Transcript Sustainable continuity of care models and their benefits

Overview of Maternity care in the UK
Jane Sandall,
Professsor of Womens Health
Department of Public Health
King’s College, London School of Medicine
King’s College, London
[email protected]
Maternity Care Is Different From Other
Forms of Health Care Because
Latent in the care of women are ideas about motherhood, the role of
women, families and sexuality
The organisation and provision of maternity care is a highly charged
mix of politics, cultural ideas and structural forces
© Sandall
The role and status of midwives influenced by above
© Albany Practice
©Sandall
© Albany Practice
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European Union Activities of a Midwife
• Provide contraception and sexual health advice
• Monitor of normal pregnancy
• Prescribe/advise on pregnancy examinations/screening
• Provide parenthood preparation classes
• Care for and deliver a woman and her baby
• Recognise signs that things are not going well, for both
woman and baby)
• Examine and care for newborn
• Monitor and care for the new mother, the baby and the
family
• Carry out prescribed treatments
• Maintain records.
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The Nursing and Midwifery Council (NMC)
All midwives must be registered with the NMC
Register for midwives and a register for nurses
Currently 20,000 full-time equivalent registered midwives (& over 600,000
registered nurses)
The NMC midwifery department promotes standards of practice and
influences change to ensure all UK midwives adopt the most up-to-date
clinical practices
The NMC sets standards for practice, education and supervision of
midwives
The NMC also investigates any allegations that a midwife (or a nurse) has
not followed their code of practice
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Education and training of midwives in the UK
Midwifery education and training programmes are only run at NMC-approved educational
institutions. Courses take a minimum of three years, unless already registered with the NMC
as a level 1 (adult) nurse, in which case the training is 18 months
55 UK universities currently offer midwifery education programmes (not all offer the 18
month option)
Training takes place at a university and at least half of the programme is based in clinical
practice in direct contact with women, their babies and families
This can include the home, community and hospitals, as well as in other maternity services
such as midwife-led units and birth centres.
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Midwifery Education
EU Directive 2005
100 prenatal exams
40 women in labour
40 deliveries
Active participation
breech/simulation
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100 postnatal women
and newborns
Observation newborn
needing special care
Episiotomy & suturing
c/o women with
pathology in O & G
40 woman at risk
Medicine and surgery
Having a baby in England
About 99% women give birth in NHS and 1% in private sector
649,837 births in hospital, an overall increase by 3.3% in one year
2.6% of all NHS deliveries at home compared to 2.3% the previous year (2004-5)
range 0.6-14%
36 % of deliveries were conducted by hospital doctors and 60% by midwives
In 2008 19,555 midwives FTE and 1,570 consultants and 2,635 registrars, plus
Drs in training
74% of women with spontaneous deliveries spent on average one day in hospital
after delivery, women with instrumental deliveries one or two days and
women with caesarean deliveries between two and four days
NHS Maternity Statistics, England: 2004-5 and 2007-08
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Current Policy
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Maternity Care Pathway
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Policy background on place
of birth -NSF
Choice of most appropriate place and professional based on
wishes, preferences and needs
Specific inclusion of home birth with risk assessment and
adequate local support
Maternity care providers and commissioners ensure that:
• The range of services offered constitutes real choice
including home birth
• Staff actively promote midwife-led care for appropriate
women including community units, hospital based units
and home birth with easy and early transfer
DH and DES (2004) NSF for Children, Young People and Maternity
Services, London, DH
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DH choice guarantees by 2009
1. Choice of how to access maternity care
2. Choice of type of antenatal care
3. Choice of place of birth
4. Choice of place of postnatal care
And…
Every woman will be supported by a midwife she
knows and trusts throughout her pregnancy and after
birth.
DH (2007) Maternity Matters: Choice, access continuity of care in a safe service
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NICE Guidelines on Home Birth
Women should be informed:
•That giving birth is generally very safe for both the woman and her baby.
•That the available information on planning place of birth is not of good quality, but suggests
that among women who plan to give birth at home or in a midwife-led unit there is a higher
likelihood of a normal birth, with less intervention. We do not have enough information about
the possible risks to either the woman or her baby relating to planned place of birth.
•That the obstetric unit provides direct access to obstetricians, anaesthetists, neonatologists
and other specialist care including epidural analgesia.
•Of locally available services, the likelihood of being transferred into the obstetric unit and the
time this may take.
•That if something does go unexpectedly seriously wrong during labour at home or in a
midwife-led unit, the outcome for the woman and baby could be worse than if they were in the
obstetric unit with access to specialised care.
•That if she has a pre-existing medical condition or has had a previous complicated birth that
makes her at higher risk of developing complications during her next birth, she should be
advised to give birth in an obstetric unit.
•Clinical governance structures should be implemented in all places of birth.
Intrapartum care: Care of healthy women and their babies during childbirth
NICE Guideline 55 2007
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Choice of place of birth –
the reality!
