‘Better Births: United in Excellence’
by Cathy Ashwin
Cathy gave an overview of the challenges facing midwives today and the future vision for the profession. The address would not have been complete without mention of the recent campaigning of the RCM from a trade union perspective with regard to the ongoing pay dispute.
Dr Ed Coats (director, Total Medics) then gave a stimulating and encouraging talk on dealing with adversity and how being part of a bigger team can help to make a difference and achieve high aspirations. Dr Coats concluded in reiterating that as midwives we can achieve the ultimate goal of improving women’s lives during pregnancy and birth, whatever their situation in life.
The student midwives split from the main body of delegates to attend sessions particularly tailored to their interests. However, in the main these sessions would be of equal interest to all.
The next main session, chaired by Louise Silverton, presented work from Professor Helen Cheyne and Professor Debra Bick exploring postnatal care. Postnatal care is often referred to as the Cinderella service, and Louise commented that in some places postnatal care is disappearing altogether.
Helen’s study has looked at ways in which postnatal care can be improved, raising the dichotomy of quality vs efficiency. All women need support to encourage confidence and wellbeing for themselves and their families, but at what cost?
Midwives are under pressure to deliver optimum care on the postnatal wards, and in the community the battle to retain continuity of care has almost been lost for many. Postnatal services come at a high price of around £800 million per annum and, as such, an efficient redesign of these services is needed to reduce these costs.
Payment by Results (PbR) is also a very complex area. Costs are not matched to the care, thus more complex ‘trade-offs’ are also needed to improve the services and use resources more effectively.
The PRAM (Postnatal Resource Allocation Model) study undertaken in Scotland by Helen and team looked at this issue. The framework for this was a computer-based aid to support the redesign. The focus was on ‘who, what, where and when’ rather than ‘what’ needing service level planning.
The study concluded that one size does not fit all, and that instead of providing a standard postnatal service to all women, it should be tailored to need taking into account local data, culture and resources. However, much off the emerging evidence is not yet clear on how to determine the support.
In conclusion, with the engagement of stakeholder discussions, decisions can be made which will encompass levels of care, specific care, values and priorities including trade-offs with the aim of matching the qualities of the service available.
Debra Bick went on to discuss the fragmentation of postnatal care, calling it an invisible service. Taking into account the antenatal health and complex issues, these do not disappear at birth but may increase physical and psychological morbidity in the postnatal period.
An interesting point raised in this presentation is if postnatal visits and care is being so drastically reduced, then students are not being exposed to sufficient insight into the needs of postnatal women during community placements.
Students need to be exposed to a variety of situations – normal through to abnormal – to be able to understand the differences from woman to woman. Attention is drawn to the NICE guidelines on 24-hour signs and symptoms. Commissioners need to be convinced of these issues when deciding on such services.
The conference proceedings then moved into the concurrent sessions and I opted to attend the session presenting on women’s experience of induced labour (Annabel Jay) and ‘No decision about me, without me: improving shared decision making when planning place of birth for women with high-risk pregnancies’ (Jennifer Hattan).
Both these presentations raised quite a bit of discussion in the question time. Annabel’s study concluded that there was a serious ‘mismatch’ of information tailored around information for women and partners on induction of labour.
Much of the information was gained anecdotally from friends and family, which was well intentioned but not evidence based, potentially causing women undue anxiety at a very important time during pregnancy.
Greater research around the timing and delivery of information about induction of labour needs to be undertaken to ensure women are given evidence-based information and that their fears and questions can be answered appropriately.
The question of planning the birth place for high-risk women is gaining momentum and raises some excellent debate. There is a slight feel that high- and low-risk women are becoming segregated in terms of place of birth, and women deemed as high risk can feel that they are being denied choice and as such begin to lose control over what happens to them during pregnancy and birth. Decision making may not be seen as a joint process between the woman and her midwife/ obstetrician.
One suggestion that has been mooted is that the criteria for care within a midwifery led unit, whether alongside an obstetric unit or freestanding, should be widened to open up the opportunity for more women to choose this option.
However, an excellent question was raised by a member of the audience in that should we be considering changing the criteria for MLU’s etc. or should we be making more use of the obstetric units by adapting them to give greater individualised care replicating the ethos of MLU’s. This would give even greater choice and optimise and normalise care for women who may have additional needs.
Wednesday opened with a question time on the main stage, with Cathy Warwick posing questions to Jackie Smith, chief executive of the NMC, and Kate Chamberlain, chief executive of the Healthcare Inspectorate, Wales.
The main focus of the session was around supervision and fitness to practice. It was debated as to whether supervision would continue in the future, and Jackie felt that she could not comment on future long-term predictions.
