Blog

  • Categories
  • Category Archives: Women

    The attached advice from the Faculty of Sexual and Reproductive Health provides details about the changes to provision of sexual and reproductive healthcare during COVID-19. It includes what type of care women can expect and how to get it – for example, how to get normal contraception prescriptions or treatment during the pandemic.  

    A link to the document is provided below, and a copy is also attached.

    FSRH has launched a comprehensive advice document for women seeking sexual and reproductive healthcare during the COVID-19 pandemic.

    The advice aims to inform and empower women to make the best choices for their sexual and reproductive health. It details the changes to provision of sexual and reproductive healthcare during COVID-19, including what type of care women can expect to access and how they can access it.

    FSRH – COVID advice-for-women-seeking-contraception-and-srh-during-covid-by-fsrh

    Leave a comment

    From Vivien Walsh in Manchester

    Right at the beginning of the lockdown, several of my friends said how concerned they were about the likely impact of enforced social isolation on those who are suffering from domestic abuse. On Monday, the (cross party) Home Affairs Committee of MPs, chaired by Yvette Cooper, reported on this, demanding “that the Government makes domestic violence and abuse a central pillar of the broader strategy to combat the Covid-19 epidemic.”

    Calls to domestic violence helplines, such as Refuge and Women’s Aid, were nearly 50% higher in the week 6-12 April than the average before the pandemic began. Visits to the website of Refuge were three times as high in March 2020 as they were in March 2019. The Home Affairs Committee called for this domestic violence strategy to combine “awareness, prevention, victim support, housing and a criminal justice response, backed by dedicated funding and ministerial leadership”.

    It also made a point of the need for specialist services for different ethnic communities, and for legal aid as an automatic right for women applying for Domestic Violence Protection Orders (DVPOs). An extension of the current time limit for reporting offences is also necessary, since many abused women will be unable to report the abuse they have suffered until after lockdown ends.

    Between March 23 and April 12 there were at least 16 killings of women and children in domestic situations, said the report on Monday. The average number of deaths from domestic violence during lockdown has gone up from 5 per week from a figure of two before. In a year that would be over 250 women killed by the person who is supposed to love them. The Parliamentary Committee had also received evidence that incidents reported were not only more frequent but involved higher levels of violence and coercive control.

    Unless the government takes action to deal effectively with domestic abuse and to properly support the victims of it, we will be facing “devastating consequences for a generation.” Funding is urgently needed to enable a growth in provision of housing for women and children escaping from violence, and to support refuges as temporary accommodation and support. Even before current emergency, England had 30% fewer than the recommended number of beds, and 64% of referrals were turned down in 2018-19.

    There is a National Domestic Violence Helpline (0808 200 247). This is the number to call for  emergency referrals as they are open 24/7. In addition there a variety of services based locally. For example Manchester Women’s Aid (call 0161 660 7999  9:30am-4:30pm Mon-Fri) provides confidential advice and information, safe temporary housing, one to one support for those living in their own homes, access to legal advice and civil orders, specialist workshops for young women 15-25, language workers and access to interpreters, specialist support for women with poor mental health and drug and alcohol misuse. The full list of services in England and Wales is at the end of the article.

    The lockdown is in place to keep people safe from the virus: but it is also providing cover for abusers. Escape from being locked in with an abuser is a matter of life and death. A decade of austerity has not only undermined our NHS, on which we are now so dependent, but has also decimated support for survivors of domestic violence. The Government must increase funding as a matter of urgency – and there will be just as much need for services as abused women and children try to return to “normal” life when the lockdown is over. And Children’s services also need a big increase in funding to make sure children as risk, not only from the mental and physical impact of domestic violence, have access to help and support.

    Amna Abdullatif (whose day job is Women’s Aid lead for Children and Young People, and who is also a Manchester City Councillor) added the following information for the SHA in this blog: “78% of survivors experiencing domestic abuse told us that Covid-19 has made it harder for them to leave their abuser. If you’re feeling trapped, we’re here for you.”

    “Our Live Chat is now open from 10am – 2pm with expert support workers just one click away. You can be reassured that our Live Chat is completely confidential. To access support and advice go to: https://bit.ly/2y7ab0Q

    “If you, or someone you know, is experiencing abuse please read our Covid-19 safety advice for survivors, family, friends and community members https://bit.ly/2yNzqoW

    There are also local services for ethnic groups, such as Saheli Asian Women’s Project in Manchester, which provides advice, information and support services to Asian women and their children fleeing domestic abuse and/or forced marriages.

    The full list of services from the Womens Aid web site is below:

    National Domestic Abuse Helpline

    The National Domestic Abuse Helpline is run by Refuge and offers free, confidential support 24 hours a day to victims and those who are worried about friends and loved ones.

    Telephone and TypeTalk: 0808 2000 247

    Wales Live Fear Free Helpline

    The Wales Live Fear Free Helpline offers help and advice about violence against women, domestic abuse and sexual violence.

    Telephone: 0808 8010 800

    TypeTalk: 18001 080 8801

    Text: 078600 77 333

    The Men’s Advice Line

    The Men’s Advice Line is a confidential helpline for male victims of domestic abuse and those supporting them.

    Telephone: 0808 801 0327

    Email: info@mensadviceline.org.uk

    Galop – for members of the LGBT+ community

    Galop runs the National LGBT+ domestic abuse helpline.

    Telephone: 0800 999 5428

    TypeTalk: 18001 020 7704 2040

    Email: help@galop.org.uk

    Women’s Aid

    Women’s Aid has a live chat service available Mondays to Fridays between 10am and 12pm as well as an online survivor’s forum. You can also find your local domestic abuse service on their website.

    The Survivor’s Handbook, created by Women’s Aid, provides information on housing, money, helping your children and your legal rights.

    Karma Nirvana

    Karma Nirvana runs a national honour-based abuse and forced marriage helpline. If you are unable to call or email, you can send a message securely on the website.

    Telephone: 0800 5999 247

    Email: support@karmanirvana.org.uk

    Hestia

    Hestia provides a free mobile app, Bright Sky, which provides support and information to anyone who may be in an abusive relationship or those concerned about someone they know.

    Chayn

    Chayn provides online help and resources in a number of languages about identifying manipulative situations and how friends can support those being abused.

    Imkaan

    Imkaan are a women’s organisation addressing violence against black and minority women and girls.

    Southall Black Sisters

    Southall Black Sisters offer advocacy and information to Asian and Afro-Caribbean women suffering abuse.

    Stay Safe East

    Stay Safe East provides advocacy and support services to disabled victims and survivors of abuse.

