I’ve set myself a few challenges for this, my third (and final) round of maternity leave. With my older two children at school and a severely diminished interest in group singing Twinkle Twinkle Little Star, I’m doing things a bit differently.
I’ve ditched (most of) the baby groups.
Instead, I’ve been looking for opportunities to get out from the warmth and safety of my laptop and try to make real life changes in maternity services. For starters, I’ve joined the Women and Families Group working on the National Maternity and Perinatal Audit (NMPA).
What is the NMPA?
One of the things that surprised me, as my friends and I began having babies, was how varied maternity services were around the country. I had, naively, assumed that there would be a well known best way to do things. After all, women have been having babies for as long as there have been women so we should have this all worked out by now right? But what was standard in my London hospital was completely different for a friend in Essex and different again in Glasgow. When I crossed the delicate but definite line, from being low to high risk, I discovered that policies could vary for different groups in the same hospital.
The NMPA is taking stock of what is going on in maternity services across England, Scotland and Wales, using the huge amount of data that is already being collected and putting it all together for some serious number crunching. From this, we can pick out where there are problems and hopefully where something is being done really well and can be shared.
What Have We Found?
So far we have two sets of results. The first of these, the Organisational Survey looked at how services are organised. Things like access to midwife-led units, staffing levels and how often units were closed.
This found that two-thirds of UK obstetric units, the traditional labour wards, now have a midwife-led alternative on site. With three-quarters of trusts offering a choice of home birth, obstetric unit and some kind of midwife-led unit.
Less encouraging were the results about continuity of care. This is something I’ve benefitted from, but only after a very bad experience without it led me to seek (and beg) for it next time around. There is evidence that seeing the same midwife for most of your care can improve outcomes for both mother and baby, but the NMPA found that only 15% of trusts offer this, and even then, only for some women. In my area, it’s only the norm for low risk mums planning home births.
The second publication, the Clinical Report, threw up some even more fascinating, and in some cases worrying results:
That thing where the media love to bring up mums being older and more obese? The NMPA has put numbers to it and they are quite striking: Less than half of pregnant women now have a BMI in the normal range and there are more Mums having their first baby in their 40’s than in their teens.
The variation in some outcomes for Mum and Baby was also a shock to me. The rates of severe blood loss and (category 3 or 4) tears for Mum, and the number of babies with low APGAR scores ( a measure of the baby’s health at birth) varied a lot between hospitals with a few “outliers” performing far worse (or better) than would be expected.
The finding that got most comments, in my twittersphere at least, was that only 13% of births are happening in midwife-led units. This is perhaps surprising given the earlier finding that most trusts offered this setting. I’ve seen a lot of people asking if women are somehow being prevented from using midwife units. Are they not fully informed? Turned away for minor reasons? But I think we also need to examine how many women start out in one and then transfer. Or would meet the criteria but go elsewhere because eg. they want the option of an epidural.
As ever, all the best research raises more questions than it answers and these first two parts of the NMPA are hopefully just the starting point.
For me, being involved in the NMPA has been fascinating. I’m a scientist, but very much a cells in a dish kinda gal. With cells in a dish, you can work very precisely to control all the variables, changing just one thing at a time, asking specific questions and always with proper controls (well hopefully). That is all impossible when looking at the care of real-life mothers and babies. There were also issues I’d never considered before:
Relying on existing data means you don’t pile anymore work onto already hard-pressed services. But exactly how that data is collected can vary and some seemingly very good or bad results might say more about what is put on the computer systems, than what is actually happening on the wards.
You also don’t have to worry about the privacy of cells in a dish, I can collect and publish whatever information I like about them. But I’ve learned that, frustratingly, dealing with real people sometimes means a conflict between what you want to know and what it’s ethical to share. Some of the very worst outcomes in maternity are thankfully so rare in the UK that, although learning from them is crucial, including the details in a study of this kind would make it possible to identify the real, individual woman or baby involved. Ethics committee aside, we have no right to share those stories, unasked, reduced to a point on a graph.
But it has also been hugely encouraging to see the effort and will that is going into this work and to feel that, as merely a Mum, I’ve been able to have some input to the process.
In November I went the launch event for the Clinical Report. The room was full of doctors, midwives, and maternity service managers. There were some very interesting discussions about the results and I for one could have spent days going over all the data and it’s implications.
But the highlight of the day was the talk given by another member of the Women and Families Group, Emma, who as well as having two very little children also heads up the Barnsley Maternity Voices Partnership.
The NMPA is all about big data and statistics, complicated maths to get averages and account for variation, but Emma reminded the room that all those numbers are real women and real babies. That an ordinary day for someone working in maternity care, may be the most joyful or terrifying time of our lives, and that however old, young, fat or thin we may be, we all need good, evidence-based care, and just as importantly, kindness too.
The NPA team are going to conduct a number of “sprint audits” looking at specific issues. One of these will focus in on maternal mental health and the NMPA team are keen to get another parent involved with this. Ideally, someone who has first-hand experience of maternal mental health issues within the last three years. I know that might be a big ask but if you think it’s something you might be able to do, the closing date for applications is Feb 5th and you can find details here: NMPA Perinatal Mental Health Sprint Audit Role Description
Your local maternity services also need input from new parents, get in touch with your local Maternity Voices Partnership, share your experiences and help shape maternity care in your area.
It’s very satisfying, having a good moan on twitter or a blog and there is a lot to be said for putting your opinion out in the world and raising awareness of issues rarely talked about. I find it much scarier to do that in real life, and I’m done having babies so it’s tempting just to hide here in my kitchen. But I have three daughters now. I might not take MissA to daily baby yoga and little bubbles singing classes, but I can share what I know, try to provoke change, and, hopefully, help to make things better for her and her sisters if they choose to become mothers one day. It’s time to put on the big girl pants, channel the wonderful Carrie Fisher and, sometimes, close the laptop screen.