However, it is important for any vehicle that not only provides information but can also act as a voice for a community, to be accurate in their reporting and appropriate in their campaigning. In this month’s main article, Sally Marchant, midwife and editor of the MIDIRS Midwifery Digest, explores the complex facts behind the stark and often very worrying headlines concerning women, while also encouraging everyone to become more involved in the issues facing mothers and their babies on a national and international scale.
Maternal and infant mortality rates — am I bothered?
For those non-UK readers, ‘Am I bothered?’ is a rather adolescent catch phrase from a popular, iconoclastic comedy programme on British TV. It portrays the rather stereotypical, but somewhat familiar aspect associated with adolescent behaviour where, if it does not directly apply to them, then it is not worthy of attention.
My reason for linking that phrase with the issue of maternal and infant mortality and morbidity is to raise recognition that we are and we should be ‘bothered’ about these issues on both a national and international basis.
How shall we cope with these issues? Will it be more like the behaviour of the adolescent who hides in their room or goes off to share their burdens in some secret place amongst their peers — or should we be working openly and collectively with individuals, communities and governments in order to make a difference?
The mortality rates for women and their babies in countries with minimal resources, in the midst of war or oppressive regimes are still heartrending and we should take time to comprehend in their enormity. At the same time, there is concern in countries of considerable wealth, such as the US, Australia and the UK, over an apparent increase in women who die in childbirth or who suffer serious physical or emotional morbidity following childbirth and are left disappointed and upset by their experiences (Lewis 2004, Sullivan et al 2004, Declercq 2006, Homer 2006). When talking about maternal mortality, while there is of course an enormous discrepancy in numbers, the main concern is that any woman who dies leaves a family bereft and possibly a baby without their mother. This year marks 20 years of the Safe Motherhood Initiative and a conference is planned in October in the UK, to recognise the work that has been achieved over this period and work still to be done (www.womendeliver.org). The very important issues around women’s health in areas of poverty and strife will be covered in a forthcoming issue of Essence, nearer to the time of the conference.
Turning back to maternity care in the UK and the need to be ‘bothered’ about the health of mothers and babies and the resources needed to support this, over the past few weeks there have been increasingly alarming headlines in a range of newspapers about the risks of having a baby in Britain (Goodchild 2007, Symons & Hagan 2007). This is surprising when one of the Government ministers set the context of health outcomes in England so positively just over two years ago in recognising 50 years of work by the Confidential Enquiries into maternal death (Ladyman 2004). Here is an extract of what he said:
"It's an honour to be asked to open this important conference to look at the findings of the latest in a long line of Reports of the Confidential Enquiries into Maternal Deaths. We should never underestimate the impact that the first 50 years of this unique enquiry has made in making pregnancy and birth safer for all the women in our country... and we can be confident that its impact will now continue into the years ahead.
And despite the title of the report, it is a good news story. A good news story for your professions, for health care planners, the Department of Health and most of all for the women who make use of maternity services."
Having a baby in the UK is now safer than ever, provided women feel able to seek care. The risk of a woman in the UK dying in pregnancy, childbirth or after delivery is extremely small; one of the lowest in the developed world. And in part this is due to the unique work of this enquiry".
In April next year World Health Day, organised by the World Health Organization, will focus on maternal health around the world. Every year over 600,000 women and 6 million newborns worldwide die needlessly from complications of pregnancy and childbirth. Over 20 million will also suffer long term disabling complications.
In some parts of the world 1 in 8 pregnant women will die compared to less than 1 in 20,000 in the United Kingdom. This represents the largest public health discrepancy in the world. In some parts of Africa, for example, childbirth is regarded not as the joyful experience we know in our country but as a time of fear and suffering.
The following was a recent subheading in an authoritative UK Sunday newspaper — 'Deaths of women during childbirth increase by 21%' (Goodchild 2007). It has not been possible to substantiate the evidence behind this statement where no publication is given to support this figure and although reference is made to a ‘forthcoming document’ this did not appear to have anything to do with maternal death in the UK (Redshaw et al 2006). Another headline grabber was presented as 'Crisis on our labour wards' (Symons & Hagan 2007). As well as presenting information on rates and increases in litigation, this also highlighted the shortfall in skilled care in labour — of the need for an additional 10,000 midwives. The article also includes extracts from women who have had poor experiences of care when pregnant. Where there is a concentration on what the statistics have to reveal, such feedback could and maybe should be considered as ‘evidence’ in its rawest form. It would seem timely and helpful to look in more depth at the facts behind the headlines and to explore the issues of concern for both women and those responsible for their care.