    Telephone: 020 8519 7241

    Text: 07587 134 122

    Email: enquiries@staysafe-east.org.uk

    SignHealth

    SignHealth provides domestic abuse service support for deaf people in British Sign Language (BSL).

    Telephone: 020 3947 2601

    Text/WhatsApp/Facetime: 07970 350366

    Email: da@signhealth.org.uk

    Shelter

    Shelter provide free confidential information, support and legal advice on all housing and homelessness issues including a webchat service.

    Sexual Assault Referral Centres

    Sexual Assault Referral Centres provide advice and support services to victims and survivors of sexual assault or abuse.

    Get help if you think you may be an abuser

    If you are concerned that you or someone you know may be an abuser, there is support available.

    Respect is an anonymous and confidential helpline for men and women who are harming their partners and families. The helpline also takes calls from partners or ex-partners, friends and relatives who are concerned about perpetrators. A webchat service is available Wednesdays, Thursdays and Fridays from 10am to 11am and from 3pm to 4pm.

    Telephone: 0808 802 4040

    Get help for children and young people

    NSPCC

    The NSPCC helpline is available for advice and support for anyone with concerns about a child.

    The NSPCC has issued guidance for spotting and reporting the signs of abuse.

    Telephone: 0808 800 5000

    Email: help@nspcc.org.uk

    If you are deaf or hard of hearing, you can contact the NSPCC via SignVideo using your webcam. SignVideo, using British Sign Language, is available on PC, Mac, iOS (iPhone/iPad) and Android smartphones (4.2 or above). This service is available Monday to Friday from 8am to 8pm and Saturdays from 8am to 1pm.

    Childline

    Childline provides help and support to children and young people.

    Telephone: 0800 1111

    Barnardo’s

    Barnardo’s provide support to families affected by domestic abuse.

    Family Lives

    Family Lives provide support through online forums.

    Support for employers

    Employers’ Initiative on Domestic Abuse

    The Employers’ Initiative on Domestic Abuse website provides resources to support employers including an employers’ toolkit.

    Support for professionals

    SafeLives provides guidance and support to professionals and those working in the domestic abuse sector, as well as additional advice for those at risk.

    Support a friend if they’re being abused

    If you’re worried a friend is being abused, let them know you’ve noticed something is wrong. Neighbours and community members can be a life-line for those living with domestic abuse. Look out for your neighbours, if someone reaches out to you there is advice on this page about how to respond. They might not be ready to talk, but try to find quiet times when they can talk if they choose to. If someone confides in you that they’re suffering domestic abuse:

    • listen, and take care not to blame them
    • acknowledge it takes strength to talk to someone about experiencing abuse
    • give them time to talk, but don’t push them to talk if they don’t want to
    • acknowledge they’re in a frightening and difficult situation
    • tell them nobody deserves to be threatened or beaten, despite what the abuser has said
    • support them as a friend – encourage them to express their feelings, and allow them to make their own decisions
    • don’t tell them to leave the relationship if they’re not ready – that’s their decision
    • ask if they have suffered physical harm – if so, offer to go with them to a hospital or GP
    • help them report the assault to the police if they choose to
    • be ready to provide information on organisations that offer help for people experiencing domestic abuse

    If you are worried that a friend, neighbour or loved one is a victim of domestic abuse then you can call the National Domestic Abuse Helpline for free and confidential advice, 24 hours a day on 0808 2000 247.

    Leave a comment

    Our response to Government guidance on COVID and self-isolation
    Our Senior Legal Officer, Katie Wood, has compiled initial guidance on COVID and pregnant women’s rights at work in light of the Government guidance. It covers health and safety, working from home, sick pay, maternity leave and pay, dismissal and redundancy. Please read and share the blog.We have written to the Chancellor of the Exchequer, the Rt Hon Rishi Sunak MP, about the Government guidance on social distancing and vulnerable adults, including pregnant women. The guidance to self-isolate has clear implications for the income of pregnant women in the workforce during their pregnancy and maternity leave, and for retention of their job. We urge ministers to make a clear public statement that the dismissal of a pregnant woman simply for self-isolating, in line with the Government’s advice, would amount to unlawful pregnancy discrimination. See our letter here and help us share it and demand immediate response from the Government.We are preparing a list of FAQs on COVID, maternity and employment rights. We shall release it as soon as it is ready. Please check our website for regular updates.

     

    Our advice lines are open
    We provide free legal advice on maternity and employment rights to pregnant women and new parents and will carry on throughout this crisis. Please note that receive a huge number of calls under normal circumstances, we are experiencing a spike at the moment. Please check our information sheets first, they cover a comprehensive range of questions.Our National Maternity Rights Advice Line is 0808 802 0029. It is open all weekdays from 10 am to 1 pm for all callers who live outside London.For London residents, please call our London Maternity Rights Advice Line 0808 802 0057, open all weekdays except Wednesdays from 10 am to 1 pm.For those with questions about NHS charging for maternity care, our Maternity Care Access Advice Service is 0808 800 0041, open Tuesdays, Wednesdays and Fridays 10 am to 12 noon.

    Please share this information with your networks and direct your contacts to the right advice line number. If you are unable to get through, please be patient. This is an unprecendented situation and we have limited capacity. We are doing our best and we shall deal with all the calls we can handle.

    Posted by Jean Smith on behalf of Maternity Action.

    Leave a comment

    Introduction

    This policy statement is intended to apply to all parts of the UK. The first 1000 days of life (from conception) are crucial for the long term health and wellbeing of families and society in general. The SHA wants adequate NHS, fully funded, woman-centred maternity care, for all women, potential parents, partners and their family/support networks (including all migrant women).  This care is from pre-conception to 6 weeks after birth and beyond.  This is because care needs to focus on long term outcomes as the evidence is that the environment in the uterus and after birth can be detrimental to individuals’ health throughout their lives. It needs to avoid the ‘business’ approach that concentrates on short term targets. To achieve this, the following is necessary:

    Overall principles

    1. To address maternal, paternal and child poverty in order to improve outcomes and to relieve stress related damage, good nutrition should be accessible to all, before, during and after pregnancy. To achieve this, public health measures, which make the healthy choice the easier choice, should be developed.
    2. The voices of women, potential parents and their support networks should be heard and listened to at all the stages of planning and evaluation of maternity services.
    3. There should be high quality physical and mental health care appropriate in a diverse society. There should be a proportionate universalist approach to give every child the best start in life. This includes migrant women and their babies.
    4. Pre-pregnancy care must be available to all to achieve the healthiest pregnancy possible. It should cover the very harmful factors in the wider and personal environment, such as tobacco, alcohol and substance misuse, air and industrial pollution, and domestic abuse, which can have devastating consequences on babies from conception and throughout their lives. Improvements are required to ensure the quality and consistency of health and safety in the workplace for pregnant women and potential fathers.
    5. Adequate time and funding for maternity leave, maternity pay, paternity leave and pay and parental leave should be available to all. Partners of pregnant women should have a legal right to take time off in the event of problems developing during the pregnancy.  Pregnant women and new mothers in education at the time of birth, and all those caring for young babies, must be supported to ensure that they are not denied educational opportunities.

