trusts receive information on their scores for different features of their antenatal care, care in labour and birth, and postnatal care, and how each compares to the national picture. However not all trusts provide data on whether respondents received their antenatal or postnatal care elsewhere, so those figures are less reliable than those for care in labour and birth.
Choice of place of birth
Only 55% of women were offered the option of a birth centre, only 43% homebirth and 12% were not offered any choices – even between hospitals.
Despite this lack of offered choice, apparently 65% said that before their baby was born they planned to give birth in a midwife-led unit / birth centre, and only 21% planned to give birth in a consultant-led unit (4% planned a homebirth and 10% had no plan). Even more surprisingly, the data on actual place of birth says that only 34% of the sample gave birth in a consultant-led unit and 63% in an MLU or birth centre, which, even allowing for the fact that those numbers exclude women having planned caesareans, is very hard to believe.
It may be that many respondents assumed that if they were cared for only by midwives while in hospital that meant that they were in a midwife-led unit, when in fact it was a consultant-led unit. It would be helpful for the survey to include definitions of what is meant by an MLU / birth centre and a consultant-led unit to make sure that in future these responses reflect the true picture.
61% of women said they ‘definitely’ received enough information to help them decide where to have their baby. How can this really be the case, when 45% were not even offered an MLU / birth centre and 57% were not offered a homebirth? It would have been better to ask, ‘Were you given evidence about the benefits and risks of giving birth at each of the following?’.
The majority replied ‘always’ to questions about being given enough time to ask questions or discuss their pregnancy (79%), midwives listening to them (83%), being spoken to in a way they could understand (89%) and being involved in decisions about their antenatal care (82%). We might question whether ‘involved’ means having a genuine discussion and being supported to make a decision or whether it just meant having the midwife/doctor’s decision explained. It would be more useful to ask (a) ‘Were you given all the information you wanted on the benefits and risks of all your care options?’ and (b) ‘Were you supported in the choices you wanted to make about your care?’.
Only 37% saw the same midwife at every antenatal check-up. This may partly explain why still only 52% said that their midwives ‘always’ appeared to be aware of their medical history and 12% that their midwife was not aware of it (though these numbers have improved slightly over time).
It is also a concern that only 75% ‘always’ got the help they needed when they contacted a midwife. Nearly a fifth (19%) ‘sometimes’ did, but 3% did not and another 3% said they were unable to contact a midwife when needed. Although the trend is improving slowly, this is still far too many women who are not always getting the help they need.
Perinatal mental health
Of those reporting a long-term health condition, mental health was the most common problem mentioned. This group represents around 8% of the total sample.
During pregnancy, a majority (67%) were ‘definitely’ asked about their mental health, 24% were asked about it ‘to some extent’ but 9% said they were not – which means one in ten mothers said that they were never asked about this important aspect of their health before their baby was born. The figures for postnatal care were better, but one in twenty new mothers said they were not asked after their baby was born.
Only 63% were ‘definitely’ given information about possible changes to their mental health postnatally, but 12% (one in eight) did not receive such information. Four-fifths (80%) were told who to contact about them, meaning 20% (one in five) were not told who to contact. These figures may be overstating the problem, as some may have been given the information but not remembered it. However, at the very least this means that substantial numbers of women are not getting the information in a form they can retain and use.
Almost a third said that at their 6–8-week check the GP did not spend enough time talking to them about their mental health, while another 30% said the GP did so ‘to some extent’. Hopefully the recent announcement of dedicated checks for new mothers, separate from the check on their babies, which should have started at the beginning of April (just after these women would have been seen by their GP), will help to address this.
Pain relief methods
Most women used the type of pain relief that they had planned to, but 38% used something different.
Interestingly, given the recent debate on women being ‘denied’ epidurals, 3% of those who did not use their planned method of pain relief (presumably an epidural) were unable to do so because there was no anaesthetist available, rather than that their midwife told them they could not have one. However, the main reasons for not using their planned method were medical reasons (27%), changing their mind (27%), the planned method not working (21%) or that there was no time to use the pain relief originally wanted (19%). Only 6% said ‘I did not need to use the pain relief I originally planned’, while another 4% were not told why they could not have it.
Labour was induced in 44% of respondents excluding the 13% who had a planned caesarean, which means that around 39% of all respondents had an induction in February 2019. For comparison, the latest National Maternity Statistics say that 33% of labours were induced in the year to March 2019. We can’t compare these figures directly, but they imply that induction rates were rising substantially through the year.