The current information about maternal and infant mortality comes from the Confidential Enquiry into Maternal and Child Health (CEMACH) report on the figures for the years 2000–2002 (Lewis 2004). A new report is planned for publication in the autumn of 2007 for the years 2003–5 (CEMACH 2007). Based on the information given in the 2004 report, the total number of deaths (391 in 1,997,472 maternities) resulted in a maternal mortality rate of 13.1 per 100,000 maternities (a ‘maternity’ is considered a live birth at any gestation and stillbirths occurring at or after 24 weeks completed gestation). The average number of births over the past few years totals around 700,000 (Department of Health 2006). Therefore, when compared with the 378 deaths in 1997–1999, this is an increase of 13 women over a 3-year period.
Calculating and reporting maternal and infant deaths is a very complex process, reflected in the 338 pages which is the length of the current CEMACH report. Where Symons and Hagan (2007) note that the current rate is ‘higher than Poland’, this fails to take into account how information is collated and considered between and even within countries. Making comparisons or inferences about the differences between previous reports or different countries is likely to be very unreliable as the extent and content of what data are obtained is likely to change over time periods and health systems. One aspect for consideration is the increase in the number of women who become pregnant while they have a pre-existing medical condition. These include women who are diabetic, who have major organ disease, or a genetic condition previously thought to be incompatible with pregnancy. Various interventions have improved the health status for women with these conditions. Pregnancy is therefore now a possibility where it would not have been considered previously and maternity services have changed to meet the specific needs of these women (Withers & Laxton 2006).
There is also a change to the ethnic profile of childbearing women in the UK, with increased numbers of women seeking care who have come from different ethnic backgrounds or who are seeking asylum (McLeish 2002). These women may have a different health profile because of their previous experiences, which could make them more at risk during pregnancy and childbirth. Social factors impact on outcomes and these include first-time pregnancy in the very young or the much older woman, and the rising incidence of domestic violence and of mental illness, especially after the birth. While many of these factors have always been associated with poorer outcomes in pregnancy and childbirth, what is now being seen is their impact on mortality. Where these are now considered a factor related to mortality, more information is obtained and these data are viewed as a more reliable and accurate resource with each new review and report. However, this means the interpretation of the information must reflect these changes if the data are to be used constructively as part of ongoing health policy initiatives.
Clearly, there should always be concern to ensure that a health service is able to offer the best possible resources but, at the same time, the context of that service and the health needs of those who use it must also be considered. This has been highlighted in recent events around the work of independent or self-employed midwives with an organisation called the Independent Midwives Association (IMA). They have been forced to mount a campaign to try to explain and gain support from members of the UK Parliament about their current status with regard to insurance and legislation. Such measures would directly conflict with government policy on women’s choice and the need for increased rather than decreased flexibility of the services available. In addition, there is increasing concern over the reduction in women’s access to NHS antenatal education resources. Where these are being withdrawn, this is likely to have an impact on the physical and psychological well-being of women who will now lack vital information about childbirth and early infant care, including promotion of breastfeeding (Parkinson 2007).
So we await the publication of the forthcoming CEMACH report, and the much promoted Strategy into the Maternity Services, but I would suggest to the national media moguls that it would be more responsible to look at what initiatives are, or should be, underway to ensure safe and effective health for women and their babies. Where there is cause for concern, this should be presented informatively, as can be seen with the recent issue raised by the BBC on the provision of antenatal classes (Parkinson 2007). This is not to ignore the real issues of funding, of resources and of ultimate governmental responsibility, but to put it in a more balanced perspective that informs and empowers rather than one that inflames and upsets.
Two recent publications are of interest with regard to exploring the views of women in pregnancy and childbirth — 'Listening to mothers II' (Declercq et al 2006) and 'Recorded delivery' (Redshaw et al 2007). 'Listening to Mothers II' is the second national survey of women’s childbearing experiences in the United States and Recorded delivery' is a national survey of women’s experience of maternity care in England in 2006. This was undertaken by the National Perinatal Epidemiology Unit in the UK and commissioned by the Department of Health and the Healthcare Commission.
'Listening to Mothers II' (Declercq et al 2006) builds on what the authors appropriately describe as the ‘landmark’ of the first initial enquiry published in 2002 (Declercq et al 2002). This brought the then state of the maternity services, the options, constraints and experiences of childbearing women in the US, to the attention of those responsible for health care provision and the need for improvement in those services. This second report adds more information, in particular about postpartum care, and a further in-depth report about these issues is planned for the future.
