Examination of Witnesses (Questions 180-199)
Tuesday 20 May 2003
MS LESLEY
SPIRES, MS
MAGGIE ELLIOT,
MS DIANE
JONES AND
MS MY
DIEP
Q180 John Austin: We talked about
the problems of the mobility of asylum seekers, it is not just
minority ethnic groups who are mobile, particularly in many parts
of London we have large numbers of homeless people who are constantly
moving around, very many of them may be pregnant with young children.
We talked about the outreach work with minority ethnic communities,
which is in one sense easier because you can go to wherever people
might congregate, however with the homeless community how do you
do your outreach work? Can you support social services?
Ms Spires: It is a particular
problem with teenage pregnancy because they will be in one bed
and breakfast and then move to another one. The only reason we
are able to track them is because they do keep in contact with
their midwives. A lot of them if they do not have anything else
they have a mobile phone, they do not have much money but they
use text messaging. They do have that confidence in the midwife
and they keep in touch. We do have a lot of problems about going
across social services boundaries. If you need to be in contact
with social services then once a woman moves out of one area into
another that seems to break down. Unless the midwife is following
that woman through the other services do not seem to do that.
That is a problem. You are going to lose women if they move from
one place to another if they do not have the confidence to keep
in touch with the midwife or the services that they are getting.
Q181 John Austin: If the housing
department of one borough re-houses a woman in a neighbouring
borough or much further away is there any mechanism by which information
is transferred to the relevant agencies about that? Should there
be?
Ms Spires: There should be.
Ms Jones: One thing is that women
carrying their own records help. If a woman has her maternity
records and she goes and seeks care in another borough she will
more than likely bring her notes with her so the midwife can see
what trust she comes from in the first place. It is very difficult
and dependent on the woman carrying her notes and showing them
to the midwife to let her know she has had care in this area.
That is one of the questions we ask if we meet a woman late in
her pregnancy, we would ask her: "Have you had any care in
any borough within the UK or do you have any records we can look
at?" So rather than duplicating information it is looking
at what is already recorded.
Q182 John Austin: For many of these
women—and this is not a judgmental statement—their
lives are very chaotic, we all see them in our surgeries, so to
actually maintain documentation can be difficult.
Ms Roth: I am not up to date with
the most recent research, certainly the studies that I know that
have been done about people carrying their own notes report it
is generally an extremely efficient way of keeping hold of it,
the loss rate is much, much lower than when it is kept in a hospital.
It may well be that for some women it does not go with them but
generally it has had a very good record in consistency and women
are very responsible, they usually care about those records.
Ms Spires: I think what it does
not address is those women who do not attend. If they attend with
their notes that is fine but if they do not you might lose them
in the system and then they have missed out on lots of ante-natal
care and maybe when they turn up for delivery it could be a child
protection issue. There are children on child protection orders
and their family will move from one place to another and we do
try and keep track of them, we send notices out round the country
to other maternity units. It is an issue if we do not know what
is happening with social services. If they do not access the care
it can be problematic.
Mrs Elliott: What would be fantastic
is if we could provide a one-to-one midwifery service for women
because in those circumstances the midwife could give the care
in another borough and that would just be brilliant. That is a
long-term aim.
Q183 John Austin: That has resource
implications.
Mrs Elliott: Absolutely.
Q184 Julia Drown: At the moment there
would be no circumstances where you would do that?
Mrs Elliott: Unfortunately we
cannot because it is two community areas and there are all sorts
of implications with honouring contracts with trusts, all sorts
of things, so it is very hard to achieve that. We have looked
at it and it would be fantastic, particularly for these extremely
disadvantaged women that would be the right way to go.
Q185 Julia Drown: Can I just pick
up on an issue on the income front, that is we have been approached
by people who have had their babies but the baby has gone in to
a special care baby unit—it might not be such an issue in
London but elsewhere where they have to travel a long way—and
the expense of visiting being a problem. People on income support
can get some help towards visiting costs, is that something that
you have experienced or have concerns over?
Mrs Elliott: We have, yes. Some
parents have babies in the neo-natal unit and they have to pay
the same charge as everybody else for car-parking. Yes, it is
very, very difficult.
Q186 Julia Drown: People on income
support would get no help with car-parking charges. There are
all sorts of issues there.
Mrs Elliott: Certainly there are
neonatal networks consultations going on at the moment.
