Memorandum by the Royal College of Obstetricians
and Gynaecologists (MA4)
1. SUMMARY
The Royal College of Obstetricians and Gynaecologists
is the professional body for doctors in the UK who work in maternity
services. The majority of Consultant Obstetricians are members
of the College. Obstetricians work closely and in partnership
with midwives to provide maternity care. Maternity care is available
to all women in the UK but there is no doubt there are inequalities
in access to care: some women do not take advantage of the services
provided and others find it difficult to access the care or do
not find the services meet their needs.
A multidisciplinary approach within medical
specialties to manage medical problems such as diabetes is well-established
in most areas but the provision of care for disadvantaged groups
is less consistent or well-developed although there are examples
of good practice. It is imperative that maternity services evolve
to provide co-ordinated inter-agency and inter-professional care.
To achieve this at a local level it is necessary for health and
social services to work together with women and their families
to develop services that meet the needs of all women including
those from disadvantaged groups.
2. INTRODUCTION
2.1 The most recent report of the Confidential
Enquiries into Maternal Deaths in the United Kingdom1 (CEMD) provides
stark evidence of the inequalities in maternity care. Women from
the most disadvantaged groups of society were about 20 times more
likely to die than women in the highest two social classes. The
relatively higher maternal mortality rates in non-white ethnic
minorities and women from the travelling communities is highlighted
as well as the association with domestic violence and late booking
for antenatal care.
2.2 The report contains recommendations
relating to all the areas where it was concluded that there were
avoidable factors and where different organisation or management
could have changed the outcome. These recommendations cover Auditable
Standards and use of guidelines, the responsibilities of Health
Professionals including attitudes, training, education and Commissioning
for maternal health services focusing on the individual social,
physical and emotional needs of each woman. There is a specific
section on the management of women with psychiatric disease.
2.3 The College strongly endorses these
recommendations but would like to emphasise the importance of
the inter-agency and multi-professional approach that will be
necessary to improve care for the women disadvantaged because
of inequalities in care. The College hopes that Commissioners
and specifically Primary Care Trusts will appreciate the necessity
to provide resources to enable development of integrated social
and clinical networks for care as well as resources for training
and education of the health and social care staff and the voluntary
sector organisations.
2.4 It is disappointing that in spite of
the facts and recommendations published in the Confidential Enquiries
into Maternal Deaths in December 2001, the targets set for Strategic
Health Authorities and PCTs in the Priorities and Planning Framework
2003-062 included so little relevance to improving maternity care
and outcomes. The College is concerned that this may delay, through
lack of resources, any positive planning for change in service
provision.
3. CURRENT WORK
AND PRACTICE
3.1 The Emerging findings of the Children,
Young People and Maternity Services National Service Framework3
has recently been published. The College is reassured by the recognition
of the relevance of maternity care to the life and well-being
of children and the emphasis on improvement in quality of care
as well as the principles of partnership and planning to meet
local needs.
3.2 The Emerging findings document makes
it clear that the Maternity module is addressing the need for
all women including those with "Ethnicity, poverty or social
exclusion issues, eg prisoners, women with enduring mental health
problems, women with disabilities, and women from transient populations".
It is recognised that this will involve development of the workforce
skills and competencies but also require enhancing communication
and teamwork between healthcare professionals, social care professionals
and with women.
3.3 The College endorses these aims but
is concerned that effective implementation and change will only
be possible with appropriate and additional training and education
for health care and social care professionals and this has resource
and manpower implications.
3.4 The College is acutely aware of the
potential shortage of appropriately qualified and experienced
obstetricians to maintain the service let alone expand it but
perhaps even more important is the immediate crisis in midwifery
numbers and recruitment.
3.5 Changing Childbirth4, published in 1993,
addressed the issue of accessibility of care. It was recommended
that every District Health Authority should have a Maternity Services
Liaison Committee (MSLC) with lay representation reflecting the
ethnic, cultural and social mix of the local population. Users
were to be actively involved in the planning and evaluation of
services.
3.6 The NHS Executive published Good Practice
Guidelines5 for MSLCs in 1996 to further emphasise the role and
place of the MSLC. The College fully supports the concept of the
MSLC as a forum for lay and professional dialogue and planning
of appropriate local services but regrets the wide variation in
effectiveness of MSLCs. One problem that has been identified is
the difficulty in finding appropriate lay and user representatives
of the minority and disadvantaged groups.
