Embedding women's voices
How are local maternity systems and services making sure that they know what women and their families want and need? Midwives looks at the crucial role Maternity Voices Partnerships are playing in shaping maternity transformation.
‘I urge you to play your part in creating the maternity services you want for your family and your community. Voice your opinions, just as you have during this review, and challenge those providing the services to meet your expectations.’ These are the words of Baroness Julia Cumberlege, independent chair of the national maternity review, in her letter to the women of England and their families, which began the 2016 report Better births.
This five-year forward vision for NHS maternity services in England makes it clear that ‘local maternity systems (LMSs) should be responsible for... ensuring that they co-design services with service users and local communities’ (Cumberlege, 2016). And, as NHS England (2017) recommends: ‘In a maternity context, the best way of instituting service user co-production is through a Maternity Voices Partnership (MVP).’ Put simply, these working groups, which replace their predecessors the Maternity Services Liaison Committees, comprise women and their families, service user representatives, such as doulas or antenatal teachers, provider staff including midwives and obstetricians, and commissioners, all working together to review and contribute to the development of local maternity care.
But how is this working on the ground? What difference can MVPs make locally? And why is it so crucial that women and families have this means of making their voices heard?
Transformation in Scotland
RCM Scotland director Mary Ross-Davie says the ambitions of the Best start maternity review are coming to life, with several continuity of carer teams now delivering services.
A small team has been established to serve the town of Larkhall in Lanarkshire, and in Forth Valley, another Early Adopter site, three teams are piloting different continuity models.
One team, comprising a mix of eight full- and part-time midwives from community and hospital backgrounds, is working on a shift basis, rather than on-call, gathering information about ‘how it feels for them, how it works, and what level of continuity they are able to provide,’ explains Mary.
‘There is a real mix of midwives, and several of them have young families, so it is a great testing ground to see how this model works,’ she adds.
Two further Forth Valley teams, one small team providing continuity through an on-call model to women with social vulnerabilities, and another slightly larger team providing on-call care for women across a geographical area, are also recording their experiences.
‘It’s an exciting time,’ adds Mary. ‘Things are really happening now and we’re able to gather some interesting data about how these approaches
In addition, a new continuity team is expected to start looking after some Lothian women before Christmas, and at Clyde maternity services, a new continuity team will go live in the New Year.
NHS Ayrshire and Arran, not one of the five Early Adopter sites, is also in the process of setting up a continuity team.
Mary adds: ‘People are now coming to us, the RCM, with more detailed questions, and we are trying to make sure we are available to support local stewards and managers to look at things like rosters, and make sure they comply with regulations and give midwives a decent work/life balance.’
A national ambition
Lisa Ramsey is the service user voice policy manager for the Maternity Transformation Programme at NHS England, a role that sees her support LMSs to engage with local women, providers and commissioners to form and run MVPs.
She says: ‘The aim is to have at least one MVP per commissioner/provider, so most LMSs will have between two and four MVPs, as women and families relate to their local maternity provision. Some 100 MVPs are in place already, and others are still being established.
‘Nationally the aim is for every woman and her partner using maternity services in England to be able to give feedback via their local MVP, and to be involved in co-production of local maternity services if they want to.’
She believes it is crucial that services are created in partnership with those who rely on them. ‘If we don’t, we are guessing what women and families want in their maternity care,’ she adds. ‘And we have to make sure we ask a whole variety of different women. MVPs need to be really easy to access for every woman using maternity services – all ages, ethnic backgrounds, abilities – so we are able to create together something that’s going to work for everyone.’
How does it feel for women?
Hearing women’s stories, their feedback, and their ideas is central to the work of the MVPs. Service user volunteers ‘walk the patch’, going into settings such as local mother and baby groups or postnatal clinics to ask women about their experiences of maternity care, good or bad. That is fed back quarterly to the full MVP membership, which will look for themes or for individual good ideas for improvements.
One of the key things to discover is how it feels for women and partners using the service, says Lisa. As well as speaking to women, MVPs can make use of the ‘15 Steps for Maternity’ toolkit, designed for MVPs, and launched earlier this year (NHS England, 2018). The idea is that a small team, including a service user and a staff member, take the ‘first 15 steps’ into a service, looking with ‘fresh eyes’ to see if the space and the care experienced are, welcoming and informative, safe and clean, friendly and personal, and organised and calm. ‘It can pick up little things like signage. If you arrive and don’t know where to go you can feel anxious, and arrive late with your blood pressure raised,’ says Lisa. ‘Getting the signs from the car park or the bus stop right can make a real difference.’
The flow of information from service users via the MVPs not only helps shape services, but is also a highly responsive ‘barometer’ of how well the changes coming through under Better births are being received, for example from those experiencing greater continuity of carer/midwife than in a previous pregnancy.
Lisa says: ‘We hear things like “she made me feel safe” or “I could trust her”. That is what continuity of carer is giving, and to be able to hear from women through the MVP is a massive tick in the box.’
