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Changing Childbirth again? Implications of the NSF

12 June, 2008

Changing Childbirth again? Implications of the NSF

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine. The meeting was chaired by Dr Luke Zander, retired general practitioner.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine. The meeting was chaired by Dr Luke Zander, retired general practitioner.

Midwives magazine: April 2005


Who, where, when and how? The implications of the National Service Framework (NSF) for the maternity care workforce

Jane Sandall (JS), professor of midwifery, Guy's, King's and St. Thomas'

The organisation of health care depends very much on politics, culture, and structural forces, but maternity is different from other types of health care, being concerned with the reproduction of society, and the essential task of normality. The relevant National Service Framework (NSF) focuses on the health of mothers and inequalities in health: `Improving the health and welfare of mothers and their children is the surest way to ensure the health of the nation' is a comment in the foreword of the NSF echoing the English Board of Education in 1914.


There has been little success in achieving the hopes enshrined in Changing Childbirth, (Department of Health, 1993) and this applies also to our guardianship of normal birth - disappointing facts that have informed the NSF and the National Institute for Clinical Excellence (NICE) guidelines. Whatever the intentions of policy-makers may be, policy is what is delivered at street level, and the commitment of professionals to provide individualised care may come into conflict with procedures requiring equity in a system designed for mass processing.


As a result of the external working-time directives and a Department of Health new workforce programme, there will be changes in professional working boundaries. There will be more hands-on care by senior staff, and an increased role for midwives, including midwifeled services. This recognises that they produce outcomes at least as good as care by obstetricians does for women who are not at high risk of complications. These key changes are due to take place with or without the NSF. The NSF is committed to flexible individualised services designed to fit around the woman and her baby's journey through pregnancy and motherhood, with emphasis on the needs of vulnerable and disadvantaged women. The standard 11 of the NSF is for women to have easy access to supportive, high-quality maternity services, designed around their individual needs and those of their babies. It recognises that for the majority of women pregnancy and childbirth are straightforward processes and events, during which medical interventions should only be recommended if they are of demonstrable benefit to mother and child.


The provision of information about choices and service provision in pregnancy and childbirth are paramount. Quality of care has a long-term impact on children's and the public health - partners and significant others have an important influence. A provision of the NSF is the location of services for childbirth as close to home as possible, within a clinical network affording appropriate levels of care for women and babies with complications. A non-interventionist service for women at low risk, focusing on normal birth, should be community based and woman centred. Care is to be provided by the right person in the right place, at the right time and with the right skills, and for more user involvement to be encouraged. A raft of community services includes direct access to named midwives providing continuity of care, strong contacts with advocates and GPs, and multi-agency working.


 Existing birth care incorporates much of the above in some places; in addition, users should be offered the choice of place of birth and one-to-one care in labour. The staff and their equipment will need to be based in the community - when tasks are shifted, the responsibility must move with them. Midwives will have to decide what and how much to delegate to maternity care assistants during and after birth. For the specified three-month postnatal care period, training issues, including the examination of the newborn and the relationship with health visitors, will be very important for midwives.


Community-based midwifery group practices will need to be co-located with sexual health and children's services. They will have to take on new ways of working, integrate efficiently with tertiary care and manage flexible budgets.We will need full-hearted support for community midwifery care, moving the emphasis away from the specialist midwifery in hospitals that receives the most attention.


Pounds, preference and partnership: the challenge of managing choice


Sue Eardley (SE), chair, Mayday Healthcare NHS Trust My background is as a trained engineer and latterly in volunteer work with the National Childbirth Trust. In this context, preference equates with choice, and the NSF does not confer the choice of unit where a woman may have her baby, but offers her the choice of the services she will receive there.


Partnership implies working seamlessly across the boundaries, giving real meaning to woman-focused care. Flexible individualisedservices imply cost and choice - this will require that the first professional to whom a pregnant woman turns must be able to start providing the essential information she will need to make choices, in itself a huge training issue. The NSF emphasises the needs of vulnerable and disabled women - only by adequate audit will we know that these are being met. The same services are to be available to all women (equality). All are to have ready access to those services, and this implies the availability of high-quality information to all (equity). The NSF aims for good clinical and psychological outcomes, with important implications for mental health, child protection, and the wellbeing of the whole family. All of these objectives are to be informed with kindness, support and respect.


 Several vital assumptions underpin the NSF. These include that:

  • Safety is guaranteed for mothers and babies - this is backed by the Clinical Negligence Scheme for Trusts

  • The care environment will be clean and hygienic practices observed

  • Care will be available at all times without delay. Unique in hospital and primary care Trusts (PCTs), maternity is a fulltime emergency service

  • Care will be woman centred and integrated, using effective information technology support

  • There will be sufficient and competent professional staff. The profile of maternity services will need to be raised to achieve priority with hospital and PCTs.


This is best achieved by evidence of the quality of care, despite the regrettable fact that the NSF is to receive virtually no new money. Nonetheless, the job has to be done, and since everything the NSF requires is being done now somewhere in the health service, we must look around, learn, and make the necessary changes. The maternity workforce is understaffed, and will need to share its work with maternity care assistants who may operate in clinical or clerical settings.