Whether or not supervision should come under the jurisdiction of the NMC was another interesting point. Jackie commented that this would require major changes to the legal framework and could pose some conflict of interest.
The length of time in which cases of fitness to practice take to be heard was also hotly discussed. This has been up to five years, but Jackie responded by saying this is now being reduced to a more realistic 15 months – which all considered is still too long.
If supervision works well then the need for midwives to be called to fitness to practice cases would be greatly reduced.
Kate discussed a pilot project in Wales where, instead of SoMs integrating supervision within their day to day role, 15 full-time posts have been appointed (originally 100), which allows for a dedicated cost-saving service.
This system also allows for succession planning in training up-and-coming SoMs. Cathy asked if this had any potential for conflict of interest, to which Kate replied that this was not the case and in fact added value to supervising practice, sharing best practice and developing excellence.
Dan Poulter is meeting with Carmel Lloyd and Cathy Warwick to discuss NMC and Supervision issues. Jackie reiterated on several occasions that the NMC is there primarily to protect the public, not to support midwives and nurses!
Deborah Hughes from ARM gained great applause from the audience with her question: ‘The NMC has not served midwives well, why should they take more control?’. Jackie agreed that for a long time the focus has been in the wrong place and, although things are improving, there is still a long way to go.
The PEARLS study (Perineal Assessment and Repair Longitudinal Study) was another highly informative concurrent session discussing the development, implementation and evaluation of the intervention.
Professor Christine Kettle and Professor Khaled Ismail, two lead researchers on the project, presented their findings. This study commenced in 2007, instigated by a previous study undertaken by Christine which highlighted lack of national guidelines for suturing the perineum, and consequently noted huge variations in practice.
The study aimed to rectify this issue by training facilitators to then train midwives and obstetricians in suturing to an approved standardised method.
Women’s views were sought both in the UK and Brazil, and demonstrated similar findings that women most feared infection and pain.
The new suturing practice reduced both of these problems. However, it was noted that unless regular training is carried out, the standard cannot be sustained as midwives and doctors move and new ones take their place.
Although the benefits to women did not appear to be great in small numbers, compare this across the whole of the UK. If a standard practice of suturing is carried out, the results will be greatly multiplied in both cost effectiveness and, more importantly, for the health and wellbeing of women.
Perineal trauma if not repaired correctly will have major implications for future pregnancies, marital relationships, physical and mental wellbeing.
The highlight of the conference for many delegates was the question time session in the afternoon with former Conservative MP Edwina Currie. Denis Campbell, a journalist with The Guardian, chaired the meeting and the panel included Edwina (former minister of health), Paul Nowak (assistant general secretary, TUC), Jo Stevens (Labour’s parliamentary candidate, Cardiff Central) and Zoe Williams (another Guardian journalist).
The aim of the session was to respond to audience questions about what their policy position would mean for women, families and delegates as NHS staff. Edwina did not receive a warm response from the audience as a result of her recent comments to Jeremy Vine on BBC Radio 2 in respect of the industrial action taken by midwives.
Currie stuck by her comments made on the JV show, and was adamant that midwives should not have a pay rise, while the other panel members supported the ‘plight’ of midwives.
Twitter feeds went manic, but to be fair to Edwina she did hold her own very well as an experienced retired politician, and was the only conservative representative on the panel.
The final session of the day was far more sedate, with it exploring the various connotations of continuity of care and continuity of carer, and what this means for midwives and women.
Louise Silverton chaired and Lesley Page, Denis Walsh and Soo Downe took part in the discussion, followed by questions from the audience.
There is no doubt that continuity of care/carer provides the best care for women their families and those supporting them through pregnancy and beyond. Thinking creatively, this can be a reality and midwives can truly be ‘with woman’, giving individualised care and achieving job satisfaction.
However, there needs to be greater communication between service providers, accountants, government, midwives and women for this to happen. We hear of midwifery led units being closed, or midwives being called from the community and MLUs to work in nearby obstetric units disguised as ‘escalation policy’.
One midwife in the audience highlighted this issue. Paula Izod, from Grantham, experienced the closure in February of the MLU she worked in, and asked the panel how this could be avoided. There was no simple answer or solution to this problem, as all suggestions have been previously tried.
Lesley Page, president of the RCM, gave the closing address, and echoed the feelings of many in the audience that it had been a vibrant and lively conference with a current of renewed optimism for the future.
New ideas had been exchanged through both the excellent presentations and debates, and most importantly through the meeting of colleagues old and new, networking to share good practice and support of each other.
Reminding us all why we are midwives!