House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by the Royal College of Midwives (MA7)

1.1 The Royal College of Midwives (RCM) represents over 95% of the UK's practising midwives, and has over 35,000 members. It is the world's oldest and largest midwifery organisation. It works to advance the interests of midwives and the midwifery profession and, by doing so, enhances the well-being of women, babies and families.

1.2 This is the RCM's submission to the sub-committee's inquiry into inequalities in access to maternity services. As requested in the Terms of Reference, this submission concentrates on the areas stated below, and at the end this submission addresses the issue of Maternity Service Liaison Committees.

— those from minority ethnic groups;

— refugees and asylum seekers;

— those who do not speak English as their first language;

— those who live in poverty;

— those who are homeless;

— those who live under threat of domestic violence;

— travellers;

— those with severe mental health problems;

— those with severe learning disabilities;

— those with severe physical disabilities;

II. THOSE FROM MINORITY ETHNIC GROUPS

2.1 The latest Census found that the minority ethnic population of the United Kingdom in 2001 was over 4.6 million (or 7.9% of the total population)[1]. The recorded size of the UK's minority ethnic population increased by 53% between the 1991 and 2001 Censuses, and therefore how public services are both accessed and used by these groups is an increasingly important consideration for policymakers.

2.2 It has now been nine years since the Commission for Racial Equality (CRE) launched the Race Relations Code of Practice in Maternity Services[2]. This document explains how the Race Relations Act 1976 applies to maternity services, offers guidance on how to eliminate racial discrimination from the provision of services, and provides examples of good practice. Evidence suggests, however, that levels of awareness and understanding of the needs of minority ethnic groups within maternity services continues to prove unsatisfactory[3]. A 1998 nationwide survey by the Maternity Alliance (MA) and the CRE, for example, found that a quarter of units had no formal consultation procedure including minority ethnic groups.

2.3 Resources are a barrier to progress, but other factors are also relevant, including: institutionalised racism; the fact that the experience of older midwives from minority ethnic groups has deterred younger generations from joining the NHS, which is further suggested by an ageing profile of those non-medical staff who are non-white[4]; complacency in areas with a relatively small local ethnic minority population; and a reluctance to address issues relating to minority ethnic groups because of the perceived sensitivity of the issue and the scale of the effort required[5].

2.4 But regardless of any barriers to progress, midwives have a professional responsibility to provide care to women—all women, regardless of ethnic origin—that is of the highest quality. So ensuring that maternity services work for women from minority ethnic groups is the work of every midwife and of everyone involved in delivering maternity services.

2.5 The RCM believes that to deliver this high quality care to women from minority ethnic groups, equality needs to be mainstreamed into the organisation and delivery of maternity services. The nuts and bolts of how this mainstreaming can be achieved is too detailed a programme to explore in this submission, but essentially it means embedding a culture respectful of diversity and intolerant of discrimination that is structured around the needs of local minority ethnic groups and ensures that these groups are engaged in any change. The RCM is currently involved in drawing up a resource guide for midwives for making maternity services work for women from minority ethnic groups.

2.6 The midwifery profession should also broadly reflect the local population.

III. REFUGEES AND ASYLUM SEEKERS

3.1 Although the UK is home to only around 2% of the world's refugees and asylum seekers[6], 110,700 people still sought asylum in the UK during 2002[7]. This statistic inevitably includes pregnant women and women who will become pregnant during their time in the UK. Given that all refugees and asylum seekers are entitled to use NHS services, this has implications for maternity services.

3.2 There are particular challenges in planning the provision of public services to refugees and asylum seekers. Far from being an homogenous group, they are highly diverse: the main countries of origin for those seeking asylum in the UK during 2002 were located in regions of the world as different as the Middle East (Iraq), Africa (Zimbabwe and Somalia), central Asia (Afghanistan) and east Asia (China). The pattern shifts constantly depending upon changing events across the globe and within individual countries. Also asylum seekers are likely to arrive without a support network of friends or family, and without any means to support themselves. Furthermore, given a genuine asylum seeker's need to flee persecution, they may not have planned to come specifically to the UK and so may well arrive unable to communicate in English.

3.3 The most recent study of pregnant asylum seekers' experiences of maternity services in England was "Mothers in Exile", published by the MA in March 2002[8]. The key finding of the study was that: "Asylum seekers and their babies survived in a support system that fell far short of meeting their most basic needs for adequate food and safe shelter. Already lonely, disorientated and grieving, half of the women also experienced neglect, disrespect and racism from the maternity services."

3.4 The RCM endorses the study's overarching recommendation that: "All agencies in contact with asylum-seeking pregnant women, new mothers and babies should recognise and meet their social, psychological and physical needs. The new support system should provide specifically for the needs of pregnant asylum seekers, new mothers and their babies." Indeed in order to put this into practice, the RCM is currently developing a framework to help midwives provide appropriate maternity services to refugees and asylum seekers.

