As the implementation framework for the National Service Framework for children, young people and maternity services (standard 11) (Department of Health, 2007),
Maternity Matters states that: ‘Commissioners and providers involved in planning maternity services must take into account… the diversity of the local population to ensure that the very best care is available.’ Options UK aims to strengthen services, increase access and improve the quality of health and social care at all levels of the health system, to improve the health and quality of life of women and their families. In 2009, Options undertook a needs assessment in the London borough of Camden to assist the local NHS and other relevant partners in understanding the health and social issues women of childbearing age and their families face.
The aim was to assess the extent to which maternity service providers were achieving the recommendations set out in
Maternity Matters and to identify the specific unmet needs of vulnerable women and women at higher risk of poor outcomes. In addition, it identified national and local barriers to implementing quality services. It did not set out to provide solutions, as these should be developed by the people involved in delivering them so that there is local commitment to carrying out action plans.
MethodsMixed methods were used to obtain the evidence:
✲ Review and analysis of relevant literature and service data, including analysis of the 2007 Healthcare Commission review of maternity services in England (Commission for Healthcare Audit and Inspection, 2007, 2008)
✲ Service mapping: assessing what is provided and whether it meets local needs
✲ Local demographic profiling through review of local
and national socio-demographic data
✲ Statistical analysis of hospital data on pregnancy outcomes
✲ In-depth interviews with: service managers and providers; local health and social care practitioners; representatives from the community and voluntary sector; service users. These interviews were recorded, transcribed and systematically analysed to identify common themes.
FindingsThe findings are presented in two complimentary reports that, together, identify key areas to be addressed in order for service users in Camden to receive care consistent with national policy.
Report 1 focuses on identifying the challenges faced by vulnerable or hard-to-reach groups. A total of 16 population sub-groups who require additional, specific or more flexible services were identified (see Panel 1), most of which have also been identified as being at higher risk of mortality and stillbirths in the CEMACH report (Lewis, 2007).
The findings identified several issues that impeded women from accessing quality care. Two were common to all: difficulty in communication and concerns about being judged (which can lead to disengagement from maternity services).
Report 2 draws out the key areas to be addressed in order for all service users in Camden to receive care consistent with national policy. The findings are reported under four themes in accordance with
Maternity Matters: choice; access; continuity of care; and safety. The key messages that arise from the findings are outlined in Panel 2.
ImplicationsThis assessment highlights key challenges and opportunities to help inform decisions. Where a challenge or opportunity might be better addressed at a London-wide or national level or by a specific local organisation, this is suggested.
Needs assessments are required under the World Class Commissioning Competencies and the NHS Commissioning Cycle. This assessment provides evidence that is helping Camden’s local NHS to better understand the delivery model and local needs. This will result in informed strategic and operational commissioning decisions about the nature, content and location of services, with a view to reducing health inequality and meeting national policy.
Involving users and potential users in an effective way is key to the current NHS and Department of Health policy-drivers, including the NHS Operating Framework and the NHS Constitution.
By assessing needs from the perspective of users, their representatives and providers of maternity-related health/social services, Camden is now in a position to design and deliver evidence-based and sustainable quality maternity services.
Panel 1. groups with specific needs
1. People from black and minority ethnic groups
(the largest groups in Camden are Bangladeshi and Somali)
2. Asylum-seekers, failed asylum-seekers
or refugees
3. Homeless women
4. HIV-positive women
5. Women with learning disabilities
6. Women with physical disabilities
7. Women with mental health problems
8. People who experience domestic violence
9. Deprived communities
10. Raised body mass index
11. Substance misusers
12. Teenagers
13. Prisoners.
Panel 2. Key messages from Camden’s needs assessment
Choice
✲ The need for service providers to develop effective ways of communicating and providing options for maternity care, including self-referral to midwives and choice of birth place, including home births
✲ Joint working by multiple service providers is key to ensuring wider choice, especially for ‘out-of-area’ women or those from relatively small groups with specific needs (for example women who have experienced female genital mutilation, hearing impairment)
✲ Users need more information about options for postnatal care.
Access
✲ To minimise disengagement with services, more effective ways are needed to communicate with people who find it difficult to understand information provided
in written English
✲ Booking processes and appointment times need to take into account users’ other commitments
✲ The format, timing and content of antenatal classes should be more flexible to suit differing needs.
Continuity of care
✲ Greater continuity of carer (not just care) is required, particularly for users from vulnerable groups
✲ Joined-up care is required for women with other health and social needs
(for example weight management, substance misuse, mental ill-health).
Safety
✲ During risk/needs assessment, women want as much emphasis placed on their individual needs as there is on clinical risk
✲ Postnatal wards are often considered unclean, noisy and lacking in privacy by users
✲ Systems for user feedback need to ensure more women’s voices are heard; seeking general feedback immediately after delivery is necessary but not sufficient
✲ Breastfeeding support needs to be improved to increase the number of women who choose to continue to breastfeed.
Cross-cutting issues
Barriers to choice, access, continuity and safety include:
✲ Inefficient IT and administrative systems
✲ Shortages of midwives and amount of time spent by midwives on non-clinical tasks
✲ Communication between service providers and maximising links with non-NHS organisations involved in providing support or services to pregnant women.
Louise Hulton is technical director, Andrea Nove research consultant, Reilly Anne Dempsey former policy and programme advisor at Options UK and Sara Nam is reproductive and sexual health adviser at Options Consultancy Services
References
Department of Health. (2007)
Maternity matters: choice, access and continuity of care in a safe service. HMSO: London. See:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 (accessed 22 January 2012).
Commission for Healthcare Audit and Inspection. (2007)
Women's experiences of maternity care in the NHS in England: key findings from a survey of NHS trusts carried out in 2007. See:
www.swdc.org.uk/silo/files/womens-experiences-of-maternity-care-in-the-nhs-in-england.pdf (accessed 22 January 2012).
Commission for Healthcare Audit and Inspection. (2008) Towards better births: a review of maternity services in England. See:
http://image.guardian.co.uk/sys-files/Society/documents/2008/07/10/Towards_better_births.pdf (accessed 22 January 2012).
Lewis G. (Ed.). (2007)
The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The seventh report on Confidential Enquiries into Maternal Deaths in the United Kingdom. CEMACH: London. See:
www.publichealth.hscni.net/sites/default/files/Saving%20Mothers'%20Lives%202003-05%20.pdf (accessed 22 January 2012).
