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UK Parliament Health and Social Care Committee Formal meeting (oral evidence session): Enquiry - Safety of maternity services in England

4/8/2021

December 15 2020

The session began with Tinuke from the FiveXMore campaign giving an outline of the campaign and sharing birth stories including her own that exemplifies why birthing people are left feeling unimportant, unheard and that their pain during the birthing period was not taken seriously.

When asked on what could be done to change the disparities and prevent future harm Tinuke and Clo from the FiveXMore campaign named the following actions:

More NHS investment into addressing these issues
Research that includes black women experts as part of the research team and more consideration of the lived experiences of those affected by the disparity.
Data collection on near misses, morbidity and illnesses and poor outcomes
The NHS must commit to a target to close the disparity gap
Black women need to be given information to make informed choices in relation to their care
The word BAME should be minimally used in maternity services to ensure that it is clear who is being referenced.

Professor Knight (Professor of Maternal and Child Population Health at the University of Oxford) agreed that there is a particular issue underlying maternal deaths with pregnant people presenting on multiple occasions and not being heard. Specific research was carried out looking at the care received by women from different ethnic groups. The results from her research suggested that there was no differences in care when comparing ethnic groups. However, there was evidence to suggest that approximately 40% of women might not have died if they had received different care.

The research also concluded that there were 17 clear biases in the care received. The 3 leading biases found were:

“Not like me” This bias was most prominent when people were caring for black women. There was less nuanced, individualised care and poorer listening skills employed when people attended to black women.
Complexity - Clinical, Social and Cultural The highest number of women who died were those with complex care needs and multiple complications. The research found evidence of structural biases resulting in inadequate care. This theme was an issue for women in all racial categories.
Micro-Aggression This bias was particularly found in the care of Asian women. Racial stereotypes were seen to be a contributing factor to these micro-aggressions in particular with women who do not speak English fluently. “Agitation was assumed to be due to mental health problems when they were actually seriously physically ill”. Specifically, the micro-aggression of using family members to interpret meant that there was less likelihood of some important personal information affecting the pregnancy being conveyed to health workers due to lack of privacy.

Professor Knight confirmed that the disparity in maternal mortality rates between black and white women has been getting wider.

Tinuke shared some of the results from FiveXMore’s consultation with 400 Black women. Of those women:

78% Did not receive advice/guidance on how to make an informed decision on home births
70% Did not receive advice/guidance on how to make an informed decision on water births
73% Were not presented caesarean sections as an option
85% Were not given advice on having an assisted birth
94% Were unaware of the Health and Safety Investigation Branch (HSIB) and were unaware of how to make a complaint when they had bad experiences during their pregnancy and childbirth, even when they were at risk of losing their life because of the negligent care that they had received.

Of those that engaged with HSIB to raise a concern 74% did not receive a follow-up.

Professor Jenny Kurinczuk, (Professor of Perinatal Epidemiology and Director of the National Perinatal Epidemiology Unit, at Oxford) Shared that whilst overall perinatal mortality has fallen from 2015, there is a racial disparity in stillbirths and neonatal deaths. There is a twofold increase for black babies and a 60% increase for Asian babies. This particular disparity appears to have slightly increased over time. There is still no explanation for the disparity although some might be accounted for by the variance in acceptability and uptake of termination of pregnancy due to a congenital anomaly and also deprivation. Further research is required.

She confirmed that the MBRRACE research shows that there is twofold difference in maternal mortality for the most deprived parents and that there are a lot of factors that are interlinked. There is still work to be done to understand the individual risk factors in a number of the issues.

Ethnicity does not create a variation in cause of mortality, almost all of the women who died had pre-existing mental health or medical co-morbidities. However, pregnant person bias does exist. The leading cause of maternal death is heart disease, the symptoms associated with heart disease (central chest pain, breathlessness and pain going down the arm) are sometimes overlooked as a symptom of pregnancy and therefore at times missed by medical staff in acute care settings or by junior or less experienced staff.

Professor Kurinczuk confirmed that the MBRRACE team is conducting a confidential inquiry into the deaths of babies to black and black British mothers. This inquiry began at the beginning of 2021.

