Trixie McAreeHead of Midwifery

February 2015

An overview of current priorities and challenges for delivery of maternity care, where maternity care is going and what this might mean for migrant women.

Overview• Objective of Care• Context• Current Provision• Priorities• Challenges• Solutions

Healthy Mum and baby

Reverse thrifty phenotype

More targeted pre -conceptual care inc. managing long term conditions

Planning for pregnancy

Sexual healthMental well beingDiet and exercise

Enhanced psycho-social support, including birth and parenting preparation

Targeting women who don’t speak English, confidence buildingPeer supportParenting support

Strategies that enhance healthy choices leading to physical well being

Emotional engagement of health professionals

Staff educationPositive careGive clear care pathways

Good nutritionTackling obesityReduction in smoking

Increase in birth weightIncrease in breast feeding

Increase in immunization uptake Increase in choice of healthy life

style habitsIncrease confidence in parenting

Mother more likely to read/talk to childChild ready to flourish at school

Child grows up into more confident adult making healthy lifestyle choices and goes

into next pregnancy healthy

Decrease in hospital admissionsDecrease in infant mortalityDecrease in long term health

problems 

Happier families, stronger communities

Leading figures from the health world are calling for a national debate on how the NHS in England is funded. In a letter to The Times, they say challenges from an ageing population mean the system is "creaking at the seams" and cannot continue as it is”.Signatories include the heads of the Royal College of Physicians and Royal College of Nursing

National Context…

• Almost 1:4 of all babies in UK are born to foreign mothers (ONS 2008)

• Youngest city in Europe=high fertility rate increased population (9.9% in 2011) 45.7% under 30 years

• Most obese city in the UK

• Risk implication for past medical, obstetric and social history

• Child poverty remains the same Birmingham is high, high unemployment

• Women that don’t speak English - If 1000 women having on average 10 interactions with the service leads to 10,000 difficult interactions.

• Increased cost incurred by those who don’t speak English (California Endowment 2006)

• Outlier for perinatal Mortality

Local Context

NHS Mandate for Pregnant Women

The NHS will:• Offer women the greatest possible choice

of providers• Ensure every woman has a named

midwife who will make sure she has personalised, one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who had maternal health concerns.

• Reduce the incidence of and impact of postnatal depression through earlier diagnosis and better intervention and support.

• Recommendation of Services via Friends and Family test.

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Arial regular for the body copy…

Q2 Installation of IM&T in ANC Deploy revised triage

pathwayRe-procure Parent EducationScope provision of a ‘Domino’

Service

Dire

ctor

ate

Obj

ectiv

es

Q3- Review & Redesign ANC

pathway- Embed FGM service - Expand fetal cardiology

service- Scope internal ‘non-

invasive’ Prenatal Diagnosis testing

- Implement uniform Birth Setting criteria

- Define & map PN pathways

- Deploy Maternity EPR- Launch of Homebirth

MSW foundation degree course

- Evaluate community IOL Pathway

Q4- Deploy

Billirubinometers for non invasive detection of hyperbillirubinemia

- Implement agreed BSOL pathways across 4 areas

Strengthen and market the maternal medicine service

Q1 - Delivery of a full Tongue Tie Service

Key Themes 2014-16:Patient ExperienceService RedesignWorkforceFuture Planning

Trust Domains:Our Patients – To deliver an excellent experience that exceeds our patient’s expectationsOur Performance – to consistently deliver clinical and laboratory outcomes that place us amongst the top

hospitalsOur Staff & Resources – To develop an exceptional organisation where people achieve their potentialOur Partners – To work with our partners to maintain and develop our service, academic and research standing

Directorate Vision

Directorate Vision

Developing sustainable services

Developing capacity to meet demand

Improving patient pathways

Supporting patient choice

Continue to enhance partnership working for childbirth related research

Service/pathway Integration

2014 - 2015

Deploy internal ‘non-invasive’ Prenatal Diagnosis testing

Deploy Domino ServiceSustain Homebirth Service (pilot ends)Benefits realisation of Maternity EPRPublish research from specialist clinicsContinued development of uniform

pathways across Birmingham providers

2015 - 2016

Issues/barriers• Economic

NHS Personal

• Communication/language/cultural issues /co-design

• Safeguarding Children Adults

• Increasing Complexity• Performance Driven

Staffing Capacity to care

• Strategy and action plan for increased capacity in place • Consider interim patient flow: position of triage,

discharge lounge• Move services where possible into the community

facilitating easy access and ameliorating capacity issues:

Pre pregnancy service One stop shop Community DAU Outpatient IOL service

• Telephone triage• Inpatient IOL suite• Intermezzo suite for latent phase women• Reviewed electronic computer systems to improve

multidisciplinary working e.g. Stow system in place for discharge and letters

Service provision:• Well Women’s Service – Female Genital Mutilation

reversal, which has been supported by Commissioners• Contraception Service for Teenagers• Tongue Tie Release Service• The New-born and Infant Physical Examination (NIPE)

service now extended to provide evening coverage and expedite discharge with over 27% of all new-born checks now carried out by a midwife fully trained in the examination of the new-born.

• Homebirth team 1% - 3%• Not only 1:1 care in labour, develop named midwife

programme

Language Issues“ Language Barriers to communication were of fundamental importance to …women since the quality of experience of all other aspects of service

were dependent on this point”Harper –Bulman and McCourt 1997

Studying experiences of Somali women

McAree, McCourt and Beake (2012) found Several women who did not speak fluent English described feeling very frightened, or panicky in labour, and issue perhaps related to greater difficulty in communicating with hospital staff, and getting information.

Women did say they were trying to learn English and saw it as importantThey mentioned the advantage of having a midwife who gets to know you, making communication easier

One group m/w spoke several community languages this was perceived by the women as a great help

Solution: Continuity of care• A number of studies as well as DoH recommendations support notion

of continuity of care• The Health and Social Care Bill calls for greater involvement of service

users• Conduit for emotional management – impact of anxiety on pregnancy

(Texeira et al 1999)• Hertfordshire study, Barker, Richards impact of SGA is long term health

problems such as developing cardio vascular and endocrine disorders in adulthood as well as having less cognitive ability

• Farquar et al (2000) did not succeed, - not set up properly• Homer et al 2003 – reduced c/s rate improved /experience (2002)• McCourt and Peace (2000) women had greater confidence and trust

• “when maternity doesn’t matter: dispersing pregnant women seeking asylum” (2013)

• Better outcomes

The importance of good information and communication and preparation

• The women emphasized the importance of this strongly. • They valued the antenatal classes, literature and leaflets

available and midwives taking the time to inform them and explain things clearly.

• On the whole the women appeared very pro-active in wanting information, though they didn’t always find asking question easy in practice, especially during rushed hospital visits.

• They wanted to be actively involved in decision making but expected professionals to give them clear and detailed non contradictory information,

• It seemed information was less available to women receiving standard care

Solution: Community based care

Women in both groups were generally critical of hospital-based clinics and care, with the exception of some positive aspects of care in labour

I found that the hospital was a bit cold, you know.

…..you feel like you’re sheep, being shepherded along. It’s not very warm and friendly like the midwives are (gp bp)

they keep you waiting for such a long time and the midwives are obviously always kind of like rushing, do you know for them its like “one out of the way, second” (standard care as opposed to group practice care nk)

Potential solutions that could be considered by the wider network

• Health Care Interpreter Network –over the internet (2006 - California 58% reduction in communication related problems such as drug error)

• Provision of English Classes (Starkey 1995)

• Provision of multi language AN classes

• Link workers lead to increased uptake in care (e.g. in Bradford 2006)

• Somali (or other) women’s Peer breast feeding Group

Potential solutions that could be considered by the wider network

• Health Care Interpreter Network –over the internet (2006 - California 58% reduction in communication related problems such as drug error)

• Provision of English Classes (Starkey 1995)

• Provision of multi language AN classes

• Link workers lead to increased uptake in care (e.g. in Bradford 2006)

• Somali (or other) women’s Peer breast feeding Group

Questions and Comments?

Let’s work together to strengthen families for all generations