IV. THOSE WHO DO NOT SPEAK ENGLISH AS THEIR FIRST LANGUAGE

4.1 Women for whom English is not their first language, and especially those who speak little or no English, face particular challenges when using maternity services. They find it hard to understand information, to give their informed consent, to express their needs and opinions, and to make choices about their care.

4.2 The 1998 nationwide survey by the MA and the CRE, referred to in paragraph 2.2, found that these challenges are not being met by maternity services as currently configured. The survey found that over one-fifth of maternity units provided information only in English, and two out of every five units relied on friends and families to interpret, even when consent was at issue for matters as serious as an invasive procedure.

4.3 It is highly undesirable to use informal interpreters—friends and family, possibly including children—as found by the survey in two out of every five maternity units. Obviously informal interpreters may not be able fully to interpret what a woman wants to say to a midwife or obstetrician, and vice versa, and this has the potential adversely to affect the care received. Moreover, a woman has little opportunity to enjoy confidentiality if a family member is acting as an interpreter.

4.4 But even for a woman who may speak at least some English, the inflection, grammar, accent or vocabulary she may use can differ widely. Equating speaking loudly with aggression, for example, can be misunderstood.

4.5 The RCM believes that resources should be in place for maternity units to call upon the services either of in-house interpreters or, in the case of languages not often required, of professional outside interpretation services. Maternity care staff should be trained in how to work with the assistance of an interpreter and in how to communicate with women with limited English. Where local need makes it feasible, an advocacy service should be available to women.

4.6 Furthermore, written material should be available in languages that reflect the linguistic needs of the local population, and this should address issues of access so that material is available in Braille and in audio. Such material is cost effective to produce.

4.7 As argued by the Disability Rights Commission, this approach should also include interpretation when necessary in British Sign Language.

4.8 Bradford Hospitals NHS Trust offers an example of how this can work well. In the city, women whose first language is not English are offered the services of a Bilingual Health Support Worker. Since the late 1980s, these individuals have supported women throughout the pregnancies and during the postnatal period, including promoting breastfeeding[9]. Maternity units, especially those in areas with a large local minority ethnic population such as Bradford, should provide this kind of service as a matter of routine.

V. THOSE WHO LIVE IN POVERTY

5.1 Women living in poverty have poorer health outcomes than others. Babies born to women in manual social classes are one and a third times more likely to be born with a low birthweight than babies born to women in non-manual social classes. And the vast majority of births to girls conceiving before their sixteenth birthday are concentrated in the manual social classes[10]. Children born into poor families will also suffer from a higher infant mortality rate and generally have poorer health. When they grow older, they are less likely to stay on in education and will obtain fewer qualifications. As they grow older still, the employment they obtain will be lower paid, they will experience more unemployment than other people and will eventually die at a younger age than other people[11]. For these reasons, it is very important for maternity services to offer the best possible care to women who live in poverty.

5.2 Maternity services for women who live in poverty need to be flexible as such women may have employment that is inflexible in terms of time commitment or may have children already and depend upon friends or family for childcare, which may be available only at certain times or on certain days. This is important, for example, in the frequency of antenatal classes.

5.3 Well-resourced and effective maternity services can maximise a baby's chances in life and ensure that each baby has the best possible start. That cannot occur whilst there are shortages of maternity care staff, for example.

5.4 The issues relating to women who live in poverty are not necessarily however about how maternity services can adapt to them. The problems lie beyond the maternity unit and helping to give the children of women who live in poverty a better start in life must be about the wider anti-poverty agenda and helping the financial circumstances of the mother.

VI. THOSE WHO ARE HOMELESS

6.1 Between July and September 2002, 33,640 households approached their local authorities and were accepted as homeless through no fault of their own and had a priority need for help. Of these households, 64% were families either with children or which contained a pregnant woman. (ref. needed)

6.2 This figure—33,640—had risen 10% on the previous quarter, and a majority of this rise was comprised of families either with children or which contained a pregnant woman. Another increasing category was people with physical or mental health problems.

6.3 Those from minority ethnic groups were over-represented among those accepted as homeless. Of the 33,640 households accepted as such between July and September last year, for example, 8,000 were from minority ethnic groups (24%, compared to less than 8% of the UK population).

6.4 Pregnant women who are homeless face many problems that are linked to their desperate situation. Many homeless people are placed in temporary accommodation while they wait for more permanent housing. Such temporary accommodation can be overcrowded, in a poor state with problems such as damp and condensation or with inadequate heating, and lack facilities such as adequate bathrooms that can make keeping clean difficult or adequate kitchens that can make maintaining a proper diet difficult[12]. A homeless woman is almost certain to have financial difficulties, which will also impact on her diet and general quality of life. All these factors will inevitably combine to have an adverse effect on her health.