More often than not feedback also includes ‘little nuggets’ of praise and appreciation for specific moments of care, and specific midwives and MSWs, adds Lisa, which are then fed back and can be ‘hugely important’ to staff. ‘It’s a real honour to be able to do that, and for midwives to get the recognition they might otherwise not have had,’ she says.
Change in action
Manjit Roseghini, associate director of nursing and midwifery at London’s Whittington Health NHS Trust, offers a raft of examples where their MVP has had an impact. These include the introduction of a ‘flash card’ to orientate women onto the postnatal ward, which was whittled down from a ‘wordy two pages, to one page, using images’ thanks to the feedback from the MVP, explains Manjit.
Women and families are consulted wherever possible, she adds, from the content of the website to the colours of the new reclining chairs, and their feedback has brought about new signage, a change in visiting times, and new co-produced information leaflets, among other things.
‘If users are not involved we can only see things from an operational perspective. We think we know what clients are going to want, what’s best for clients, and yes, we are empathetic and sympathetic, but actually it is the client walking on to that ward, being in that bed. Until you’re that person, living and breathing it, you can’t really feel what they’re feeling.’ The MVP model is a robust and practical one believes Manjit: ‘Meetings are very much action driven. It’s not about having a bit of a moan, or patting ourselves on the back and saying how wonderful everything is. There is a formalised, structured approach, and what comes out of it is opportunities – themes and challenges – and how we run with that.’
She adds: ‘Without them, how can you be reassured that you are running a responsive service, which is fit for purpose and built around the needs of women, babies and their families?’
At Reading MVP, feedback has led to new personalised options for women having a caesarean birth, explains chair Emma Taylor.
‘The personalised caesarean birth project was led by one of our service user reps, who spoke with women postnatally, and found that women who had had a vaginal birth generally felt positive about their experience, while those who had a CS were more down, and talked in terms of “my baby is safe”, without pride or excitement.
‘The exception was one woman who had had a personalised caesarean birth in London.’
After a year of evidence gathering from other services and research papers, a convincing case for personalised caesarean birth was made to clinicians at the Royal Berkshire Hospital, where it was introduced earlier this year. It allows women to choose from a list of options, including bringing down or removing the drape, immediate skin to skin, optimal cord clamping, and delaying checks or doing them while the baby is having skin to skin.
‘Not all women choose all or indeed any of the options, but the important thing is that they can if they want to. We are about to run a survey to capture women’s experiences of and thoughts on personalised caesarean birth, so that we have some data to show how successful it has been, and to help inform future practice,’ Emma says.
The MVP has also helped in the development of the Rainbow Clinic for women who are pregnant after the loss of a baby, she adds. ‘One of the things they talked about was wanting not to have to keep telling staff their story when they saw different midwives or specialists,’ says Emma. ‘An insert for the notes was suggested, and I suggested that we hold a co-production event, so that families could design that sheet, and we did that recently.
‘We are still finalising the design, but the event was a great success, and the final sheet looks nothing like what we expected it would, which shows the power and value of involving women and their families from the conception of the idea. It is now something that truly reflects their needs.’
Bringing about Better births
In ways large and small MVPs are bringing energy and innovation to the Better births vision, highlighting the positive impact on both providers and service users.
‘Better births really drives what we do. The feedback we get from women is so in tune with all those Better births requirements, it really gives more power to your elbow to move those things forward,’ says Emma.
‘The more that Better births is implemented, and the more we are doing things that women want from the service, the more positivity we hear back from women. That is fantastic for staff and helps with recruitment and retention, and staff morale. They feel really valued.
‘We know they work so hard under so many constraints, so if they can be buoyed up, and feel that what is happening really is important and does make a difference, I hope it helps them keep going when things prove difficult at times.’
Ruth Prentice, lay chair, Northern Lincolnshire MVP
‘One of the roles of MVP service user reps is to go out in the community and listen to mums, and partners when possible, about their experiences.
‘I recently attended a mum and baby group to ask for feedback and several of the mums there praised a particular midwife by name for the exceptional care she had provided. A couple of weeks later, at our MVP meeting, a community midwife attended for the first time as she is interested in getting more involved.
‘An important part of our agenda is to share service user feedback and we are keen to share and minute any praise for staff so they hear about it and can use it for appraisal. As I shared the feedback I noticed the midwife was looking a little flushed. Despite our introductions at the start of the meeting, I had failed to realise she was the midwife named by these mums!
‘It was lovely to be able to share this with her and have her hard work, great care and dedication acknowledged in this forum. I think it put a smile on her face.’
Cumberlege J. (2016). Better births. Improving outcomes of maternity services in England. A five year forward view for maternity care.See: england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf (accessed 21 October 2018).
NHS England. (2017). Implementing Better births: A resource pack for Local Maternity Systems. See: england.nhs.uk/wp-content/uploads/2017/03/nhs-guidance-maternity-services-v1.pdf (accessed 21 October 2018).
NHS England. (2018) Fifteen steps for maternity. Quality from the perspective of people who use maternity services. See: england.nhs.uk/wp-content/uploads/2018/05/15-steps-maternity-toolkit-v9-1.pdf (accessed 21 October 2018).