3.7 Further recommendations in Changing
Childbirth were that regular monitoring of the uptake of services
should be carried out to identify those women not seeking care
or taking advantage of the services available so that a strategy
could be developed to make services readily available to these
women. Service specifications were to incorporate the needs of
women with disabilities so that they could have full access to
services and confidence that their needs were understood.
3.8 The College notes that had these recommendations
been implemented then it may not have been necessary to re-visit
the issues of access to care again now. The College would seek
reassurance that any recommendations made by the Select Committee
and endorsed by the government will be backed up by an implementation
plan as well as a toolkit for monitoring and auditing the change
and improvement in outcomes.
3.9 The College fully supports the concept
of the Maternity Service Liaison Committee and envisages an increasing
role of the MSLC in promoting and developing inter-agency and
inter-professional strategic planning and education. The College
would welcome a review of the membership and remit and of MSLCs.
We would see the MSLC as the forum to lead and advise on effective
health and social care for pregnant women and those with a new
addition to the family, in the local area. The College recognises
the importance of user, patient and public involvement and input
to planning and monitoring services. It will be important that
the MSLCs have adequate funding to carry out their remit effectively
and show measurable health gain.
4. TEENAGE PREGNANCY
AND SEXUAL
HEALTH
4.1 The sub-committee has listed various
disadvantaged groups but has not included teenage mothers. Any
discussion on inequalities in access would be incomplete without
consideration of the problems of teenagers and young mothers.
Although we realise that there has already been investment in
Teenage issues through, for example, the Teenage Pregnancy Unit,
members of the College are concerned that teenagers should not
be seen in isolation but as part of the main agenda for change
and improvement in services.
4.2 In 1997, nearly 90,000 teenage conceptions
occurred in England, resulting in 56,000 live births. Around 7,700
conceptions were to under 16s. The Social Exclusion Unit Report6
set out a strategy for tackling the high rate of teenage pregnancy
and the social exclusion of young parents.
4.3 The Modernisation of Maternity Care
(2002) 7 report emphasised that maternity care can help teenagers
to become confident and effective parents and help to reduce the
cycle of deprivation. One of the initiatives outlined in the Teenage
Pregnancy action plan was Sure-Start plus—personal support
for pregnant teenagers and teenage parents under 18. The College
understands that Sure-Start plus has been successful (eg in Hull)
and we would strongly support extending this in other areas.
4.4 The National Strategy for Sexual Health8
focuses, amongst other things, on inequalities in access to care.
Maternity care forms part of a continuum of sexual and reproductive
health care. Family planning and sexual health clinics give opportunities
for providing pre-pregnancy education and information to women.
Midwives and health visitors can provide contraception and family
planning advice. Staff working across disciplines and breaking
down the barriers of individual areas of expertise improve care
and continuity.
4.5 An example of a multi-agency team approach
to care is demonstrated in the Hull Sexual and Reproductive Health
Services where a doctor works in family planning, genito-urinary
medicine and the substance abuse service as well as providing
antenatal care for drug users. The multi-agency team has support
workers, social workers, midwives and health visitors providing
a holistic approach to care for women who find it difficult to
attend clinics. Obstetricians and consultants in Sexual and Reproductive
Health are keen to promote and develop multi-agency working to
improve the care of this group of disadvantaged patients.
4.6 Another disadvantaged group that should
be considered within the Maternity Services is patients with HIV.
The number of patients with HIV is higher in London than other
parts of the country but the issue is important because of providing
correct management when local experience is limited because numbers
of cases are low. The Sexual Health Strategy8 makes it clear that
there are considerable savings from each case of HIV prevented
but also addresses the problem of de-stigmatisation. All pregnant
women are offered HIV screening and appropriate backup and resources
must be available. The Sexual Health Strategy must not be considered
in isolation but in parallel with maternity service provision.
The importance of interagency and multi-professional co-ordination
cannot be over emphasised in the quest for better health outcomes.
5. SPECIFIC DISADVANTAGED
GROUPS
5.1 Those from minority ethnic groups, refugees
and asylum seekers and those who do not speak English as their
first language.
The underlying problem in providing equal and
accessible care to these groups is in understanding the cultural
differences and in communication. The groups provide examples
of the requirement for multi-professional education of carers
and identification of specific health and social carers to be
lead professionals and to use their added knowledge to act as
a resource for the whole team.
Interpreters must be available so that relatives
are not relied on for communication. Information leaflets in appropriate
languages should be available and educational videos may be useful
(Fife Acute Hospitals NHS Trust).