    Specific stages of care

    1. Antenatal care and education should be accessible to women and potential parents (and their families) from all backgrounds and cultures. Those working should have the right to paid leave to attend. Such education can be provided one to one or within groups.  The groups can be women only or mixed or with special provision for marginalised groups as deemed appropriate in local areas.  Collaboration between midwives and health visitors (and others as appropriate) to facilitate this education is ideal.
    2. All parents should have access to parenting skills support, particularly to prevent and mitigate adverse childhood experiences. The roll out of the Flying Start scheme in Wales is a good development, in contrast with the huge cuts to Sure Start schemes in England.
    3. All care should aim for a safe, respectful and positive birth experience for all women. Women should have a fully resourced, real choice of place of birth (home, midwifery or obstetric unit) having been fully informed about how these will meet their individual medical and personal needs. To achieve this, home birth should be backed up when there is an emergency with adequate pre hospital care (provided by community-based midwives and paramedics specifically educated on maternity care).  Such pre hospital care should enable safe, timely and appropriate transfer to hospital obstetric and neonatal paediatric services.  Midwife–led units should be available to women, and hospital based care should respect and support women’s decisions.
    4. Continuity of care from midwives (and other relevant health care professionals) is crucial. All women should have a named midwife, who works as part of a community-based team of midwives, and who coordinates care with others, such as obstetricians, health visitors, GPs, physiotherapists, and dietitians, as necessary. Ideally there should be continuity of carer throughout the antenatal, intrapartum and postnatal periods. All women should have one to one care during established labour.
    5. Women and their partners, families/support networks should be supported emotionally and physically in the early days after birth. There needs to be adequate and realistic help with breast feeding, including midwifery, health visitor and peer support. Postnatal education and support should be available, via groups or on a one to one basis, ideally continuing educational provision stated during pregnancy.
    6. Community based mental health services need to be available to support women (collaborating with midwives, GPs and health visitors), as well as sufficient mother and baby inpatient psychiatric provision.
    7. There should be full funding of neonatal special and intensive (levels 2 and 3) care.

    Staffing

    1. More staff should be recruited to end the use of agency staff. This includes keeping staff from EU countries and making them very welcome. NHS staff should be actively supported and valued in order to relieve work-related stress and burnout and prevent attrition, so that in turn they are able to give the best quality care.  The culture of risk, fear and blame should be resolved.

    Research and education

    1. Funding for research into maternity care, preterm birth, still birth, neonatal and perinatal mortality and birth injuries should be increased.
    2. Investment is required in the education of healthcare professional students involved in maternity care. These students should receive non means tested NHS bursaries while being educated. Where appropriate there should be joint education between students such as midwives, paramedics, health visitors and doctors (potential future GPs, obstetricians and paediatricians) both before and after qualification. The latter should not have to be funded by the clinicians themselves.

    (References to back up the recommendations of this policy are available on request)

    Leave a comment

     

    Make the UK the safest place world to have a baby!

    Why is the UK still not in the top ten countries for infant mortality and for maternal deaths? Why? We are a rich country. We have an established high-quality health service. Healthcare is supposed to be accessible to all. How come babies and mothers die or are badly hurt at birth? How come Black and Ethnic minority babies suffer most? Why do poor areas have worse outcomes than wealthy areas? Why is infant mortality rising? (The infant mortality rate is the number of children that die under one year of age in a given year, per 1,000 live births. The neonatal mortality rate is the number of children that die under 28 days of age in a given year, per 1,000 live births. These are both common measures of health care quality, but they are also influenced by social, economic and environmental factors). Are there fundamental problems with core policy documents like the maternity review “Better births”? These are painful questions.

    Our campaign wants real improvements for mothers and babies. This posting is not intended as a clinical paper, it is a discussion amongst activists and concerned citizens about where the problems lie. A key set of participants in this discussion are mothers who have given birth, including those who have lost babies, grandmothers and other birth partners, and women who could not conceive.

    Our campaign published our Maternity Manifesto during the election but though well shared on Facebook, it did not get into any parties’ manifesto.

    We also called a national meeting on issues in maternity care.

    What then are the factors that result in UK outcomes at birth worse than other advanced countries?

    The answers include shortage of NHS funding, staffing shortages, poor management in some hospitals, staff in fear of speaking out, some policies and procedures, disrespect towards the women carrying the baby, and, as cited in the East Kent enquiry, a lack of practical understanding by staff and by mums of the need to “count the kicks” in the latter part of pregnancy. The introduction of charges for migrant women has also caused deaths. NHS material seems to centre the cause on mothers who smoke, or who are overweight. (Now smoking in pregnancy is plain stupid, it really is, and most mums would not do so if they were not addicted. Don’t do it!). However, other countries, Greece for example, who smoke more, have better outcomes in pregnancy than does the UK. Wider problems like obesity and diabetes, and even women giving birth older, are mentioned in the literature about this. Again, the age of the mother as a factor, but this is only partly true. Giving birth older is often safer than giving birth too young. Globally it is most often young girls who die in childbirth.

    Answers may lie in the financially and emotionally vulnerable place that pregnant women occupy in our society, including poverty, violence and stress. Poverty and inequality are factors in infant mortality; “The sustained and unprecedented rise in infant mortality in England from 2014 to 2017 was not experienced evenly across the population. In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100 000 live births per year (95% CI 6 to 42), relative to the previous trend. There was no significant change from the pre-existing trend in the most affluent local authorities. As a result, inequalities in infant mortality increased, with the gap between the most and the least deprived local authority areas widening by 52 deaths per 100 000 births (95% CI 36 to 68). Overall from 2014 to 2017, there were a total of 572 excess infant deaths (95% CI 200 to 944) compared with what would have been expected based on historical trends. We estimated that each 1% increase in child poverty was significantly associated with an extra 5.8 infant deaths per 100 000 live births (95% CI 2.4 to 9.2). The findings suggest that about a third of the increases in infant mortality between 2014 and 2017 can be attributed to rising child poverty (172 deaths, 95% CI 74 to 266).” (Our bold for emphasis).