6.5 It can be a challenge for maternity services to keep track of homeless women, who are obviously much more likely to move between addresses frequently than someone is not homeless. This makes it much harder to provide to such women the continuity of care that would offer them a high-quality level of maternity care.

6.6 Again, as with women who live in poverty, problems facing homeless women are not necessarily about how maternity services can adapt to them. The problems about inequality are deeper and answers lie beyond the maternity unit. Having well-resources and effective maternity services is part of the answer, but helping to give the children of homeless women a better start in life must be about the wider anti-poverty agenda and helping the financial circumstances of the mother.

VII. THOSE WHO LIVE UNDER THREAT OF DOMESTIC VIOLENCE

7.1 One woman in four will experience domestic violence over her lifetime[13]. Evidence has demonstrated that pregnancy can actually trigger or exacerbate domestic violence[14], with the damaging and even life-threatening impact that can have on the physical and mental well-being of a woman and her baby.

7.2 It is the midwife who is the professional who will have most contact with a woman during her pregnancy, and so it is the midwife who is ideally placed to detect any symptom or sign of domestic violence during pregnancy.

7.3 Where domestic violence is suspected, a midwife should discuss this with the woman in a private environment to ensure confidentiality is maintained[15]. Where the woman does not speak English as her first language, a sensitive interpreter should be present, and a friend or family member should certainly not act as an informal interpreter.

7.4 Any documentation of domestic violence must be done in such a way as to maintain strict confidence, and a midwife should offer the woman the support, information and referral she needs. A midwife should respect and accept a woman's decision about how to act, whatever her decision may be.

7.5 Just such a system is being implemented in East Sussex Hospitals NHS Trust[16]. At the Trust, questioning women about domestic violence is a routine part of antenatal care. Following extensive consultation, midwives at the Trust have undergone training in how to question women about domestic violence in a way that ensures their safety. Care has been taken to ensure that whilst midwives are able to look for indications of domestic violence, the whole process remains confidential.

7.6 The RCM believes that midwives are ideally placed to identify abused women, but their contribution is often hampered by inadequate coordination of services.

7.7 The RCM recommends that every midwife assumes a role in the detection and management of domestic abuse, given its damaging impact on the outcome of pregnancy. Every midwife has a responsibility to provide each woman in her care with support, information and referral appropriate to her needs. Of course, both money and time are required to ensure that all are trained to do this.

7.8 The RCM believes that domestic abuse in pregnancy is best challenged by a multidisciplinary approach, in which professionals work in partnership with the woman herself, and which includes support for both the abused woman and the midwife.

7.9 The RCM advocates that a systematic and structured framework be developed to facilitate the midwife's role, by introducing policies and guidelines within maternity units such as those used in East Sussex.

VIII. TRAVELLERS

8.1 Pregnant women who are travellers face problems associated with their transient lifestyles. Travellers may have living quarters that are cramped, which is not ideal for the promotion of good health and makes it hard for a pregnant woman to avoid things such as passive smoking. Depending upon the particular circumstances of each woman, the accommodation in which they live may lack some facilities that promote cleanliness and good diet, although this is certainly not the case for all women in this group.

8.2 As with homeless women, it can be a challenge for maternity services to keep track of homeless women, who are obviously much more likely to move around the country than someone who is not itinerant. This makes it much harder to provide to such women the continuity of care that would offer them a high-quality level of maternity care, and then good follow-up care in the postnatal period.

8.3 A way to address this problem as it affects travellers is for maternity services to be more flexible and responsive to women who move around the country. At present the records held on the computer system in one area may not be compatible with a system used elsewhere. This needs to be addressed not only for the needs of travellers, and perhaps homeless women as well, but more generally to cope with a relatively mobile population.

IX. THOSE WITH SEVERE MENTAL HEALTH PROBLEMS

9.1 Of all pregnant women, 3-4% suffer from a severe mental illness, such as schizophrenia or manic-depression, while a tenth to a fifth of all pregnant women have a debilitating but less severe mental health problem[17].

9.2 The Confidential Enquiries into Maternal Death (CEMD) [18]in the United Kingdom in 2001 clearly stated that there has always been a large degree of under-ascertainment of maternal deaths from mental illness, and this year the CEMD concluded that suicide is the leading cause of maternal deaths.

9.3 The CEMD recommended that "a perinatal mental health team which has the specialist knowledge, skills and experience to provide care for women at risk of, or suffering from serious postpartum mental illness should be available to every woman" and "women who require psychiatric admission following childbirth should ideally be admitted to a specialist mother and baby unit, together with their infant. Where this service is not available then a transfer should be considered."

9.4 The CEMD also acknowledges the under-reporting of domestic violence. There is a strong association between domestic violence and mental health problems, with obvious implications for risk to the mother, the baby and others.