Maternal Mental health and Suicide
The data suggests that race is not a contributing factor when looking at risk of maternal suicide, however there is a bias that normalises or dismisses symptoms of parents who are vulnerable to suicide therefore preventing intervention and support. Another issue is that the majority of women who died in this way sought help on multiple occasions but our current care systems are not holistic enough to give visibility to concerning patterns. MBRRACE urge that repeated presentations should be viewed as a red flag and an emphasis should be placed on making diagnosis not just excluding them.

Continuity of Carer
The consensus from both Professor Knight and Tinuke was that continuity of carer would work in cases where the right team with the right expertise to provide individualised care were put in place to support women, particularly those with complex needs.

Preliminary outcomes from the interim Ockenden Report
Donna Ockenden shared that the overarching issue was a failure to listen to the families and also a culture of placing blame on the families when things did not go as they should have.

There was a culture of pressuring pregnant people to give birth vaginally and avoid c-sections, even when there was a contraindication to do so. The pressure was from both obstetricians and midwives.
Women and pregnant people need to be listened to.
Informed choice with regard to place and mode of birth should be based on accurate information and free from ideological bias.

Women and pregnant people with complex care needs should be under consultant oversight.
Antenatal consultations should be used as opportunities for continual risk assessment to understand which pregnant people are in need of specialist attention.

RCN Chief Executive Gill Walton confirmed that an approach that could be taken to address the national shortage in maternity the workforce is to specify the requirements necessary to support one safe birth and use that for guidance. Dr Edward Morris (president of the RCOG) agreed.

Both also agreed that maternity should have sound representation at the board level of NHS Trusts. There was consensus amongst both that whilst the HSIB provided good information to also meant that local opportunities to learn from mistakes were lost.

Additional scans later in pregnancy
Professor Gordon Smith from Cambridge University, spoke on the usefulness of a presentation scan at 36 weeks to help assess risk and provide information for informed choices to be made about location and mode of birth. He suggested that this would reduce the likelihood of emergency C-section if it is already determined that the baby is in breech or other presentation that may require additional support.

How to use the data currently collated to create lasting change.
There was agreement with Dr Morris and Gill Walton that there needs to be a more responsive data collation system that could potentially be anonymised and collect data from the CQC inspections, HSIB, NHSR, the NIS and all of the inquiries and reports that are ongoing with additional datapoints from the families. This could potentially also alert Trusts of cultural issues that need to be addressed. Dr Morris confirmed that an additional layer is not required but the data that is already collected must be used in a more systematised and timely fashion. We should hear about the near misses and feed all of this information into the governance system of the trusts so that they can learn and improve in a more responsive way.

The damaging effect of using the term “normal birth”
Both the heads of the RCN and RCOG were asked to commit to not promoting the use of the term “normal birth’ because of the impact it may have on families when considering the mode of birth that is safest for their particular needs. The potential for a hidden pressure to be exerted on families by the labelling of physiological birth as “normal” was identified by the committee. Both heads agreed that they would not encourage the use of this term.

Source:https://committees.parliament.uk/event/3111/formal-meeting-oral-evidence-session/

Written by Elizabeth Odunlami

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MBRRACE UK Rapid Report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK

4/8/2021

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(March - May 2020)

Following the SARS-CoV-2 virus, MBRRACE initiated a rapid notification system for maternal deaths associated with the virus. Expedited reviews were conducted to collate information relating to the virus for pregnant people “with confirmed or suspected SARS-CoV-2 infection during or up to one year after pregnancy, and any deaths of women who died from mental health-related causes or domestic violence, which might have been influenced by public health measures introduced to control the epidemic such as lockdown.” The reviews reported were from deaths occurring in the period of March to May 2020. Healthcare Safety Investigation Branch (HSIB) also contributed to this report using data from their own investigations of maternal deaths linked to SARS-CoV-2.

