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Analysis

A Cinderella story

21 January, 2014

A Cinderella story

Often dubbed the ‘Cinderella service’, postnatal care seems doomed to cutbacks. But overlooking the crucial period beyond birth could be putting women at risk at their most vulnerable, as Helen Bird discovers.
Midwives magazine: Issue 1 :: 2014

Often dubbed the ‘Cinderella service’, postnatal care seems doomed to cutbacks. But overlooking the crucial period beyond birth could be putting women at risk at their most vulnerable, as Helen Bird discovers.


Cover issue 1 2014

Once upon a time, a visit from a community midwife was as commonplace as one from the postman. Today, it’s a slightly different tale.

Last year, a survey of maternity services across 137 NHS trusts showed that just 25% of women saw a midwife once or twice after going home. The results from more than 23,000 responses also suggest that, since the last survey in 2010, more women wanted to see a midwife more often and fewer felt that they saw a midwife as much as they wanted (CQC, 2013).

The latest quality standard (NICE, 2013) outlines the need to assess various aspects of mothers’ physical and mental health postnatally. It recommends the use of an individualised care plan for each woman, and stresses the need for women themselves to be aware of any signs that her own health, or that of her baby, may not be well.

But if the situation is such that women only receive a couple of postnatal visits, and, as seems to be the case with some trusts, even fewer, are proper assessments even possible?
In 2012, singer Lily Allen brought the media’s attention to the lack of postnatal care she felt she was receiving after the birth of her second child when she tweeted about it. ‘I know it’s not the midwives’ fault,’ she wrote, ‘but surely we can do better than this.’

It seems that this sentiment continues to be echoed across the UK, by midwives and mothers alike, and it is on the premise of ‘doing better’ in postnatal care that the RCM has based its latest campaign. ‘Pressure Points’ focuses on five key issues that are based on the NICE (2013) quality standard. These include reviewing each woman’s personalised care plan at each of the minimum of three postnatal contacts, providing breastfeeding information and support, and assessing women’s emotional wellbeing.

In order to gauge the current standard of services, the RCM devised separate surveys for midwives, MSWs, students and mothers, the results of which are due to be published soon. In the meantime, it is those out in the field who are feeling the strain on this vital, yet seemingly overlooked, aspect of maternity care.

Laura*, a community midwife based in Somerset, explains to Midwives the irony of the situation. ‘It breaks my heart, because the women are at their most vulnerable post-delivery,’ she says. ‘They go through so many hormonal changes, and they need support.’

Sarah* is a rotational midwife in Norfolk, who has been pulled into the community due to the shortage of staff. She says that, while she’s happy to pitch in because she knows how much the community needs the support, the cutbacks mean midwives aren’t able to provide women with the postnatal service that they deserve. ‘They’ve slashed the workforce but we still have to do the visits, although these have been whittled down to the bare minimum,’ she says.

However, the true impact of this apparent shortfall in care is hard to determine in the absence of data, Sarah adds. ‘We don’t have the figures to be able to say the readmission rate or mental health issues have gone up,’ she says. ‘We feel that we would see an increase, but we don’t know.’

And the issue of minimal postnatal contact seems to be the case in many parts of the UK. Laura confirms that, for ‘straightforward’ cases, mothers are seen by a midwife on their first day at home, on day five ‘if they’re lucky’, and on day 10 or 12 for discharge. Perhaps more worrying, though, is that in some areas, this doesn’t even appear to be the minimum standard. ‘In a neighbouring trust to where I work, if you’re a first-time mother you get a visit at the weekend; if you’re a second-time mother, you get a phone call,’ says Laura.

Clearly, this practice is falling hugely short of the recommended care guidelines. But what is the solution? Cathy Trinick, head of midwifery at Pennine Acute Hospitals NHS Trust tells midwives that she has been fortunate that there has been investment within her service and currently has a 1:28 ratio for births.

This ratio also includes the use of band 3s in postnatal care in the community and in the hospital. One of their roles is to provide support to women prior to and after CS. ‘Postnatal care is a priority due to public health and the growing safeguarding agenda,’ she says.

Indeed, it could be argued that all women are vulnerable after having a baby – emotionally as well as physically. Suicide is thought to be one of the leading causes of maternal death in the UK (RCOG, 2001), which is one of the reasons that the government has pledged to ensure there are enough trained mental health midwives for the whole country. Health minister Dan Poulter says: ‘This means women will be much more likely to get the help and support they need, which will go on to have huge benefits for families and children.’