Q187 John Austin: I was going to
come on to the travelling community, a greater proportion of travelling
communities are more static than before, since the Caravan Sites
Act. It has always been an area of access to services, do you
have any particular experience in the travelling community?
Mrs Elliott: Lesley has been very
successful in starting to set up a one-to-one midwifery service
specifically for that group. It is a very, very good way forward
because you can really keep tabs on those people, provided they
do not move out of the area, because they are a high risk group.
Ms Spires: Midwives have built
up a relationship with the travelling group. We have a big permanent
site near us, although they do move in and out of the site. It
takes time for them to accept any health professionals into their
community but once you have got passed that barrier in a way it
is easy after that because the midwives go in there and it is
more of social event, people come to say hello to them. I think
it is an achievable aim to go and address the issue of the travelling
community, particularly one of the worst ones of poor attendance.
If you are providing care in the community you have one hundred
per cent attendance rate and that is what we have with this scheme.
That is very achievable.
Mrs Elliott: It is extraordinary.
Ms Jones: I think it is really
good where you can offer that one-to-one service and only a midwife
can do the midwifery aspects of the job. In an area like Newham
we have a chronic shortage of midwives and it is very, very difficult
to reach out to these vulnerable groups because what we are hearing
is if you give one-to-one support you are able to achieve a lot
with these women. Where you cannot we are currently putting on
a skeleton service and we are trying to provide for these vulnerable
groups, and we have many within our area, but the resources are
just not there. We have to look at so many dynamics, other ways
of employing other people other than midwives to do certain aspects
of it. When it comes to maternity care it is midwives that you
need and that is one of the difficulties, we are struggling to
actually meet the needs of our population.
Q188 Julia Drown: Mrs Elliott, in
particular you have mentioned domestic violence on a few occasions
and obviously it is a huge concern in maternity services, in particular
because it seems to be a provocation to start with.
Mrs Elliott: It is one of the
highest causes of maternal death so it is a huge concern.
Q189 Julia Drown: Are there particular
aspects of best practice that you feel we should be recommending
as a Committee or other things that the Government should be doing?
Mrs Elliott: It is about relevant
support and training for midwives to recognise when this happens
and also for them to know what to do because it is really, really
not something that is easy to deal with. You are not going to
get somebody that is subject to domestic violence on the Maternity
Services Liaison Committee. It is about how you support the midwives,
and giving them the right support, advice and education in order
to give that.
Ms Roth: There is another point,
the evidence base for how best to respond and what best to offer
them is very poor at the moment. There was a review published
some months ago, there is no way of demonstrating the long-term
benefit of that kind of intervention and I think that is something
that really needs to be looked at. The other thing is I think
we need to acknowledge that the social problems faced by woman
do not divide themselves according to groups. The Somalian woman
who is on your group or whatever woman might well also be someone
who is facing domestic violence, that needs to be acknowledged,
that it is not exclusive to one particular group or another.
Q190 Julia Drown: Are you concerned
that the more it gets addressed as an issue the more it gets picked
up by the general public and that might stop people coming forward
to access maternity services? Is there a way round that, ie partners
may try and stop them accessing maternity services?
Mrs Elliott: That is a huge possibility,
yes.
Q191 Julia Drown: It is not something
that you are experiencing so much?
Mrs Elliott: Not at the moment,
no. I do not know. It has not been brought to our attention, we
do not know if that is happening or not.
Ms Jones: In our experience we
are asking women about issues round abuse, only if they are on
their own. When I have a new case I ask women these questions
and they are not offended by it, they are actually quite glad
that somebody is asking those questions. It is just a forum for
them to speak about what is happening in their lives. They may
not want to do anything about it but the fact that somebody has
listened to them in a non-judgmental way shows women, the few
I have had contact with, it is beneficial.
Ms Roth: To bring in the language
issue, it is one of the unidentified areas that are experienced
by women who have to rely on relatives for their communication.
It certainly inhibits being able to have that conversation in
that space. It is certainly one of the things that advocacy has
attempted to address to give women the space that belongs to them
and is not intruded on by somebody else in the family.
Ms Diep: We have to support women.