There is not space to discuss the findings of the report in any detail, but here are some tit-bits to whet the appetite. Two hundred mothers participated in a telephone interview and 1,375 women completed a survey online making a total of 1,573 participants. Issues of concern were obesity (about a half of the women were overweight or obese), the proportion of unplanned pregnancies (four in ten mothers did not intend to be pregnant, at that time or at all), and most women gained information about pregnancy and birth from books or TV shows. On a positive note, most women identified their pregnancy early and sought prenatal care within the first trimester. Based on 79% of women who received care from obstetricians at the time of birth, it will not be a surprise to most midwifery readers to see that what is described as ‘technologically-intensive childbirth care’ was the norm. A worrying aspect that might arise from this is that many babies were not placed in their mother’s arms within an hour of birth as the staff undertook apparently non-urgent routine care on the babies instead (39%). After the birth, nearly all mothers had what is described as a maternity care office visit from three to eight weeks postpartum. Physical and mental health morbidity (63%) appeared to be at quite high levels. The authors noted an underlying prevalence of what is described as ‘physical exhaustion’ in 62% of women, with many women having difficulty sleeping even when the baby was not requiring their attention.
The whole report is detailed, informative and explores the relationships between some of the common factors for pregnancy, birth and postpartum health. At one point there is mention of an annual figure of around four million mothers and babies in the US. I have some difficulty considering such a methodological nightmare with regard to representative sampling and it is my view that this is certainly a step in the right direction. I look forward to the more in-depth report on postpartum health in due course.
Turning to the recent UK survey, 'Recorded delivery' (Redshaw et al 2007), this involved 4,800 women, randomly selected from the National Births Register for England over one week in March 2006. The reason it was undertaken, and its value to those residing in England, is that it forms a comparison with a previous survey in 1995 (Audit Commission 1997), and once again offers a baseline or snapshot of the whole range of maternity care services as experienced by its consumers. The authors suggest it should be of interest to policy-makers and hopefully, to the Department of Health as they were one of the funders (my comment).
There are no real surprises in the report for those already reasonably well informed about the issues facing maternity care in the NHS, but some things should be noted as being consistently poor — this includes the cleanliness of hospital wards, the still very low rates for home births and lack of this being offered as a choice, and the often negative impression of the woman’s contact with the midwife. Conversely, doctors seem to have improved their communication skills (from 66% in 1995, to 93% in 2006), but as fewer than half of the sample (49%) received exclusive midwife care antenatally, this might have been as a result of meeting them more often. It would be unhelpful to pick out any more isolated data as the whole point of the report is that it should be read in the context intended, and that it offers considerable insight into the experience of these women. Taking an overview, it could be considered that the majority had at least ‘good enough’ care throughout their pregnancy, the birth event and afterwards, and that this is arguably fairly representative of the service offered and available.
I am aware that there has been a great deal of activity in this area over some time in Wales and Scotland (Hundley et al 2002, Wright 2003, Fox 2004, McGuire et al 2004, Hardacre 2005, NHS Quality Improvement Scotland 2005). These have not been highlighted due to lack of space. Northern Ireland has recently undergone some major changes to its education and practice framework (Northern Ireland Practice and Education Council for Nursing and Midwifery 2006), and is also offering new models and policies in the area of women’s health (Barrowman & Clarke 2003). There are more initiatives planned for a review of the maternity services in England and for more informed and collaborative work within the NSF. All of this should be viewed in a positive light but there is an element that the glass is half empty and it is of concern that there does not appear to be a jug full of resources to fill it. There are still significant gaps between the desired level of care provision, both in appropriate skilled care for women throughout their pregnancy, birth and beyond, and in certain aspects of social care. Where staff are stretched to over-capacity in being able to provide care, this negates positive feelings about the job which will ultimately spill over into how women are cared for, verbally as well as physically, as well as recruiting to job vacancies if there were any (Rouse 2007).
The aim to enable women to be at the centre of their care will need considerable input from a very wide perspective if it is to become a reality. Am I bothered? Yes, I am very bothered and MIDIRS as an organisation aims to contribute in any way we can that will help to make a difference on a national and international level.
Author: Sally Marchant, Editor, MIDIRS Midwifery Digest
References:
Barrowman L, Clarke R (2003). Northern Ireland in changing midwifery environments. British Journal of Midwifery 11(10):S12.
Declercq ER, Sakala C, Corry MP et al (2002). Listening to mothers: report of the first national US survey of women's childbearing experiences. New York: Maternity Center Association.
Declercq ER, Sakala C, Corry MP et al (2006). Listening to mothers II: report of the second national US survey of women's childbearing experiences. New York: Childbirth Connection.
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Sally Marchant, Midwife and Editor of MIDIRS Midwifery Digest | MIDIRS 2007
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