    The UK is a rich advanced country, with a long history of universal healthcare but we have rising infant mortality. “Rising infant mortality is unusual in high-income countries, and international data show that infant mortality has continued to decline in most rich countries in recent years” and “In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100,000 live births per year, relative to the previous trend“.

    Poverty is not the sole cause of high Infant Mortality though, Cuba has good outcomes equal to the UK for infant mortality. Cuba is very poor indeed and the UK is one of the wealthiest economies (sadly Cuba does less well on maternal deaths).  

    Research shows out of 700,000 births a year in England and Wales, around 5,000 babies are stillborn or die before they are a month old”. 5,000 babies each year. There have been major news stories about baby deaths in many hospitals, notably in ShropshireEast Kent and Morecombe Bay.

    Maternal deaths. The UK is not in the top ten countries with the lowest infant mortality rate, neither is it the safest place to give birth. In 2015-17“209 women died during or up to six weeks after pregnancy, from causes associated with their pregnancy, among 2,280,451 women giving birth in the UK. 9.2 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy.” In 2016 The UK ranked 24th in the world in Save the Children’s Mothers’ Index and Country Ranking Norway, Finland, Iceland, Denmark, Sweden, Netherlands, Spain, Germany, Australia, Belgium, Austria, Italy, Switzerland, Singapore, Slovenia, Portugal, New Zealand, Israel, Greece, Canada, Luxembourg, Ireland, and France, all did better than the UK. The situation in some other countries is massively worse than here but that is no excuse. But these baby and mothers’ deaths must stop. We cannot sit back and let these deaths continue.

    Let’s be clear, the situation for women in pregnancy and childbirth is massively better than before the NHS, and is head and shoulders better than in the USA today. But maternal mortality is an issue here in the UK, and a huge issue in poorer countries, especially where women give birth without a trained professional being in attendance. Quite rightly professionals and campaigners in the UK participate in international endeavours to improve this situation. The NHS should be training and sending midwives to those countries, instead, it is recruiting midwives from poorer countries. In Europe we have cuts in healthcare through Austerity; in the global south, the same concept of cutting public services to the bone is called Restructuring.

    Why is the UK, a rich country with (almost) universal health care not doing better by its mothers and babies? Look at just this case and see the problems in the provision of maternity care;

    Archie Batten

    Archie Batten died on 1 September 2019, shortly after birth.

    When his mother called the hospital to say she was in labour, she was told the QEQM maternity unit was closed and she should drive herself to the trust’s other hospital, the William Harvey in Ashford, about 38 miles away.

    This was not feasible and midwives were sent to her home but struggled to deliver the baby and she was transferred by ambulance to QEQM where her son died. Archie’s inquest is scheduled for March. (BBC).

    We know that temporarily “closing” maternity units because they are full is a common occurrence. Women then have to go to a different hospital. Induction of labour can be halted because the unit is full. It is not a pleasant situation for mothers. Some maternity units have closed permanently, meaning mothers have to travel further for treatment, at a time when the ambulance service is under great strain (though being in labour is not considered an emergency for the ambulance service!).

    Shortage of Midwives and consequent overwork for the existing staff. The UK has a shortage of three thousand five hundred midwives. The midwife workforce is skewed towards older midwives who will retire soon.

    Gill Walton, general secretary and chief executive of the Royal College of Midwives said “We know trusts are facing huge pressures to save money demanded by the government, but this cannot be at the expense of safety. We remain 3,500 midwives short in England and if some maternity units regularly have to close their doors it suggests there is an underlying problem around capacity staffing levels.

    Training midwives is not just about recruiting new starters to university courses. There need to be sufficient training places in the Hospitals who are already working flat out, leaving little time for mentoring of students, as well as places in the Universities. Alison Edwards, senior lecturer in midwifery at Birmingham City University, who says: ‘It isn’t as simple as recruiting thousands more students as this requires the infrastructure to support it.

    ‘You need more tutors, more on-site resources and, perhaps more importantly, more mentors and capacity in placement areas – which is currently under immense strain.’ 

    One student midwife wrote about her experiences in this letter, where she described very hard work without either pay or good quality mentoring.

    The government and the NHS call for Continuity Care from Midwives. This means the same midwife or small team of midwives cares for the mother through her pregnancy, birth and postnatal period. We too believe this would be wonderful if it were possible. It is however impossible with the existing ratio of midwives to mothers. Providing continuity of care to the most vulnerable mothers is a good step. NICE have reduced this to the idea of each woman having a named midwife. One to One a private midwife company claimed to provide this but was unable to continue trading, and went bust leaving the NHS to pick up the pieces.

    Nationally the NHS is underfunded and looks set to continue so. Much of the problem comes from a long period of underfunding. We spend less than 9.8 per cent of GDP on health. Switzerland, Germany, France, Sweden, Japan, Canada, Denmark. Belgium Austria Norway and the Netherlands all spend more. That places the UK 13th in the list of high spenders on health care. The US spends 16.9 %. (although a lot of that money is diverted from patient care to the big corporations and insurance companies). The NHS was the most cost-efficient health care service in the world.

    Underfunding causes staff shortages. Some errors at birth come from staff being overworked and making mistakes.

    Some, our campaign believes, flow from fundamental flaws in government policy such as in the Maternity Review, where the pressure is on staff not to intervene in labour.

     Listen to the Mother. Some of the deaths are from women not being heeded in pregnancy and childbirth. This is backed up in reports from mothers, including some quoted in the big reviews mentioned above. However, overworked and tired staff who know labour like the back of their hand can easily stop heeding an inexperienced mother.

    Poverty kills mothers and babies. As we said above, some deaths, poor baby health, and injuries come from growing maternal poverty and ill-health. Low-income families find it hard to afford good food. Food poverty affects a staggering number of children. The charity UNICEF estimates that “2.5m British children, or 19%, now live in food-insecure households. This means that there are times when their family doesn’t have enough money to acquire enough food, or they cannot buy the full variety of foods needed for a healthy diet. In addition, 10% of these children are also classified as living in severe food insecurity (the European average is 4%) and as a result, are set to experience adverse health.”

    Studies show that;

    The Independent inquiry into inequalities in health (Acheson 1998) found that a child’s long term health was related to the nutrition and physique of his/her mother. Infants whose mothers were obese had a greater risk of subsequent coronary heart disease. Low birth weight (under 2500 g) was associated with increased risk of death in infancy and with increased risk of coronary heart disease, diabetes and hypertension in later life. Accordingly, the Inquiry recommended, ‘improving the health and nutrition of women of childbearing age and their children, with priority given to the elimination of food poverty and the reduction of obesity’. (NICE )

    A significant number of deaths of new mothers come from mental health issues that spiral out of control. Some of these will be newly developed conditions and some existing conditions made worse by pregnancy and childbirth. Mothers family and professionals must all be on the alert and intervene early. There are good ways to treat mental health in pregnancy.