I have my own client and I have been seeing her for a long, long
time. Her husband is violent towards her. Her husband has another
wife but he still stays with her. The husband beat her very badly
but there is no report from the GP to say she has been hit by
her husband and one week later the baby died, she had a stillborn
baby at only 16 weeks pregnant. I tried to encourage her to report
it to the police and tell the doctor but she said: "The baby
is dead, what do I, I have no more support. Yes, the hospital
supports me but outside who will support me and maybe my husband
will beat me again and then who will help me". She will not
report it. Most Chinese or Vietnamese never report to Victim Support
or the police, or anyone.
Q192 Julia Drown: Is that because
you would not able to refer them on?
Ms Diep: Because they do not have
other people speaking the same language it is very difficult for
them.
Q193 Julia Drown: There is a need
for the question of domestic violence to fit in with the wider
strategy about what you do if somebody needs support.
Ms Spires: Disclosure is one thing
but it is what you do about it.
Q194 Sandra Gidley: I want to start
by talking about pregnant women with severe mental health problems
during pregnancy, they obviously need specialist help but what
role is there for midwifery and obstetric staff in helping such
women access the range of services available?
Mrs Elliott: It is a huge role.
It has been identified as an area for maternal death, so it is
a big problem. Once again we are looking at, and I keep saying
it, setting up a case load practice group for these women because
if they have that support then hopefully we will be able to resolve
some of their issues. Having the same midwife looking after them
must help that situation.
Ms Spires: The midwives in these
circumstance need support from the mental health team. Unless
the midwife has mental health training it is not easy to support
a woman through the whole of the pregnancy. We are fortunate in
that we can access the mental health team within our trust but
it has to be recognised it is not an easy role for the midwife.
Q195 Sandra Gidley: A lot of the
mental health trusts are separate these days.
Mrs Elliott: There are issues
about midwives and obstetricians accessing mental health.
Ms Roth: There is probably a role
here for community mental health workers. It is an area that needs
to be actually investigated and there needs to be intervention.
It is a little like domestic violence. At the moment we do not
know what midwives are doing with respect to the social and mental
health needs of women, we do not know what they ought to be doing.
There is a little bit of a gap in the literature, it is an area
that needs collaboration between the two areas of care to devise
responses that would support in the right way.
Mrs Elliott: There are not clear
guidelines at all about how you deal with those women.
Ms Spires: There are mental health
teams within hospitals and there are community mental health teams
and I do not think there is always a transition between the two
and the midwife can be caught in the middle. Our trust is talking
about perinatal health services, but I am sure that is not happening
in every trust, that is passing from the hospital setting to the
community setting, and that is so important for a new mother.
Q196 Sandra Gidley: It is probably
slightly beyond your area of responsibility but I wonder if you
would like to use this opportunity to comment on post-natal depression,
particularly severe cases? Are we doing enough with women who
suffer? Are there enough facilities and understanding available?
In my area they are booked into the Priory.
Ms Jones: Within our mental health
trust they do not recognise post-natal depression as a mental
health problem. We have a lot of difficulty doing an assessment
of these women in the first instance. We need to address that
problem. We contact them saying: "We need your support"
but unless the woman displays bizarre behaviour which warrants
them admitting her to a mental health hospital there are issues.
We are trying to troubleshoot to prevent this. Most mental health
teams do not recognise post-natal depression at all. What happens
is if a woman displays some bizarre behaviour she cannot go to
the mother and baby unit, so she is separated from the baby and
admitted to a mental health hospital, which is going to exacerbate
her problem because she is not with the baby. Those are the problems
that we are dealing with at the moment. We are trying to come
to some agreement with our mental health trusts as to how best
to address these situations.
Q197 Dr Taylor: That is another recommendation
you want out of us.
Ms Jones: In all of these issues
that we are talking about we need to have better liaison with
the other departments and other professionals to address these
issues, because it is on the increase.
Q198 Sandra Gidley: Moving on to
disability groups generally, not just mental health problems,
there are a lot of voluntary organisations which give a lot of
help, advice and support do you think that maternity services
make the best from most of those resources, are they welcomed
or regarded as a hindrance?
Mrs Elliott: It depends on the
individual service. I have worked for lots of services as a junior
and senior midwife and some services will embrace them and others
do not.
Q199 Sandra Gidley: Can you give
us an example of how it works particularly well and how it has
worked badly, without naming voluntary organisations?
Mrs Elliott: I can. Some units
will use SANDS incredibly well and some do not.
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