Birth of a new era in maternity services

On the day of the release of the first Friends and Family Test feedback for maternity services, NHS England’s national clinical director for maternity and women’s health, Dr Catherine Calderwood, speaks out on the challenges being faced and actions being taken.

Our staff need to become better communicators and use their own childbirth experiences to help maternity services improve.

There has been an explosion in the country’s birth rate, up 10 per cent in the last 15 years. We now have almost 700,000 births in England’s hospitals every year, so it’s not surprising there have been calls for more midwives.

This is a situation we are working hard on to address. But increased staffing isn’t the only way we can improve the services we provide.

By speaking to mums and mums-to-be, giving them realistic expectations, by listening to their concerns and by making sure we do something about addressing any concerns or complaints they raise with us, we can deliver improvements to maternity services nationwide.

We need to listen, learn and act.

It is for this reason I am delighted the Friends and Family Test has been extended to maternity services. It gives us an opportunity to take vital, live feedback and use it to improve and fine tune the services we are providing.

Delivery rooms are busy places and can be stressful and scary places, not least of all for mum and dad! But it’s at times like this that the midwife can use their experience and their knowledge to put everyone at their ease.

Many midwives and obstetricians are mums and dads too. They know what it is like to have a baby, they know the extremes of anxiety and elation a woman can go through in a matter of hours and the mixture of instinct and fear which can accompany a birth. They know of the concerns women have, the need to know what is happening and to be reassured.

It is at this critical time that we have to learn as staff in maternity services to be there with and for the mum, to take time to give them reassurance and to speak to them honestly and give them time to express their concerns or to ask questions.

The maternity service is different to most other services the NHS offers people, in that the population we care for are not ill – they are having a baby. We have to respond when a mother goes into labour – it’s not like we can put it off!

Maternity is also unique in that fact that this time is always remembered as part of a family’s annual calendar – both in the positive and the negative. Parents remember and celebrate the birth of their child and those moments in the delivery room may remain with them always. If the care is poor or the outcome sad, the same memories endure. Those hours in maternity can affect a woman and her family for the rest of her life – good or bad.

As a mother of three children myself, two girls aged 11 and 12, and a boy of seven, I know what it is like in a delivery room. I had my children at my own local unit. And I am typical of our staff: 99 per cent of midwives are women, 47 per cent of obstetricians and 73 per cent of current trainees are all women.  So that is a lot of first-hand experience we can bring to our work which is to support, in a critical moment in their lives, the 70 per cent of British women who have children.

I think, as with previous surveys, the Friends and Family Test feedback will tell us that women like to be asked and they like to have the opportunity of telling their story, and that we will listen to what they say.

The difference with FFT is that we must really use this opportunity to change our services – from the small things such as ensuring the soap in the shower is easily reached by a new mum once she has had her baby, to bigger things such as ensuring the delivery room is properly equipped and that mums aren’t left alone.

We also know we must use our own childbirth experience as part of the service we provide and pass that on in a way that is easily understood. We are not perfect and sometimes provide background knowledge that can be confusing to a woman, especially in the heat of the moment. Or we don’t think it is important to explain something, and there are instances when women don’t like to ask. We need to take the time to give information that is clear and concise and easy to understand.

We already know that most women prefer one-to-one care with a single midwife throughout their pregnancy. In many areas this is happening but it is not always possible due to simple factors such as staff holidays, sickness and shift patterns.

This brings me to the issue of staffing levels. We have seen an explosion in the birth rate in the last decade and during that period the NHS has been playing catch up. In the last few years we have recognised the shortfall and done a lot to address the situation. We currently have more than 21,600 full time equivalent midwives – more than there have ever been. That’s an increase of 1,300 midwives in the last three years.

In 2012 and 2013 we recruited 2,500 trainees a year. That is a total of 5,000 midwives in training, the most ever, and they will qualify over the next three years. We are also going to continue recruiting trainees at the same rate. For the first time in a decade we are recruiting faster than the birth rate is increasing.

