Maternity

Maternity services have continued to attract widespread political and media attention over the last twelve months, for all the wrong reasons.

Donna Ockenden’s final report on large scale avoidable harm at Shrewsbury and Telford (covered in the section on “patient safety”, below) was published in March 2022. In her foreword, Ockenden exposed a fundamental flaw in the Trust’s practice and culture: “for far too long women and families who accessed maternity care at the Trust were denied the opportunity to voice their concerns”.

The government concurred, with Health Secretary Sajid Javid pointing to “a systemic failure to listen to families affected many of whom had been doggedly persistent in raising issues over several years”.

Shrewsbury and Telford sits alongside Morecambe Bay and Cwm Taf, where women’s experiences were also ignored, and East Kent and Nottingham University Hospitals Trust, where similar revelations seem likely. None of these are “bad apples”. They are part of an overarching culture in which patient experience is not given sufficient weight within the “hierarchy of evidence”.

This report from the Care Quality Commission makes the point again: “a failure to engage with, learn from and listen to the needs of local women [continues] to affect the safety of some hospital maternity services”.

Maternity Voices Partnerships are a vital link between maternity services and patients – but the CQC finds that working relationships between MVPs and maternity services vary.

Where relationships are good, MVPs can help with information materials and public outreach, as well as internal provider matters such as safety reviews. Importantly, they have “direct channels of contact” with the Head of Midwifery, and “felt confident that they would be able to raise safety concerns”.

On the downside, some MVPs felt that their role was not well understood by providers. This includes “the MVP not being involved early enough in the process to give meaningful feedback and the trust being defensive to suggestions from the MVP”.

There are disparities in funding for MVPs, and some MVP Chairs are expected to go above and beyond their paid role. This is seen as “a barrier to women from some communities or groups getting involved, perpetuating issues with a lack of diversity”.

The report calls for “true engagement” with Maternity Voices Partnerships, and says that “local maternity systems need to improve how they engage with, learn from and listen to the needs of women, particularly women from Black and minority ethnic groups”.

The House of Commons Health and Social Care Committee, for its part, has been looking beyond maternity service providers, and asking some searching questions of government.

The Committee’s independent expert panel has looked at government progress against its policy commitments for maternity services in England. Using the Patient Experience Library as a key part of its evidence-gathering enabled it to unearth important aspects that do not necessarily show up in official statistics.

On the basis of the evidence that we provided, the panel found that:

• Positive impact in maternity safety was not achieved equally across different groups of women, such as women with disabilities or women from minority ethnic or socioeconomically deprived backgrounds. • There is a relationship between charging for NHS maternity care and inequitable outcomes for women from destitute or immigrant backgrounds. It is some of the women that are most in need of maternity care that are charged for it. • Women with learning disabilities may avoid maternity care due to a of lack of confidence, negative staff attitudes, lack of clear explanations of what is going on, or fear of the involvement of social services. • Asylum seeking women can be more likely to have to move to different areas multiple times during pregnancy, making receipt of continuity of carer more difficult. Similar issues are faced by women from Travelling communities.

Using a CQC-style rating system, the expert panel found that government progress against its own maternity policy commitments “Requires Improvement”. On personalised care specifically, it was “Inadequate”.

Moving up to an even more strategic level, this study compared Australia’s maternity strategy with similar strategies from England, Wales, Scotland, Ireland, Northern Ireland, Canada, and New Zealand. The analysis included some wider insights into maternity politics, culture and strategy, as follows:

• In the Australian strategy, the term “woman-centred” encompassed the values of safety, respect, choice, and access. • The essence of these values appeared in every other plan reviewed. • Continuity of midwifery carer appeared to be an add-on to the Australian strategy, in contrast with the English, Scottish, and

Welsh plans, which advocate for continuity of midwifery care for all women. • There was significant variation in the positioning and professional autonomy of midwifery –however, where the midwifery profession is strong, midwifery models of care and place of birth options were more likely to be discussed and recommended. • In countries where birth at home and in birth centres is widely accepted, the recommendations in maternity plans were more in line with evidence, human rights, and consumer demands.

There were inconsistencies in all the documents reviewed around where the final decision making lay when it came to choice and autonomy in maternity care. This is in spite of the fact that the right of people to make autonomous decisions about their own bodies is enshrined in the Universal Declaration on Human Rights and applies, without exception, to pregnant and birthing women. This, say the authors, “leaves women in a vulnerable position when it comes to choice and autonomy in nearly every strategy/plan we reviewed”.

The authors conclude that “In countries with an established, valued and autonomous midwifery profession, maternity guidelines appear to better align with evidence”. Their suggestion is that “Priority must be given to the choices women make and the best available evidence, not the power and interests of organisations and individuals”.