    Reducing the social and economic stresses around pregnancy would also help reduce the deaths and suffering

    When Birth goes wrong it can be a dreadful experience for everyone involved. In most cases, the panic button brings in a well-drilled team of experts who can solve nearly every problem and do it calmly. At other times, it is dreadful, as described in the coverage of the birth and death of baby Harry Richford. Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital in Margate in 2017 but died a week later. https://www.bbc.co.uk/news/uk-england-kent-51097200

    Sands, the baby death charity explains that there are many causes of babies dying before birth. Crucially important is that mothers are heeded when they are concerned and that everyone Counts the Kicks

     

    Maternity is not the only area of the NHS that suffers. There have been serious mistakes in NHS planning including closing far too many beds. The NHS closed 17,000 beds and now is working beyond safe bed occupancy. There are 100,000 staff vacancies. Waiting times in A and E are dreadful, as are waiting times for cancer treatment. NHS managers and the Government have taken the NHS far from the Bevan model of healthcare (for history read this).

    Press coverage. How does the press cover the NHS, and baby deaths? There are very real problems in the NHS and maternity care but the coverage in the press of these problems seems to switch on and off in strange ways, often to suit Conservative Party political requirements. The NHS and the Government are masters of propaganda and news manipulation. The public needs to learn to judge the news and to look both for actual problems and look out for bullshit and manipulation. Why was news of the arrest of the nurse from the Countess of Chester hospital headlines on the 70th Anniversary of the NHS? Why was the news of the understaffing there not given similar nationwide publicity? Why have we heard little or nothing since?

    If the government can switch the blame to the professionals in the NHS (but not their mates the high admin of the NHS), then they seem to be happy to publicise the problems. In other cases, problems are swept under the carpet.

    Professionals expect to (and do) take responsibility for their own actions. Mistakes will be made. It is impossible to go through life without some mistakes. When we are dealing with life and death mistakes can be catastrophic, even where there is no ill intent.

    Malicious action is rare.   There are the terrible cases of serial murderer Harold Shipman, and the convicted surgeon Ian Paterson who falsely told women, they had breast cancer and operated on them unnecessarily. The hierarchical system in the NHS and the lack of regulation in private hospital, which was described as “dysfunctional at almost every level” allowed that harmWe have not found such a case in maternity.

    Unintentional bad practice, however, has also harmed babies. No one went to work intending to harm in the events publicised in the Morecombe Bay Enquiry into the deaths of 11 babies and one mother. It was said that “The prime responsibility for ensuring the safety of clinical services rests with the clinicians who provide them, and those associated with the unit failed to discharge this duty over a prolonged period. The prime responsibility for ensuring that they provide safe services and that the warning signs of departure from standards are picked up and acted upon lies with the Trust, the body statutorily responsible for those services.”

    The Enquiry described what happens like this “In the maternity services at Furness General Hospital, this ‘drift’ involved a particularly dangerous combination of declining clinical skills and knowledge, a drive to achieve normal childbirth ‘whatever the cost’ and a reckless approach to detecting and managing mothers and babies at higher risk.”

    The Furness General Hospital was pushing for Foundation Trust status at the time and was not exercising the necessary supervision.

    “Maternity care is almost unique amongst NHS services: the majority of those using it are not ill but going through a sequence of normal physiological changes that usually culminate in two healthy individuals. In consequence, the safety of maternity care depends crucially on maintaining vigilance for early warning of any departure from normality and on taking the right, timely action when it is detected. The corollary is that, if those standards are not met, it may be some time before one or more adverse events occur; given their relative scarcity in maternity care, it is vital that every such occurrence is examined to see why it happened.

    So, many factors come into play in such incidents of harm to mother and baby. Professionals too can be emotionally wrecked by tragedy.

    Huge personal and professional lessons can be learned from a detailed review of cases where mistakes are made. There is a whole literature about learning from mistakes. The worst such incidents are referred to as Never Events. This is just one article about such errors but there is a whole field of research devoted to it. Serious Mistake Reviews often happen at the end of shifts, and in the worst cases, may lead to long public enquiries.

    NHS as a research organisation One of the great virtues of the NHS is the research base it offers professionals. What happens in the NHS which covers 62 million people is studied, evaluated, and researched. This is invaluable to staff and above all to patients. Sadly this research is also of interest to big business especially to those who sell health insurance and to the big corporations who have their ‘snouts’ in the NHS ‘trough’. Research for the common good is clearly different from research to make money. We see that regularly in big pharma. Cheap effective medicines do not make money for the companies. Yet the government is giving away our medical data to companies to make a profit.

    There are also “errors” that happen when everyone is following accepted procedures and protocols; “untoward events, complications, and mishaps that resulted from acceptable diagnostic or therapeutic practice”. Procedures within the NHS can be robust and well researched, and problems still occur.

    https://www.mamaacademy.org.uk/news/mbrrace-saving-lives-improving-mothers-care-2019/

    Research matters. Only by studying outcomes can these errors be revealed. A classic example is the once customary practice of episiotomy, cutting a woman to prevent tears to the perineal skin in childbirth, which is now no longer used except in an emergency. Research both formal and informal changed that practice. As another example of such research, Liverpool Women’s hospital has been involved in research about the benefits of leaving the baby attached by the cord if they are born unwell. NHS staff and other health professionals, academics and pressure groups are working hard to improve outcomes for mothers and babies. Each mothers death is reviewed in the MBRRACE-UK report

    https://mamadoc.co.uk/the-maternal-mortality-report-we-should-all-learn-from/

    Never again. The tragedy of the death of a mother and or baby is felt by that whole extended family. Most families want to know it will never happen again. Cover-ups and lies mean it will happen again, so brutal honesty is needed.

     

    The aftermath of medical treatment or neglect which causes real harm is complex. Whether the outcome is death, life long impairment, or long term physical and mental health issues, these are very significant events for all concerned.

    Campaigners in Liverpool campaign for SEN funding to be returned. 2019

    If a baby is born with life-changing impairments, the baby is left facing catastrophic difficulties and the mother and family can face major heartbreak and hardship. The huge love we have for our kids (may it long continue), whatever their issues, does not prevent the financial, housing and employment issues families with disabled children face. Nor does it guarantee the best educational opportunities, SEN is being battered by cuts. but parents and teachers are fighting back.