There are examples of special service provision
to meet the local needs of specific groups. There are special
clinics for African women with issues around female genital mutilation
(for example at the Whittington Hospital, London, Guys and St
Thomas' Hospital, London and the Central Middlesex Hospital).
In Wandsworth, where there is a population of asylum seekers,
refugees and second generation Asians, the open access family
planning service has direct access to midwifery services so patients
can easily flow between maternity and family to take advantage
of appropriate care.
5.2 Those who live in poverty, those who
are homeless and travellers.
Although maternity services are available for
these women the problem is making sure they access the services
early and then maintain contact. Systems must be in place to follow
up non-attenders and to provide user-friendly access with home
visit care if necessary as well as transfer systems when the patients
move areas (Fife Acute Hospitals NHS Trust).
5.2 Those who live under the threat of domestic
violence.
Women from all social and cultural groups suffer
domestic violence. Twelve per cent of the women whose deaths were
reported in the latest CEMD report1 admitted suffering domestic
violence and it is known to start or intensify in pregnancy.
Current knowledge on domestic violence was reported
by a study group of the Royal College of Obstetricians and Gynaecologists9
in 1997. The importance of education and a multi-disciplinary
approach to the detection and management of domestic violence
were emphasised but also the fact that robust research data are
lacking. It was noted that further research is necessary into
the prevalence and models of intervention.
The College has a particular concern that all
the professionals involved in detection and management of women
suffering through domestic violence must have a thorough understanding
of the sensitivity and importance of confidentiality.
The College is aware that work is being taken
forward by the North Bristol NHS Trust on domestic violence, including
identifying pregnant women who are affected and the training of
their staff to deal with the problem.
The College recognises the importance of training
obstetricians in recognition and management of domestic violence
and has included the topic in the recently revised Trainees Log
Book.
The Department of Health publication Domestic
Violence: A Resource Manual for Health Care Professionals in March
200010 gives advice for detection and management of domestic violence.
We are not sure how widely this manual has been used.
5.4 Those with severe mental health problems.
Maternal deaths associated with mental illness
are under-reported in CEMD1. When all deaths up to a year after
delivery are included, deaths from suicide are the main cause
of death overall. Services for women with perinatal mental ill
health have been considered in the plans for implementation of
the Mental Health National Service framework and outlined with
examples of good practice in the document Women's Mental health:
Into the Mainstream11.
The College supports the requirements for service
development and particularly endorses the need for a mental health
practitioner in each mental health service with an interest in
perinatal mental health to lead to improvement of local service
provision. The problems of mental health provide another example
of the case for effective co-ordination of inter-agency care.
Multi-professional education is paramount to improvement in outcomes.
5.5 Those with severe learning difficulties
Ensuring that people with severe learning difficulties
have equal rights to non-disabled people is a particular challenge.
The necessity for being proactive in providing sensitive help
and advice on sexual and reproductive health matters for this
group cannot be overemphasised, both to protect the women and
safeguard their children. Ideally pre-pregnancy advice should
be offered and these women should be involved in planning the
packages of care and support that will be necessary to enable
them to bring up a child. Individualised and yet transparent pathways
of care are required, as well as co-ordinated social and health
care.
5.6 Those with severe physical disabilities
This group of women covers a very wide range
of physical disabilities which they may have been born with or
have developed during their lives. As Obstetricians we are aware
that the women have usually come to terms with their disability
and know their limitations but also they know the barriers they
encounter in trying to lead as normal a life as possible.
Obstetricians and midwives are at a disadvantage
because they may only encounter women with a particular disability
infrequently and do not have the chance to become an expert in
management of the particular problem nor the resources to provide
optimum care. Many of the patients have contact with voluntary
sector organisations and self-help groups who can advise and anticipate
the problems that may be encountered and it is important that
the doctors and midwives take advantage of the help that is available.
The College would welcome the development of
networks and help-lines to provide a resource to help in planning
the care and anticipating the problems women with physical disabilities
will encounter. Each woman with a disability should have a lead
clinician (probably a midwife) to co-ordinate their care but this
lead person needs access to a network of expert contacts to aid
in planning and to meet the needs of the women and her family
during pregnancy, the birth and postnatally.
It may be appropriate for each tertiary centre
to appoint a midwife co-ordinator for women with disabilities
in the region, to act as a consultant and a resource for advice.
An example of good practice in this area is the appointment of
a Disability Advisor at Liverpool Women's Hospital NHS Trust.
