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Maternity services in England must become safer, more personalised, kinder, professional and more family-friendly.
That’s the vision of the National Maternity Review, which today (Tuesday) publishes its recommendations for how services should change over the next five years.
The NHS England commissioned review – led by independent experts and chaired by Baroness Julia Cumberlege – sets out wide-ranging proposals designed to make care safer and give women greater control and more choices.
The report finds that despite the increases in the number of births and the increasing complexity of cases, the quality and outcomes of maternity services have improved significantly over the last decade. The stillbirth and neonatal mortality rate in England fell by over 20% in the ten years from 2003 to 2013 (HSCIC Indicator Portal NHS Outcomes Framework Indicator 1c). Maternal mortality in the UK has reduced from 14 deaths per 100,000 maternities in 2003/05 to 9 deaths per 100,000 maternities in 2011/13 9 (MBRRACE-UK Confidential Enquiry into Maternal Death 2015. Figures exclude coincidental maternal deaths). The conception rate for women aged under 18 in England, a key indicator of the life chances of our future generations, reduced by almost half, between 1998 and 2013 (ONS, Conception Statistics, England and Wales, 2013).
However, the review also found meaningful differences across the country, and further opportunities to improve the safety of care and reduce still births.
Prevention and public health have an important role to play, as smoking is still the single biggest identifiable risk factor for poor birth outcomes. Obesity among women of reproductive age is increasingly linked to risk of complications during pregnancy and health problems of the child.
The framework highlights seven key priorities to drive improvement and ensure women and babies receive excellent care wherever they live. To make care more personal and family friendly, the report says that the following is needed:
Personalised care, centred on the woman, her baby and her family, based around their needs and their decisions, where they have genuine choice, informed by unbiased information.
- Every woman should develop a personalised care plan, with their midwife and other health professionals, which sets out her decision about her care reflecting her wider health needs
- It also recommends trialling an NHS Personal Maternity Care Budget which would give women more control over their care, whether it is through an existing NHS trust or a fully accredited midwifery practice in the community
Continuity of carer, to ensure safer care based on a relationship of mutual trust and respect in line with the woman’s decisions.
- Every woman should have a midwife, who is part of a small team of four to six midwives, based in the community who knows the women and family, and can provide continuity throughout the pregnancy, birth and postnatally
- Community hubs should enable women and families to access care close to home, in the community from their midwife and from a range of other services, particularly for antenatal and postnatal care.
Better postnatal and perinatal mental health care, to address the historic underfunding and provision in these two vital areas, which can have a significant impact on the life chances and wellbeing of the woman, baby and family.
- Postnatal care must be resourced appropriately. Women should have access to their midwife (and where appropriate obstetrician) as they require after having had their baby. Those requiring longer care should have appropriate provision and follow up in designated clinics
- The report endorses the recommendation of the Mental Health Taskforce published last week for a step change in the provision of perinatal mental health care across England
A payment system that fairly and more precisely compensates providers for delivering different types of care to all women, while supporting commissioners to commission for personalisation, safety and choice.
To make care safe, with better outcomes, the report says the following is needed:
Safer care, with professionals working together across boundaries to ensure rapid referral, and access to the right care in the right place; leadership for a safety culture within and across organisations; and investigation, honesty and learning when things go wrong.
- There should be rapid referral protocols in place between professionals and across organisations to ensure that the woman and her baby can access more specialist care when they need it.
- Teams should routinely collect data on the quality and outcomes of their services, measure their own performance and compare against others’ so that they can improve.
- There should be a national standardised investigation process for when things do go wrong, ensuring honesty and learning so that improvements can be made as a consequence
Multi-professional working, breaking down barriers between midwives, obstetricians and other professionals to deliver safe and personalised care for women and their babies.
- Those who work together should train together. Multi-professional learning should be a core part of all pre- and post-registration training for midwives and obstetricians, so that they understand and respect each other’s skills and perspectives.
Working across boundaries to provide and commission maternity services to support personalisation, safety and choice, with access to specialist care whenever needed.
- Providers and commissioners should come together in local maternity systems covering populations of 500,000 to 1.5 million, with all providers working to common agreed standards and protocols.
The report also recommends that NHS England seeks volunteer localities to act as early adopters to test the model of care set out in the report determine which flexibilities are required, and identify the most viable solutions for the long term.
Baroness Julia Cumberlege, Chair of the Maternity Review said: “To be among the best in the world, we need to put women, babies and their families at the centre of their care. It is so important that they are supported through what can be a wonderful and life-changing experience. Women have told us they want to be given genuine choices and have the same person looking after them throughout their care. We must ensure that all care is as safe as the best and we need to break down boundaries and work together to reduce the variation in the quality of services and provide a good experience for all women.”
Simon Stevens, the Chief Executive of NHS England, said: “The independent review finds that quality and safety of NHS maternity services has improved substantially over the past decade, and most new mums tell us they are looked after well. But it rightly argues that the NHS could and should raise its game on personalised support for parents and their babies, better team working, better use of technology, and more joined up maternity and mental health services.”
Around 700,000 babies are born every year and for the majority, birth will be straightforward, with most families reporting they had a good experience.
However, as birth rates continue to increase, with more women giving birth later and increasing numbers requiring more complex care, the system is under increasing pressure. It is also clear that the quality of care varies across the country.
The review was tasked with setting out recommendations for how maternity services should be developed to meet the changing needs of women and babies. It was conducted by an independent panel consisting of NHS staff, professional bodies and user groups.