Maternity strategy
agendaNi reviews the changes being made to maternity services, including a greater role for midwives and a renewed emphasis on public health.
Pregnant women are increasingly being referred to midwives – as opposed to GPs and consultants – as part of Northern Ireland’s new approach to improving maternity services. The Strategy for Maternity Care was published in July 2012 and runs up to 2018. It followed on from a consultation held between September 2011 and January 2012, and aims to achieve six outcomes:
• every baby and family being given the best start in life;
• effective communication and high- quality maternity care;
• healthier women at the start of pregnancy;
• effective, locally accessible antenatal care and a positive experience for prospective parents;
• safe labour and birth care with improved experiences for mothers and children; and
• appropriate advice and support for parents and children after birth.
Health Minister Edwin Poots wants to ensure more consistency in the quality of maternity care. In keeping with the Transforming Your Care proposals, a pregnant woman will initially be referred to a local midwife rather than a GP. Following a preliminary assessment, the midwife will help her to make informed decisions about her antenatal care and the place of birth.
Some women will require consultant-led care if complications develop. There should be a culture of “continual updating” whereby midwives and consultants are informed by the best research and can also ask researchers to look into issues which need more study.
Reducing the number of unnecessary caesarean sections is an important priority. In 2010-2011, 29.9 per cent of births in Northern Ireland were caesarean sections compared to 25-26 per cent in other parts of the British Isles.
The exact reason for this is not known but a section in one pregnancy can lead to more complications in later pregnancies. The proportion of assisted deliveries (13.5 per cent) was comparable to neighbouring countries but the proportion of normal deliveries (56.2 per cent) was below the norm of 61-62 per cent.
Objectives
Pregnancy, the strategy explains, is a normal physiological process but it is important that women are as healthy as possible before it begins as many pregnancies – up to a half – are unplanned.
Consistent public health messages will focus on the factors which are known to harm the health of mothers and their unborn children. The most significant causes of harm are grouped as follows:
• diabetes, obesity and poor nutrition;
• teenage pregnancy, smoking, alcohol and poverty; and
• gender-based violence, substance misuse and poor mental health.
Prospective parents will be given all relevant information about the pregnancy, including the risks and benefits of the available birth options.
At present, nine out of 10 births take place in consultant-led units.
Each consultant-led unit will be accompanied by a midwife-led unit, and more freestanding midwife-led units will also be considered. The most complex cases will still be referred to the Royal Maternity Hospital in Belfast.
The majority of antenatal care is currently provided by consultant obstetricians, which often involves unnecessary travel and long waits in hospitals. The strategy points out that there is “no persuasive evidence” that obstetric appointments are needed for healthy women. Instead, they can receive better support from midwives in the community.
Maternity assessment units provide careful clinical monitoring to women with certain conditions (e.g. diabetes) but the inappropriate use of these units has put “undue pressure” on other services. Again, this problem can be reduced by referring women directly to their local midwife.
Antenatal education is being updated to include more information about coping in early parenthood, breastfeeding and the importance of parent-child interaction for infant brain development. Many women only attend antenatal classes during their first pregnancy.
The Family Nurse Partnership programme is also being rolled out. This is an intensive programme for vulnerable, first-time young parents that begins in early pregnancy and ends when the child reaches two years of age. It aims to improve antenatal health, child development and parents’ economic self-sufficiency.
The programme currently has places for 300 teenage mothers in the Belfast, western and southern areas. The whole province should be covered by 2015.
Postnatal care
Most women return home within one or two days after birth. This is the best time to discuss the whole maternity experience and also to plan ahead for future pregnancies. A postnatal care plan will be agreed with the woman and updated as required. Every woman should also receive the ‘Birth to Five’ book.
Postnatal care will be provided by midwives and maternity support workers and will involve 10 or more days of home visiting.
A regional hand-held maternity record is designed to be used by all health professionals who will see the woman during her pregnancy. The board wants the record to be provided consistently across the region.
Maternity units are being benchmarked at a regional level and also against similar units in Britain and the Republic. The strategy’s implementation is being overseen by the Health and Social Care Board and the Public Health Agency.
The strategy was “widely welcomed by midwives in Northern Ireland,” Royal College of Midwives regional officer Breedagh Hughes told agendaNi. “It recognises that good health begins before birth and acknowledges the important role of the midwife in promoting healthy lifestyle choices for women at a time when they are particularly receptive to these messages.”
Hughes was pleased that the strategy also recognises women’s right to choose the type of care that they have and their place of birth. She also welcomed the appointment of a project manager to ensure its implementation.
Progress points
Asked to outline progress to date, the Health and Social Care Board pointed to an ongoing review of antenatal education programmes and existing smoking prevention programmes for pregnant women. The Public Health Agency is looking at what more can be done to help mothers who have drug or alcohol addictions.
All five health and social care trusts are implementing ‘normalising birth action plans’. A regional review of community maternity care has also commenced, with the aims of moving more antenatal care for women with straightforward pregnancies into the community and helping women to make early direct contact with a midwife.
Maternity units
Consultant-led and midwife-led units are located alongside each other at Altnagelvin, Craigavon and Ulster. Five hospitals have consultant-led units only: Antrim, Causeway, Daisy Hill (Newry), South West and the Royal Jubilee Maternity Hospital.
The South West Hospital has a room for women who are deemed appropriate for midwife-led care. Midwife-led units are due to be established at Antrim, Daisy Hill and the Royal Jubilee. Freestanding midwife-led units operate at the Downe, Lagan Valley and Mater hospitals.