     

    The cost of financial “compensation” from an injury to a newborn is huge because it is life long. The cost of this “compensation” used to be carried by the government but the system changed to make hospitals “buy” insurance from a government body which is set up like an insurance company. The cost to the hospital is charged on the basis or earlier claims, like car insurance. Obstetrics make the highest claims of any section of the NHS.

    Liverpool Women’s Hospital had a huge case (not about babies) some years ago, arising from a surgeon who left many women damaged after incontinence operations. Their total bill, over 5 years, according to the Echo, was £58.8 million. “The NHS trust has been forced to pay out £58.8m in the last five years for both recent and historic negligence cases.

    The limited work we do, as a campaign, in holding the hospital to account, leads us to believe lessons have been learned by the hospital. However, in every hospital, there are pressures which could lead to problems. These pressures include financial and organisational, problems of management ethos, and the potential for bullying, the distrust by the staff of their management, and disrespect for whistleblowers.

    The NHS has gone through years of reorganisation after reorganisation. In that time the financial and government pressure has been to complete the re-organisation, or face catastrophic consequences so very many hours of admin and senior doctor time has been wasted on this process. That time could have been focussing on saving babies.

    At STP and national level, there are other problems. The NHS is intensely political. There are deep structural problems. (We believe the NHS should return to the Bevan Model of health care)

    The NHS is not only deprived of adequate funding, but it has also been forced to implement many market-based changes, including the internal market, outsourcing and commissions of services to for-profit companies. These market-based structures are expensive.

    The NHS has also seen dire staff shortages resulting from stupid decisions like removing bursaries, not training enough doctors and the hostile environment to migrant staff.

    There are moral and financial issues in all cases of such errors. The hurt to the babies is our priority.

    Baby deaths and severe injury at birth have complex roots. Though what happens in the hospital is crucial, it is not just what happens in the hospitals that matter. The stress, poverty and anxiety many mothers endure during pregnancy do sometimes affect the outcomes for the child. Many women are still sacked for being pregnant but families can rarely cope with just one wage (do fight back against sacking pregnant women!). See Maternity Action for details. Both mums and midwives can call Maternity Action for advice.

    Low pay or the dreaded universal credit can make food heating and rent all too expensive. This can lead to food poverty. Women do not yet have real equal pay but mothers have the worst pay of all  Benefits are no longer allowed for a third child. even though most claimants are working. Whether parents are working or not, every child has a right to food and shelter, be they first or 10th child. The child gets no choice!

    Not every pregnant woman is in a stable caring relationship. Housing, especially private renting, becomes more difficult when women are pregnant. Who can forget the story of the homeless woman giving birth to twins in the street? Pregnancy is often the time when domestic violence is inflicted on a woman but it is the time when women are least able to walk away. Poverty kills babies too.

    Please join us in campaigning for better outcomes for all mothers and babies in the NHS and across the globe. We want this to start a discussion, so please send us your views. and information

     

    Leave a comment

    This article was first published by Simon Collins at HIV i-Base on 2 September 2019.

    On 2 September 2019, leading HIV charities including HIV i-Base and the UK-Community Advisory Board (UK-CAB), published an open letter to Rt Hon Amber Rudd MP in her capacity as Minister for Women and Equalities, calling for an urgent intervention to include sexual health in the upcoming Government Spending Round. [1]

    In England, the responsibility for sexual health was disastrously shifted from the NHS to local authorities, whose public health budgets have been cut in real terms by £700 million over the last five years.

    These cuts have directly reduced access to sexual health services, where many people are unable to routinely access treatment and testing due to limitations in allocation of daily appointments.

    Many of these cuts disproportionately affect lesbian, gay, bisexual and transgender (LGBT+) and black and minority ethnic (BAME) communities, and young people.

    A similar joint letter calling for increased funding for sexual health was also sent today by LGBT+ groups from the Labour, LibDeb and Conservative parties.

    Last year, a review of services in South London reported that 1 in 8 people with symptoms were being turned away from sexual health clinics. This included 40% who were under 25 years old and 6% who were under 18.

    References

    1. Green I et al. Urgent request to intervene: Funding for sexual health services. 2 September 2019.
      http://www.tht.org.uk
    2. Collins S. Almost 1 in 8 people with symptoms turned away from sexual health clinics in SE London: 40% are under 25 and 6% under 18 years old. HTB 01 May 2018.
      http://i-base.info/htb/33968

    Please see this Press Release from BASHH (British Association of Sexual Health and HIV) and BHIVA (British HIV Association) from October 2018: Government funding cuts leave sexual health and HIV care at ‘breaking point’

    Leave a comment

    Lesbian and bisexual women are at increased risk of being overweight or obese compared to heterosexual women, according to new research from the University of East Anglia and UCL.

    Gay men however are less likely to be overweight than their straight counterparts, and more at risk of being underweight.

    The study, published today in the Journal of Public Health, is the first to investigate the relationship between sexual orientation and body mass index (BMI) using population data in the UK.

    The findings support the argument that sexual identity should be considered as a social determinant of health.

    The research team pooled data from 12 UK national health surveys involving 93,429 participants and studied the relationship between sexual orientation and BMI.

    Lead researcher Dr Joanna Semlyen, from UEA’s Norwich Medical School, said: “We found that women who identify as lesbian or bisexual are at an increased risk of being overweight or obese, compared to heterosexual women. This is worrying because being overweight and obese are known risk factors for a number of conditions including coronary heart disease, stroke, cancer and early death.

    “Conversely, gay and bisexual men are more likely than heterosexual men to be underweight, and there is growing evidence that being underweight is linked to a range of health problems too, including excess deaths.

    “We also found that gay men are significantly less likely than straight men to be overweight or obese.

    “This study demonstrates that there is a relationship between sexual identity and BMI and that this link appears to be different for men and women.

    “There are a number of possible explanations for these findings. We know that sexual minority groups are more likely to be exposed to psychosocial stressors, which impacts on their mental health and their health behaviours such as smoking and alcohol use and which may influence their health behaviours such as diet or physical activity.

    “These stressors include homophobia and heterosexism, negative experiences that are experienced by the lesbian, bisexual and gay population as a result of their sexual orientation identity and are known to be linked to health.

    “Until 2008, sexual orientation wasn’t recorded in health surveys. This means that until recently it has not been possible to determine health inequalities affecting lesbian, gay and bisexual people.

    “Continued collection of data on sexual orientation identity within national health surveys allows us to measure the health of sexual minorities.

    “We hope that policy makers and clinicians will be able to use this fresh evidence to provide better healthcare and tailored advice and interventions for lesbian, gay and bisexual people. We need longitudinal research to understand the factors underlying the relationship between sexual orientation and BMI, and research to understand more about being underweight, especially in this population.”