As stated by the NICE quality standard (2013), the first 10 to 14 days after birth are crucial for the assessment of emotional changes. Arguably, it is the woman’s home that provides the best setting to do so. While many trusts have set up postnatal clinics in children’s centres, midwives are not necessarily best placed to pick up signs of mental health problems, or indeed other domestic issues, in such a setting. ‘Women are very different when they’re in their own environment,’ agrees Cathy.

Of course, it is not only the emotional impact of having a baby that we need to consider. The practicalities of day-to-day life become far more difficult post-birth too. Outside the UK, there are well-established systems in operation, which are designed to provide comprehensive support to mothers and families. In China, for example, ‘yue sao’ postnatal care, which involves women providing nursing help to new mothers and their babies, is booming.

The Netherlands has a similar system, known as ‘kraamzorg’, which offers one-to-one emotional and practical support. Midwife Jan Rogers was so impressed upon seeing the service first hand that she decided to bring it to the UK, setting up a private company that offers mothers 25 hours per week of postnatal support as a basic package.

‘The idea is that we complement the community midwife,’ says Jan. And, while there is a cost associated with the service, making it a luxury many families simply can’t afford, Jan says that, in an ideal world, the situation would be different. ‘Community midwives are so stretched, and our breastfeeding rates aren’t brilliant,’ she says. ‘My ideal would be that every woman got this service, but that’s not going to happen with postnatal care.’

Community midwife Laura puts this, in part, down to the dissolution of the family unit. She says: ‘If you watch Call the Midwife – I know it’s going back to the 50s and 60s – but you still had that family unit, and we’ve gone away from that. I think if we could pull it back, and have something more community-based, we would do so much better with our breastfeeding rates.

‘It’s gone so far back the other way that we’ve completely lost sight,’ she adds.

But is there a way to pull it back? Barrister Barbara Hewson says that, depending on the future of the health service, there may be a contractual obligation to provide a certain level of care.

‘If the NHS is being reconfigured into clinical commissioning groups, perhaps local patient groups and maternity groups could be lobbying those new entities, to make sure that postnatal care is being commissioned from trusts,’ says Barbara. ‘If it’s part of the commissioning contract, then trusts couldn’t refuse to provide it.’

In the meantime, individual trusts across the UK are doing their best, with what little resources they have, to improve the postnatal service they offer. One example is University Hospitals Coventry and Warwickshire NHS Trust, where staff have launched a new group, ImPosE (Improving Postnatal Experience).

SoM Claire Croxall says: ‘Historically, our complaints stem around postnatal care, which I think is the case nationally. So, with the feedback we’ve had from our own trust impressions and our Friends and Family Test, we’re trying to make some changes on the postnatal ward to improve the service.’

While it may seem idealistic to hope for a ‘happily ever after’ for postnatal care, midwives and women alike can only hope that, through campaigns such as the RCM’s and increased awareness on the part of the government, we can bring a focus back to woman-centred care beyond birth.


In a mother’s words
Once my baby had been safely delivered, the care was awful. I had a third-degree tear that required me to go to theatre. I was in recovery for five hours because there was no one to take me to a ward.

The next day, my baby wouldn’t feed very well. I expressed my concern that he couldn’t open his mouth properly and couldn’t latch, but this was dismissed. I’d been in for over a day but my son hadn’t had his 24-hour check because there wasn’t anyone free to do it. This ended up being done at my doctor’s surgery.

On day four, I drove over 100 miles and paid a private practitioner to fix my son’s tongue tie, as when I rang the community midwife she wouldn’t come out to look at it, she just told me that the trust didn’t cover it and I’d have to find someone to sort it out privately.

The staff were lovely but completely and utterly understaffed and overworked. I don’t blame them at all; I blame the system.



*Names have been changed

For more information about Pressure Points, click here.


References

Care Quality Commission. (2013) Maternity services survey 2013. See: www.cqc.org.uk/public/publications/surveys/maternity-services-survey-2013?cqc (accessed 13 January 2014).

NICE. (2013) Postnatal care. Quality Standard 37. See: guidance.nice.org.uk/QS37 (accessed 13 January 2014).

RCOG. (2001) Why mothers die 1997–1999. The Confidential Enquiries into Maternal Deaths in the United Kingdom. RCOG Press: London.






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