Aside from recruitment there are other ways that we can work more imaginatively to ensure we provide the sort of personal maternity care that women desire. One way is the creation of small teams of five or six midwives to provide care throughout a woman’s pregnancy. This sort of working needs a champion, with complicated rotas to organise, and midwives need to be signed up to it.

Or we can have one team that provides the antenatal and post-natal care, and then a childbirth team, which may be more practical and a quicker fix to the care we offer than trying to have one midwife all the way through the pregnancy. In this way, the mother would see just a few people which would put her at her ease.

We know there is evidence that one-to-one care is what women want and we know that if a woman forms a close relationship with one or two midwives,   there is evidence of benefit such as reduced medical interventions. There is also evidence that women and families can contribute positively to patient safety.

But this is really tricky. It is often impossible to predict the number of births we are going to have on one day. We can and do move staff from other areas and find innovative solutions to enable the best quality care possible for women and their families. On the one hand we need to ensure we have enough midwives on duty to provide the quality of care women need during childbirth, but on the other hand we don’t want to have midwives twiddling their thumbs. It’s a conundrum we wrestle with every day.

Another criticism we may face from feedback in the Friends and Family Test, which has come out in other surveys, is that women have felt hospital wards, toilets and bathrooms are not clean enough, or that there were inadequate facilities during delivery or a lack of or poor equipment.

Uncleanliness is totally unacceptable and feedback from FFT will help us immediately tackle this in the few areas that it occurs.

We are already using FFT feedback to improve maternity services in other areas. For example, the University Hospitals Coventry and Warwickshire NHS Trust received feedback raising issues over the new birth centres discharge process, visiting for partners and making FFT more visible.

As a result staff have worked to speed up the discharge process, changed the visiting for partners so they can now stay on the ward at night, and have designed new boards making feedback opportunities more visible to mothers as part of their drive towards “Improving the Post Natal Experience”.

We have invested in clinical leaders and managers in 12 senate areas – strategic clinical networks – where they can use FFT, help us look at the challenges and make sure we work using best practice.

The networks can look at the feedback in a wider contact – examine where it is good and how they achieved it. Using others’ experience will help us improve performance throughout.

FFT will focus our thinking. Childbirth is more than a clinical experience – it’s a life event and it’s important that people take away a lot more from it than just a healthy mum and baby.

We must communicate better, make sure complaints go down and proactively deal with problems and, in the many, many maternity units where services are being lauded, let staff know as a deserving boost to morale.

FFT is about transparency, and we know that women and their families appreciate us being open and honest, even when it hasn’t been an ideal birth or experience.

By listening to women and acting on their FFT feedback, we can and will improve things. Not just the clinical or safety issues, but the whole childbirth experience.

We genuinely want women to be part of the team – part of the whole – they are the eyes and ears and are a vital part of the team if they want to be.  The Friends and Family test will enable them to help us.

Details of the Friends and Family Test maternity data for December 2013 can be found on the NHS Choices website. The FFT maternity data for October and November for all Trusts is within the statistics page of the NHS England website.

Dr Catherine Calderwood is National Clinical Director for maternity and women’s health in NHS England. She is also a medical adviser for Scottish Government and an obstetrician and gynaecologist working in Edinburgh.

Catherine has a special interest in high risk pregnancy, particularly in those women with complex medical problems and continue to have an obstetric medicine antenatal clinic. She carries out a number of teaching and training roles in both obstetrics and gynaecology and in general medicine. Research interests include thromboembolic disease in pregnancy and she is an investigator on the AFFIRM study which will study the effect of the introduction of a standardized education and management plan for the care of women presenting with decreased fetal movements in hospitals throughout the UK and Ireland.

Catherine is chair of the UK maternal, newborn and infant Clinical Outcome Review Programme – the new process for confidential enquiries into maternal, newborn and infant deaths and severe morbidity run by MBRRACE-UK.