Those who had their labours induced were much more likely to have an unplanned caesarean than those who laboured spontaneously (22% vs 11%), to have an assisted delivery (21% vs 14%) and to have an epidural (47% vs 19%) or opiate drugs (31% vs 20%) for pain relief.
Care & communication in labour
The lack of progress on Continuity of Carer is illustrated by the fact that only 16% were attended in labour by midwives who had been involved in their antenatal care. Even one-to-one care in labour was limited, with only 9% having a member of staff with them at all times.
Although the majority (78%) said they were not left alone in labour ‘at a time when it worried them’ (and this figure shows improvement over time), there were still many who were worried by being left alone at one or more times. This included 11% (one in ten) during early labour, 6% (about one in sixteen) later in labour, 2% (one in fifty) during the birth and 7% (about one in fifteen) shortly after the birth.
Most (72%) were always able to get help from a member of staff when they needed it, but 16% said only sometimes and 3% said they did not get help when needed.
Overall, this means many women were left alone when they were worried and/or were unable to always get help when they wanted it. Provision of one-to-one care during labour, let alone Continuity of Carer through pregnancy, labour and afterwards, clearly has a long way to go.
Though it has become a bit less common, far too many women still reported that their concerns during labour and birth were not taken seriously (16% overall but 19% of those having their labour induced) or that they did not have the opportunity to ask all the questions they wanted after the birth (only 56% said ‘yes, completely’ and 18% ‘not at all’).
The majority (78%) said that they were ‘always’ involved in decisions about their care during labour and birth; however, 18% said only ‘sometimes’ and 4% that they were not. This shows a worryingly frequent lack of informed consent in labour.
There has been little change in the use of helpful birth positions, with 82% giving birth on a bed and 60% lying down (37% in stirrups, 23% lying flat or supported by pillows). Another 14% were ‘sitting / sitting supported by pillows.’
Only 18% said they were standing, squatting or kneeling, and that presumably includes the 11% who birthed in a birth pool.
The number birthing in stirrups is actually up from 32% in 2013 to 37% in 2019, even though the percentage of assisted births has shown no corresponding increase (hovering between 14% and 15% over this period). In fact, almost one in four women (24%) who had an unassisted vaginal birth report that they birthed in stirrups. What is going on?
Postnatal care in hospital
The ability to get help from a member of staff postnatally was poorer than during labour, with only 62% able to get this ‘always’ and 6% saying they did not get help when needed.
There has been some improvement in mothers’ ability to get the information or explanations they needed from staff on the postnatal ward, with 66% saying they got it ‘always’ compared with 58% in 2013. However, that still leaves 27% who said they only got it sometimes and 7% who did not get what they needed.
Almost half the sample (44%) said that their discharge from hospital was delayed, but unfortunately they were not asked for how long. The main reasons were waiting for baby checks (27%) and waiting for medicines (22%).
Postnatal care at home
Again, Continuity of Carer is lacking, with only 28% saying that they saw the same midwife every time postnatally. Also, 23% said that the midwife they saw did not appear to be aware of their or their baby’s medical history.
Only 9% had Continuity of Carer throughout the perinatal period, seeing the same midwife postnatally as for their antenatal care and labour. Another 36% saw the same midwife for their postnatal care as for their antenatal care, and 2% saw the same one postnatally as for labour but had not seen them antenatally. More than half (54%) were seen postnatally by midwives that they had never met before.
Most people saw a midwife as often as they wanted, but 25% would have liked to see one more often. This is worse than in previous years (21% in 2017 and 23% in 2018).
Less than half (48%) were offered a choice about where to have their postnatal care, though this was a big improvement on last year (42%).
Only just over half (54%) said they ‘definitely’ received information about their physical recovery after the birth and 10% (one in ten) said that they were not given this. Only 42% thought their GP spent enough time talking about their physical health at the 6–8-week check. (See also Perinatal mental health).
The survey provides some interesting – and sometimes worrying – insights into the state of the maternity services, but there is scope for significant improvement in the questions being asked, which would enable a much clearer picture in some areas.
It has just been announced that the 2020 survey will not go ahead due to the coronavirus pandemic. Whilst this is understandable, it is unfortunate that we will miss this opportunity to discover how Trusts’ responses to the pandemic impacted on maternity care.
AIMS hopes that the CQC will use the time between now and the 2021 survey to address some of the issues we have highlighted here, and also to explore ways of making the survey more accessible to those groups who are currently under-represented.
1) National results: www.cqc.org.uk/publications/surveys/maternity-services-survey-2019
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