    ‘Sexual orientation identity in relation to unhealthy body mass index (BMI): Individual participant data meta-analysis of 93,429 individuals from 12 UK health surveys’ is published in the Journal of Public Health on Thursday, February 21, 2019.

    EDITOR’S NOTES

    1/ For more information or to request an interview, please contact the UEA communications office on +44 (0)1603 593496 or email communications@uea.ac.uk.

    2/ The paper is available from the following dropbox link: https://www.dropbox.com/sh/fxypgrqt4niuh89/AAAOA0H8AStuNFGOZlW13OQMa?dl=0

    3/ The University of East Anglia (UEA) is a UK Top 15 university. Known for its world-leading research and outstanding student experience, it was awarded Gold in the Teaching Excellence Framework. UEA is a leading member of Norwich Research Park, one of Europe’s biggest concentrations of researchers in the fields of environment, health and plant science. www.uea.ac.uk

    4/ About UCL (University College London)

    UCL was founded in 1826. We were the first English university established after Oxford and Cambridge, the first to open up university education to those previously excluded from it, and the first to provide systematic teaching of law, architecture and medicine.

    We are among the world’s top universities, as reflected by performance in a range of international rankings and tables, and are committed to changing the world for the better.

    Our community of over 41,500 students from 150 countries and over 12,500 staff pursues academic excellence, breaks boundaries and makes a positive impact on real world problems.

    www.ucl.ac.uk | Follow us on Twitter @uclnews | Watch our YouTube channel YouTube.com/UCLTV

    Lead researcher Dr Joanna Semlyen is available for interview. We have Globelynx TV and ISDN radio facilities on campus. Let me know if you would like to set something up.

    Lisa Horton

    UEA communications office
    +44 (0)1603 592764 / l.horton@uea.ac.uk

    Leave a comment

    Chipping Barnet CLP notes that access to contraception is a fundamental human right underpinning equality, impacting on the health, structure and prosperity of both society and families. The 2012 Health and Social Care Act disadvantaged women, separating much of the funding for contraceptive care from the NHS by moving the responsibility for commissioning into Local Authorities, with NHS providers competing for contracts. As a result, the commissioning of contraception is now separate from the commissioning of other aspects of women’s health, including abortion. From both a woman’s and a clinical perspective, this is illogical. Compounding this, the impact of austerity on Local Authorities has led to a reduction in services, reduced access and to a postcode lottery for contraception in England.

    Chipping Barnet CLP believes that contraceptive services need to be fully funded and accessible in all areas of the UK, with co-operation replacing competition. It welcomes the commitment of the Shadow Health Department to abolish competitive tendering for these essential services, and to work with clinicians to establish centres of excellence alongside regular accessible clinics to which women have free and easy access to confidential care.

    Chipping Barnet CLP calls on the Labour Party to resolve to deliver fully funded contraceptive services in all areas of the UK, setting up a working group whilst still in opposition, composed of experienced clinicians and commissioners, to write a blueprint for delivery which will be implemented within the first year of the Labour Government.

    Published by Jean Hardiman Smith with the permission of Sarah Pillai ( Chipping Barnet CLP )

    Leave a comment

    I can’t recommend this film – which focuses mainly on older political activists campaigning for the NHS – too highly.
    (Statement of competing interests: I feature briefly in the film)

    Pensioners United

    Directors: Phil Maxwell, Hazuan Hashim

    Country: UK

    Running Time: 75′

    Year: 2018

    A potent account of a passionate group of pensioners who unite together to fight for a better life for themselves and those who will follow them. Starring Jeremy Corbyn, Harry Leslie Smith, the late Tony Benn, and thousands of inspirational pensioners from across the UK.
    ~ Allyson Pollock

    Leave a comment

    For everyone who couldn’t make the Conference, here is Alison Scouller’s ( Vice Chair ) speech. An audio file is also posted.

    Jean Hardiman Smith

    Hello Alison Scouller here, sorry I can’t be with you. These are my thoughts to accompany the SHA discussion document before you. We decided to write this policy as part of our wider policy work, as we had no statement of the SHA’s perspective on maternity care.
    I’m a retired midwife who worked in hospital, community and latterly as a midwifery lecturer in South Wales. To devise a policy I took inspiration from the Save Liverpool Women’s Hospital campaign’s manifesto for maternity and worked initially with two Welsh members, Billie Hunter, Professor of Midwifery and Gill Boden who is a campaigner for AIMS, and another Midwifery Professor Mavis Kirkham from Sheffield as well as liaising with our secretary Jean Hardiman Smith. Since then we have revised the policy considerably, following suggestions and contributions from Central Council members.
    We have taken on board the particular concerns of the Liverpool campaigners in the context of the creeping privatization of the English NHS, but in writing this policy we had to have a policy which is applicable across the UK. Therefore the first paragraph sets this out. .
    We decided that the right to access contraception and abortion that should form part of another document about reproductive rights, including fertility treatment, and that here we should focus on care for pregnancy.
    As you can see in point 1) we put the importance of addressing poverty centre stage, and the overarching importance of good nutrition from pre to post pregnancy, in fact throughout everyone’s life! We decided not to be too specific on particular public health measures, as our policy has to be applicable in different versions of the NHS and the wider context. We also included the issue of other forms of stress and their detrimental effect on pregnancy outcomes, both in terms of women and babies.
    The next 2 points emphasize the importance of those at the centre of maternity care needing to be listened to, whether it’s about their own individual situation or in terms of general observations about how care should be. Planning for care should of course reflect diversity in all communities. In order to address inequalities in society, whilst all should receive the same level of care, extra provision should be there for some, as was recognized by previous Labour Governments in projects such as Sure Start.
    We went on to identify issues related to specific stages in pregnancy itself, having covered the pre pregnancy period. In point 6) Antenatal care is clearly crucial to ensure that women are aware of as many aspects of their health as possible, such as family history, normal physiological changes of pregnancy, Body Mass Index , any pathological conditions already present or precipitated by pregnancy, and how these may impact on their pregnancy outcomes. It needs to be accessible as early in pregnancy as needed. It should be as local to women as possible and include at least one home visit, unless the woman does not wish for this, with her named midwife.
    When we talk about antenatal education this does not mean in a formal, school type environment but can range from physically meeting in a group setting with a midwife to having education available on CDs, online and via social media. It’s not just about being given information for example about how labour may progress but also learning practical skills to cope with it, such as exercise and relaxation. It’s also about what happens after the birth and coping strategies for parents. The social and support aspects of women and family members meeting with others going through a similar experience are usually the most valued by those enjoying group education. Of course specific needs have to be catered for, so that some women may prefer to attend women only groups and prefer less formal settings.
    The evidence for the effects of adverse childhood experiences on people’s ability to be good parents is now quite compelling, hence point 7)
    In relation to point 8) We know from research and experience that women’s wishes in relation to place of birth are determined by many factors, and these are very varied. Health care professionals must strive to provide as much evidence based information to enable women and their families to make the right choices for them. All places of birth carry some risks, with home birth and stand alone birth centres there are always concerns about access to ‘back up’ in emergencies. On the other hand there are risks associated with unnecessary intervention (mistimed, inappropriate and even dangerous) in childbirth, both in terms of mortality but also morbidity of mothers and babies I think Lesley page coined the phrase ‘too much too soon, too little too late’ to summarise the problems unfortunately still occurring. The other thing to bear in mind is the importance of antenatal care and education in ensuring safe outcomes. If that care is as it should be, then women at risk of complications are less likely to have poor outcomes because care will have been tailored to mitigate those complications.
    Moving on to point 9) we identify the importance of continuity of care. This can be difficult to achieve in cash strapped services but has been consistently shown in research and other feedback to be a key concern for women and promotes positive outcomes.
    Finally we put in relation to after birth, points 10) and 11). Physical, emotional and mental health are equally important here. Increasing breastfeeding rates would make a huge difference to children’s health, yet initiation and continuation of breastfeeding rates in the UK remain low. Once again peer support has been shown to be critical to breastfeeding success, as well as support from midwives and health visitors.
    In the past, care of women’s mental health has lacked coordination between midwives, health visitors, GPs and community mental health nurses. Equally where babies have been compromised by maternal complications before or during birth and/or being born preterm then neonatal special and intensive care cots should to be available as needed.