In NPEU study (Recorded Delivery 2007)
38% of women were given the option of
home birth at the booking interview (cf
18% in 1995)
57% given choice to have baby at home
in 2008 (HCC Survey)
However, rates of home birth in England
for 2005-6 were 2.6%
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Home births 2001-2007
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Birth Centres/midwife-led units
Trusts with:
OUs only
OUs and
AMUs
OUs, AMUs
and FMUs
OUs and
FMUs
OUs
AMUs
FMUs
No.
%
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2
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1
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1
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1
84
14
1
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17
3
13.2
3.3
10
2
2
6
1
2
15.1
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FMUs only
HCC Data 2007 www.npeu.ox.ac.uk/birthplace
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65.8
2.6
25 AMU
54 FMU
Birth Centre activity levels
in England 05/06
birth centre
Birth Centre Activ ity 2005-2006
Edgware
Hemel Hempstead*
Shrewsbury*
Royal Bournemouth
Trowbridge*
Dover
Stroud
Crowborough*
Weston-Supermare
Jubilee*
Westmorland
St Austell
Hexham
Gosport
St Mary's
Chorley*
Frome*
Wallingford
Andover*
Maldon*
Shepton Mallet
Wakefield
Hythe
Paulton*
Devizes*
Blackbrook^
Penrith**
Wantage*
Corbar
Grange***
Lymington
Bridlington*
Braintree*
Clacton*
Harwich
Grantham
Ludlow*
Romsey
Bridgnorth*
Okehampton
Malton
Whitby
Robert Jones*
Gilchrist
0
100
200
300
deliveries
Tyler 2007
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400
500
600
Birth Centres
Any BC under 300 births/yr needs to take on additional
community midwifery activity to be financially viable
BUT must balance financial affordability with wider
policy agenda around choice, quality, access, reducing
inequalities, recruitment and retention and capacity
Commissioning Frameworks assessing what % of
women categorised as low medical complexity and
low/high social complexity could give birth either in
midwifery units or at home
Tyler 2007
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Defining normal birth
Women who:
Started labour without
induction.
Did not have any
anaesthesia.
Did not have a caesarean.
Did not have an instrumental
delivery
Did not have an episiotomy
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Trend in ‘Normal’ Birth Rates
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Childbirth interventions 2007-08
An estimated 47% (51% including home birth) of deliveries
were ‘normal deliveries’ defined as those without surgical
intervention, use of instruments, induction, epidural or general
anaesthetic - slight increase on previous year
Caesarean rate rose slightly to 24.6%
20% of labours induced
12% were instrumental deliveries
During labour 36% of women had an epidural, general or spinal
anaesthetic
13 % of women had an episiotomy
NHS Maternity Statistics, England: 2004-5 and 2007-08
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Normality – priorities for
implementation from NICE
One to one care: a woman in established labour should
receive this as significantly less likely to have CS or
instrumental birth, will be more satisfied and have a more
positive experience of birth
Use of water: the opportunity to labour in water is
recommended for pain relief as it reduces pain and the use
of regional analgesia. Immersion in water has the potential to
reduce by up to 90% the proportion of women who report
severe pain in labour.
Intervention should not be offered or advised where
labour is progressing normally and the woman and baby
are well.
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Women’s experiences
In 2007, the proportion of women
having pethidine was lower (33%
compared with 42% in 1995)
The use of continuous electronic
fetal monitoring in labour was lower
(41%) than in 1995 (53%), with
greater use of different types of
intermittent monitoring.
38% indicated that at this stage
home birth had been a possible
option, which is greater than that
reported for 1995 (18%).
93% women reported doctors
talking in a way women could
understand compared with 66% in
1995.
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Redshaw et al 2007, Recorded Delivery, NPEU
Current policy concerns UK
2008
Choice in place of birth
Safety of out of hospital birth and midwife led
care
Rising caesarean rates
Reducing Inequalities
System safety
New in 2009
What models of care are cost-effective
Maternity workforce and skillmix
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Implementation – what will it take?
Dissemination and discussion at Trust/PCT level on current
practice and where it deviates from guideline
Midwife as first point of contact (NSF) (13% only in NPEU
2007 cf 12% in 1995)
PSA Delivery Agreement – first contact before 12 weeks
Strategy to ensure competent and skilled mws to support
increased number of births outside obstetric units if active
promotion of choice of place of birth takes place
Significant changes in the ways midwives work to enable
one to one support – admin, support roles, role at CS
Review of models of midwifery care and skillmix
Targets - see 10% home birth in Wales
Will to change
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Evidence, Professions, the public
and policy
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Research Agenda
What are the outcomes for women at low risk in different birth
settings? - Birthplace
Can quality and safety be improved by different models of
care? – Implementation of models of midwife-led care
(Cochrane)
How can inequalities in outcomes (maternal and perinatal
mortality and morbidity, health and wellbeing) be reduced?
How can care be improved for socially excluded groups?
Can improving the quality and safety of maternity care save
money???
What is the best staff skillmix in maternity care?
How can system safety be improved?
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