6. SUMMARY AND
RECOMMENDATIONS FOR
ACTION
6.1 Multi-agency and multi-professional
co-ordinated care is an underlining theme to reduce the inequalities
and access to care in maternity services. (1.0)
6.2 Multi-professional and multi-agency
training in education is necessary to achieve co-ordinated maternity
services (2.3)
6.3 The RCOG would welcome the chance to
work with the RCM, the Department of Health and appropriate social
care agencies to develop multi-agency and multi-professional training
packages for dissemination and use at a local level. (2.3)
6.4 Commissioners and Primary Care Trusts
must recognise the time needed to enable staff to achieve appropriate
levels of professional development and training. Consultant obstetricians
require time within their job plans to both maintain and improve
their skills and competencies but also to train and assess doctors
in training. This time should be specifically recognised as fixed
sessions within the job plan. (2.3)
6.5 The crisis in midwifery recruitment
and retention must be addressed. The importance of workforce planning
both for midwives and for medical workforce cannot be overemphasised.
(3.4)
6.6 National guidance on provision of services
especially to reduce inequalities and access is overdue but must
be adaptable to local needs. (3.5)
6.7 Maternity Services Liaison Committees
are the appropriate forum for dialogue and interaction between
health and social care providers, patients and the public. Users
and the public must be involved in planning and evaluation of
local services. (3.6)
6.8 Commissioners must provide adequate
resources and funding for Maternity Services Liaison Committees.
(3.9)
6.9 Inequalities in maternity care should
not be taken in isolation but services should be developed in
parallel, and co-ordinated with all Sexual and Reproductive Health
Services as well as social care services. (4.4)
6.10 Communication is a priority for care.
Interpreters should be available to avoid the need to rely on
relatives. (5.1)
6.11 Information leaflets should be available
in appropriate languages for each group of patients but do not
replace the need for face to face contact for communication between
the carer and the patient. (5.1)
6.12 Robust systems for following up non-attenders
in clinics and to provide user friendly access must be in place
within every service. (5.2)
6.13 The need for a multi-disciplinary approach
for the detection and management of domestic violence is well
recognised but requires interagency and multi-professional education.
It has been recognised that further work is required on effective
interventions to improve outcomes and reduce domestic violence.
(5.2)
6.14 There should be a mental health practitioner
in each mental health service with an interest in perinatal mental
health to lead and co-ordinate care for women with severe mental
health problems. (5.4)
6.15 Co-ordinated care between social care
services and women's sexual and reproductive health services must
be co-ordinated in order to provide care packages appropriate
for women with learning difficulties and to pre-empt any difficulties
with support services. (5.5 and 5.6)
6.16 Women with severe physical disabilities
require specific care, support and planning, both for pregnancy
delivery and care of their baby and child. Individual health care
professionals may not have experience to know specific requirements
and we recommend that a disability advisor be appointed within
each region to set up networks for advice and care. (5.6)
7. REFERENCES1 Lewis
G, Drife J. Royal College of Obstetricians and Gynaecologists.
Why Mothers Die. Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom 1997-99. RCOG Press, 2001.
2 Department of Health. Improvement, Expansion
and Reform: The next Three Years. Priorities and Planning Framework
2003-06. London: Department of Health September 2002.
3 Department of Health. Getting the right
start: The National Service Framework for Children, Young People
and Maternity Services—Emerging findings. London: Department
of Health, April 2003.
4 Department of Health. Changing Childbirth
Part I: Report of the Expert Maternity Group. London HMSO,
1993.
5 Department of Health. Maternity Services
Liaison Committees, Guidelines for working effectively. London:
Department of Health, 1996.
6 Report by the Social Exclusion Unit. Teenage
Pregnancy. The Stationery Office Ltd, June 1999.
7 National Childbirth Trust, Royal College of
Midwives and Royal College of Obstetricians and Gynaecologists.
Modernisation of Maternity Care, a toolkit for Primary Care
Trusts in England. National Childbirth Trust, Royal College
of Midwives and Royal College of Obstetricians and Gynaecologists,
2002.
8 Department of Health. The national strategy
for sexual health and HIV. London: Department of Health, 2001.
9 Ed S Bewley, J Friend and G Mezey. Violence
Against Women. RCOG Press, 1997.
10 Department of Health. Domestic Violence:
A Resource Manual for Health Care Professionals. London: Department
of Health, March 2000.
11 Department of Health. Women's Mental health:
Into the Mainstream. Strategic Development of Mental Health Care
for Women. London: Department of Health, September 2002.
May 2003
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