    Leave a comment

    For everyone who couldn’t make the Conference, here is Jessica’s speech to our Fringe meeting on the future of Women’s health that I referred to earlier in a members email.

    Jean Hardiman Smith

     

    Thank you for inviting me to speak to you today. My name is Jessica Ormerod. I run a research and information organisation called Public Matters with my lovely friend and colleague Deborah Harrington.
    Although we write about all aspects of the NHS and other public services, I have a particular interest in maternity. I have been writing about maternity issues for seven years since I was the chair of the maternity services liaison committee for Lewisham Hospital which coincided with our fight to save our maternity services. We won that fight but we have by no means won the war because as you know maternity services up and down the country are being closed and downgraded.
    But before anything else I want to paint the picture of what is happening to the NHS as a whole. Because every closed maternity ward, service or reduction in staff is the direct result of changes to the NHS that have been happening since the 2012 Health and Social Care Act. These changes are having a devastating impact on access to care. It is no exaggeration to say that we are witnessing the reversal of 70 years of universal, comprehensive and equitable care.
    The 2012 Health and Social Care Act put into place all the major elements for a step change in the privatisation of the NHS.

    A QUANGO called NHS England was formed as the Commissioner-in-Chief of the service, with over 200 subordinate local commissioning units. These commissioning units broke with the tradition of planning services, replacing it with buying in from public, private and voluntary sector providers. Areas of work are subdivided into contractable units and NHS public providers are obliged to compete. The loss of a contract means loss of income, which has a knock-on effect on the viability of the public sector, which is left with high cost acute care and a reduced income.

    In 2014 a new CEO was appointed to run the NHS in England. He created a new plan for the NHS, the Five Year Forward View and this was greeted by the establishment as a welcome antidote to what was seen as the fragmented mess left by the 2012 Act (this was only a mere 18 months on from it being enacted). But it’s important to recognize that far from being an accident, the Act achieved the fragmentation necessary for privatisation to be embedded at an organisational level, including many major health industry players taking key roles in the commissioning and policy-making process.

    At the heart of NHS England’s Five Year Forward View is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care are relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services.

    We could say the scope of this aspiration is far reaching or we could say it is pie in the sky. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service with much of the change becoming the responsibility of local authorities.

    The process of transforming the NHS in England, is based on close co-operation between successive politicians and Department of Health managers over many years with the US Health Maintenance Organisation or Accountable Care Organization principles of managed care. This process is continuing without any checks and balances of substance within the formal organisational structures of government. Politicians go to great lengths to deny both privatisation and US influence on the current changes.

    There is, however, a groundswell of resistance to the damage being done to the NHS and there is a lot of knowledge surrounding individual service contractions and closures, but little in the public domain about the overall programme of change. And that is what I am here to talk about today.

    The National Maternity Review, aka Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.
    44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems. Unlike the Integrated Care Organisations which are now under consultation, they have been put into place with very little fanfare or institutional opposition.
    As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England consistently refers to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.
    In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.
    But what makes maternity different from other services?
    Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.
    Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.
    Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP. They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.
    Currently women can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ – that’s a midwife-run facility on hospital grounds, or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services which is blood, air and surgeons. A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.
    Put this into the context that since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.
    Who is driving the changes to maternity?
    Surprise, surprise, Better Births panel includes private health providers and those private companies are working with government to re-write policy.
    Although most current providers are NHS hospitals, private providers are now being strongly encouraged. Local Maternity Systems set their own payment systems. This means that they can choose whether they pay via their geographical population or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.
    NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations – I don’t need tell you about this because you’re part of it! The sites were told to be bold and radical. Another incentive is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site.
    LMSs are encouraged to work alongside private providers in order to offer women a wider choice. As most women have previously been cared for by the NHS this simply means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this does actually reduce the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.
    Better Births tells us it is working on a new accreditation scheme for maternity providers. But in a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard.
    Private providers are required to have a contract with the NHS in order to receive payment via a Personal Care Budget. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will apparently encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. But it is decidedly unclear about how this can be achieved. The guidance talks about using Personal Care Budgets for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.
    Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.
    What does this all mean?
    Scale and pace have taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of this new policy.
    This is a top-down reorganisation of a national service with little to no consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.
    The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction!
    Clearly long gone are the years of epidemiological study, of public health planning, of consultation with experts.
    Better Births is based on consumer choice issues around personalised maternity care. There is a serious lack of evidence that this restructuring will give women the vital services they need. There are fewer services, obstetric departments are being stretched even further and technology is replacing face-to-face clinical care.

    On the other hand, it embeds private care and fee-for-service. And, most importantly of all this is not how a national public service works.

    2 Comments

    For those who were unable to attend Conference, here is Dr Coral Jones speaking at the conference.

    https://www.youtube.com/watch?v=q7oiIeuQfqk&feature=share

    Jean Hardiman Smith

    Leave a comment