Mothers should move seamlessly through the systems of advice and help available, and the organisation of this is the task of lead midwives. With the introduction of commissioning of maternity services by general practices, units will have to consider how to encourage GPs and families to choose them, and how to make themselves attractive to new staff. They will need to develop links with Trust boards, the voluntary sector, and Patient and Public Involvement forums. These are a key vehicle for raising awareness of the needs and views of patients and the public, and placing them at the centre of health services. Maternity services liaison committees (MSLCs), linking national, local and user issues, will have an important role in monitoring the NSF. Stimulating change, building and developing partnerships, the NSF offers the challenge to professionals and the public of real involvement in the success of the service.


The NSF - delivering for women? Will the NSF change the experience of childbirth for women?


Richard Hallet (RH), chair, Eastbourne MSLC To answer the question in my title, I believe that the NSF can and will deliver. The following are some extracts from the NSF: `This standard recognises that, for the majority of women, pregnancy and childbirth are normal life events; it aims to promote women's experience of having choice and control in giving birth to their baby.


The standard seeks to improve equity of access to maternity services, which will increase the survival rates and life chances of children from disadvantaged backgrounds. It also aims to ensure that all mothers and babies receive high-quality clinical services, providing high-quality midwifery, obstetric and neonatal services in a culturally sensitive way, together with effective family support, focused on those with high needs. PCTs, in partnership with local authorities, will wish to focus on some of these in setting local targets. `This NSF is based on the care pathway approach. Care pathways are used to illustrate the woman's progress through the variety of services available. They have emerged in the past decade as an important technique for continuous quality improvement in health care and are increasingly seen as a key NHS resource. `Services delivered through the care pathway approach will be integrated by the introduction of managed maternity and neonatal care networks. These are linked groups of health professionals and organisations from primary, secondary and tertiary care, and social services and other services, working together in a coordinated manner, to ensure an equitable provision of high-quality, clinically effective care.


The vision `Flexible individualised services designed to fit around the woman and her baby's journey through pregnancy and motherhood, with emphasis on the needs of vulnerable and disadvantaged women. Women being supported and encouraged to have as normal a pregnancy and birth as possible, with medical interventions recommended to them only if they are of benefit to the woman or her baby. Midwifery and obstetric care being based on providing good clinical and psychological outcomes for the woman and baby, while putting equal emphasis on helping new parents prepare for parenthood. Community-based facilities are fully equipped and staff have the skills for initial management and referral of obstetric and neonatal emergencies. Consultant-led services have adequate facilities, expertise, capacity and back-up for timely and comprehensive obstetric emergency care, including transfer to intensive care.'



The vision gives some very clear messages, and the scope of the NSF is as wide as you could wish:

  • For the vulnerable and disadvantaged: language, culture, drugs, alcohol, HIV, travellers, mental illness, chronic conditions, prisoners, asylum-seekers, domestic violence, teenage mothers and fathers, the bereaved

  • For normality: midwife-led care, local and community, improving women's experience, choice, the birth environment, birth pools, home birth, promoting normality

  • For medical care: facilities, expertise, capacity, back-up for timely and comprehensive obstetric emergency services including intensive care, neonatal transfer as part of a managed maternity and neonatal care network.


The danger for maternity services is that any one emphasis becomes too dominant. Medical care becomes centralised in large hospitals - the normality agenda can express hostility toward the medical, and the vulnerable and disadvantaged may be sidelined by both. The balance of these tendencies will need continuous reassessment, and the imperatives of the NSF provide balance, partly by encouraging new integrated ways of working, but also by placing the woman at the centre of the service. Evidence-based care, monitoring and data collection are to be characterised by honesty and openness - it will be personalised, and informed by kindness, support and respect, reinforced by programmes of user feedback. And you (including users) have to be the change you want to see, not leaving it to others. The success of the NSF will depend largely on the resources available to it, on adequate staffing, midwifery leadership, and a clear plan of implementation. Will it have teeth? The decision of the NMC to require the Commission for Healthcare Audit and Inspection to carry out an audit on each Trust they visit will be effective ± providers and users listening to each other is essential. A business would die if it did not keep close to its consumers - the MSLC is a conduit for this, and self-audit will ensure that its activities are constantly under review. The NSF's expected standard is that women will have easy access to supportive, high-quality maternity services, designed around their individual needs and those of their babies. Will it change the experience of childbirth for women? Why do I believe that it will? Because everything in the NSF is being done well somewhere now.




Following Professor Sandall's presentation, the chair recalled the excitement with which Changing Childbirth was received over ten years ago, and and compared this with the lower key reception that the NSF has received, despite its many promises of improvement in the maternity services. Beverley Beech of the Association for Improvements in Maternity Services (AIMS): There is a lack of balance in the maternity services, with the medical model heavily outweighing normality. Fewer than one in ten women are getting a normal birth.


