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