The key lessons and recommendations:

Senior obstetric review of pregnant people is crucial in the context of COVID-19. Where relevant multidisciplinary team care should be given with daily review. The most likely person to be overlooked is someone who is unwell but not displaying a need for “continuous level 3 care, but with multiple problems and for whom therefore no-one takes a leadership role” in their overall care.
Critical care treatment should be provided in another setting if beds are not readily available, treatment should not be postponed.
Infection with COVID-19 should be considered as an additional risk factor for thromboembolism. This should be addressed by prompt reassessment and proactive management. Emerging evidence points to a link between COVID-19 and increased risk of thrombotic disease. Pregnant people have further increased risk for thromboembolic events even more so in the 3rd trimester, caesareans increase the risk further.
A minimum standard of orientation should be given for staff working in new clinical environments. This relates to medical staff being redeployed at short notice to new clinical environments who were unfamiliar with the critical care equipment that they were required to use and monitor in order to care for patients.
Pregnant or postpartum people with medical complications should be treated the same as non-pregnant people when considering antiviral or therapeutic treatment for COVID-19 as part of early care or compassionate use programmes. Exclusion from clinical trials should only occur when there is a clear reason.
Pregnant people need clear guidance on when to speak to their midwife or go to the hospital. If necessary this should be provided by an interpreter. The stay at home/self-isolate guidance for COVID-19 and partner restrictions resulted in pregnant people staying at home and self-medicating for several days without seeking additional support. Clear guidance is required for pregnant and postpartum people about the risks of deterioration and when to seek urgent medical attention. People from Black and Minority Ethnic backgrounds or those with other risk factors should be advised to seek additional guidance without any delay if they have any health concerns.
Communication with families and partners and facilitating visits when people are critically ill is a priority. An interpreter should be used when required.
Continuation of perinatal mental health services is essential. In some instances, face-to-face care is necessary in some instances to prevent people from taking their own lives. Referral on more than one instance with mental health concerns should be considered a ‘red flag’ requiring clinical review to avoid patients being sent to different mental health services without being seen by someone with mental health expertise. Using video as a tool for professional review should be considered and the thresholds for face-to-face consultations should be lowered to take into account the additional stress of the COVID-19 context.
People experiencing domestic violence need adequate safeguarding, this may include moving to a safe environment even in the context of COVID-19 restrictions. The issue of safety and care should not just be focused on the child(ren) but any person experiencing domestic violence.

Whilst the report provides guidance primarily directed at those providing clinical care, key takeaways can be taken from the above summary for those supporting families or clients who are pregnant or in their postpartum period.

Source MBRRACE Rapid Report 23 March 2021
https://www.npeu.ox.ac.uk/mbrrace-uk/reports#main

Written by Elizabeth Odunlami

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How I work it - Natalie Bouscarle

4/8/2021

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Name: Natalie Bouscarle
Business name: Your Doula

1. What services do you offer?
Birth doula support, Postnatal doula support, Overnight support and Mindful Birth Hypnobirthing

2. Where do your clients come from?
I tend to find a lot of my clients come from Instagram, in my DMs, or through my contact page on my website.

3. What works for you and what has been less successful?
Putting my prices up to a fee that I feel proud to work for has been a big success for me. I found that offering packages at discounted prices did not benefit me or my business, and I definitely learned that the hard way.

4. Has the way your run your business changed since we went into lockdown last year?
During the first lockdown I moved all my support to virtual support. I was very fortunate that the clients I had at the time were happy to accommodate this new way of working together. As the lockdown eased, I did move in to in person support again which was so nice to be able to do. During lockdown 3 when my children were then off school, I had to make the decision to move all postnatal clients to evening hours. My new working hours for January through to March were 5:00-10:00pm. I was really surprised at how well this worked and my clients seemed to really benefit from some evening support.

5. What do you wish you had known when you started out?
That clients are not phased or worried about you being “coached”. I soon gained confidence in the knowledge that it's far more about the connection you can form with potential clients than the previous experience you have.

6. What’s your biggest tip for new doulas?
Don’t wait until your website and social media is looking spotless before putting yourself out there. And have faith in the universe, the right clients will find you.

7. And doula-life hacks?
For me it was getting some jumpers with my logo printed on them. Having a “uniform” for my work has made a big difference to ruining less clothes with all the fluids that come from being a doula…. I also find it makes me look professional whilst still looking approachable.

8. What is next for you and your business?
I have recently trained with the wonderful Emiliana at The Mindful Birth Group to teach hypnobirthing courses. For me I love the idea of being able to incorporate this into my birth packages.

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Member Newsletter

UK Parliament Health and Social Care Committee Formal meeting (oral evidence session): Enquiry - Safety of maternity services in England

MBRRACE UK Rapid Report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK

How I work it - Natalie Bouscarle

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