Is the NSF going to restore some semblance of balance? Government and Trusts have not to date showed enthusiasm for change, and I cannot see how the service will change for women until it is community based, with midwives carrying their own caseloads. We are still knocking on the same doors ten years after Changing Childbirth. Change will require extensive retraining. Wendy Savage: For this to work, the majority of midwives will have to come out of the hospitals and work in the community. So much has been lost since the advent of risk management. We need many primary care midwives and secondary care specialist midwives in the hospitals. Lesley Page: Continuity of care is very difficult to achieve in large institutions. I am concerned that with the establishment of managed maternity care networks, which are key to a successful service, the system does not become unbalanced by higher recruitment numbers to the hospitals than to the community, as is the case in London at present. JS:


Community midwives too often have their offices located in acute hospital Trusts - how then can they know their communities? I am also concerned that best care of women with complicated pregnancies and labours should not take second place. SE: Other NSFs have been published and implemented in the past few years, and we have been able to learn from them, and they have led to demonstrable change, bringing the NHS up to date - they do have teeth. Different ways of working have been accepted, and sensible contracts agreed. The NSF is saying: `If you think it works and can prove it works, go ahead and do it', and that goes for community midwifery. Nothing in the NSF rules it out. The detail of change is for local decision. The opportunity is being recognised - as Agenda for Change comes in, everyone's skills and competencies are being assessed as never before with Cumberlege (Department of Health, 1993) and Winterton (House of Commons Health Committee, 1992).


Furthermore, this government is taking patient and user involvement seriously - women and their families will now have some clout. RH: If you want to set up midwife-led units or keep them going, visit those that are succeeding and find out how they did it. Achieving results means contacting all the providers and users of the service: midwives, district general hospitals and their obstetricians, GPs and users. We have to work together rather than blame each other. A former NHS community midwife now working independently: If pay structure, recruitment and retention are to be adequate, the work of community midwives needs to be understood and respected by managers, obstetricians and hospital midwives. Too often when a mother is transferred from the community to hospital the foregoing work of the midwife is completely ignored. SE: We will need to accommodate staff preferences where flexible working is concerned - the NSF gives the opportunity for midwives to earn respect by proving that they can work in different ways. The maternity service is one of a hospital's shop windows, and families become involved with it at a time in their lives when they have very little other contact with the health service.


A good maternity experience will form their opinions of a hospital as a whole. This, and impressing the clinical governance committee, are useful ways for a maternity service to come to the notice of a Trust board. Seldom if ever are women asked for their opinions of a maternity service. The appointment of consultant midwives will usefully increase the influence of midwifery as a whole. Responding to a question from the chair, it was reported that more than enough midwives are keen to work in the community.


A manager, however, expressed the anxiety that the drain from hospitals could result in a loss of consultant obstetricians, paediatricians and anaesthetists. A questionnaire by the RCM has shown a preference for working in teams in the primary care setting. An NMC visitor has identified a funding problem: Despite the stated preference by midwives for midwife-led units, Trusts are reluctant to support them financially. There are significant training implications that will require investment. There are midwives at present working in hospitals who are keen to move to the community, but they are waiting until there is adequate funding there. I believe that this funding should come from children's Trusts and not from acute NHS hospital Trusts.


The chair picked up on this reference to the children's Trusts and asked Heather Mellows, RCOG junior vice-president and co-chair of the external working group: maternity of the NSF, to comment on whether they would indeed be the physical base for midwives working in the community. She could not confirm it, but the children's centres might serve this purpose. She believes that managed maternity networks that reach widely into the social system will have a more important place in the working of the NSF. These should guarantee a woman's smooth passage through the system of maternity care, ensuring that she gets any necessary advice and support in a coordinated way from the time of her first contact. The best way for this NSF to improve the maternity services is by reacting to measures of patient satisfaction as gathered by all the professionals and the Health Care Commission reviewers - a numerical target for this cannot be achieved. Success will depend on teamwork between midwives, obstetricians and all concerned in maternity care. RH: It is a great privilege to be a member of a multidisciplinary team such as the MSLC, which is in a position to effect change.


JS: The policy context has changed in the past ten years, and this gives us opportunities to make improvements with or without the NSF.We will make the best of these opportunities by looking at the services from a woman's point of view.


SE: Always keep equity in mind. This NSF is a ten-year plan, so do not expect everything to change at once. Other areas of health care have shown that a NSF can be made to work within the financial constraints - it is up to you and your teamwork. From the chair, Luke Zander reflected in conclusion that one template is not likely to suit the whole country - flexible working within localities will probably become the norm. If everything is being done well somewhere now we need a clearing house by which to share the knowledge and experience that exists.


Further information


JS referred the meeting to the website: www.jiscmail.ac.uk/caseloadmidwifery  that offers a discussion forum for midwives. Reference was also made to the website: www.mslc.org  where guidelines and shared practical examples of practice can be found. A link to the NSF is available at: www.btinternet.com/~basil_lee/nsf.html  




Department of Health. (1993) Changing  childbirth: report of the expert maternity group (Cumberlege report). HMSO: London. Department for Education and Skills. (2004) Maternity module for the National Services Framework for children young people and  maternity services. Department of Health: London. House of Commons Health Committee. (1992) Second report on the maternity services (Winterton report). HMSO: London.


 This report appears in full on the Forum's website, see: www.motherhood.org.uk, where references and the extensive discussion are included.





































































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