9.5 Breaking the Circles of Fear is the report of a study undertaken by the Sainsbury Centre for Mental Health. This qualitative research project specifically studied the views of users, carers and staff regarding mental health services received by African Caribbean people, because this community is, according to the report, "massively over-represented in the most restrictive part of mental health services". Key themes from the research include: the perception of mainstream services as inhumane, unhelpful and inappropriate; lack of user, family and carer involvement in services; coming to services too late because of fear and problematic care pathways; and a lack of community-based crisis care.

9.6 Two of the report's conclusions are particularly important: "In this report, there are few pleas for culturally determined services. Instead, service users and carers repeatedly ask to be treated `with respect and dignity' and they demand better information about services with less coercion, less reliance upon medication and other physical treatment and more choice" and "in a major departure from many other reports concerned with tackling discrimination, the report questions the validity of organising services around cultural identity. The observation is made that disparities in health and social care persist despite the many cultural initiatives that have taken place...Instead the case is made for services to tackle inequality as an issue of `customer care' rather than as a problem of ethnicity."

9.7 While the RCM is particularly concerned about the inequalities in health and health services experienced by black and ethnic minority groups, we agree with the above conclusions. High quality services for all will serve to balance inequalities, while having the flexibility to be customised appropriately for local populations.

9.8 While the RCM would argue for increased resources for mental health services, with the increased investment we would suggest a national review of the provision of care for pregnant women and new mothers and their babies. There are entire counties without mother and baby units, requiring midwives and mental health professionals to refer to larger cities some distance away. This compromises care, safety, and the well-being of mothers and babies. Where there is no alternative to separation, subsequent maternal and infant bonding can be compromised.

9.9 Likewise we have concerns about the lack of specialist practitioners available to childbearing women with mental illness. Not only do such women often receive care from general psychiatrists, but also mental health care is too frequently delivered without input from midwives.

9.10 The RCM would endorse the approach outlined above for how maternity units should approach the delivery of maternity services for women with severe mental health problems. This has clear implications for the level of funding received by maternity units.

X. THOSE WITH SEVERE LEARNING DISABILITIES AND THOSE WITH SEVERE PHYSICAL DISABILITIES

10.1 The RCM believes that it is the responsibility of all those involved in the provision of maternity services to meet the needs of pregnant disabled women and their families[19].

10.2 The RCM supports the principle set out in Changing Childbirth, that: "It is important that services reflect the needs of women who have disabilities and ensure that action is taken is overcome the obstacles which confront them. While physical obstructions are of course a frustrating problem, there are other equally daunting barriers resulting from the prejudice and ignorance of able-bodied professionals." [20]

10.3 The nature of a woman's disabilities may be wide-ranging, but the principles of woman-centred care are as important in their maternity care as they are for able-bodied women.

10.4 Midwives can play a significant role in offering women with disabilities the quality of maternity care they should expect. A named midwife gives the disabled woman a trusted carer with whom she can discuss concerns, ask questions, identify issues and experiment with adaptive and creative approaches to meeting her needs throughout her pregnancy, delivery and postnatal period. This will help the midwife develop an understanding of living conditions, physical surroundings and relationships as well as of the availability of information and networks of professionals and voluntary organisations locally. This is particularly important where a disabled woman chooses to use an advocate to support her, which may very well be the case with regard to women with mental disabilities.

10.5 Midwives should empower disabled women to make informed choices about all aspects of their pregnancy and delivery, including place of birth, antenatal testing, delivery position and postnatal support.

10.6 Antenatal screening should be approached sensitively, with an awareness and understanding of inherited and non-inherited disabilities.

10.7 Should an abnormality be detected, the midwife should support the woman in reaching her own informed choice over the appropriate course of action, being careful not to make assumptions or express her own views on what outcome is desirable.

10.8 Parent education should be flexible, creative and accessible. In some cases it may be more appropriate for midwives to work with women in their own homes, reflecting the woman's abilities and the way she manages her domestic life. Disabled women should never be excluded from mainstream antenatal and postnatal groups, except by choice. When participating in some groups, discussions about foetal abnormality need to be handled carefully and disabled women should be given an opportunity to raise concerns privately.

10.9 It is vital that users have access to suitably qualified translators and interpreters, including for British Sign Language.

10.10 Disabled women, like all pregnant women, should be invited to carry their own notes and take a full and an active role in decisions about the nature of their care. Women should be asked what they want included in notes about their condition so this information does not have to be continually repeated to new carers.

10.11 Adjustable equipment will increase the independence of disabled women and will reduce staff workload, therefore the right equipment and forward planning are crucial. Prior to admission the woman should be given an opportunity to visit the maternity unit and check that facilities are appropriate to her needs, including familiarising her with the environment and giving her an opportunity to meet other staff.

10.12 Again, East Sussex Hospitals NHS Trust is offering an example of good practice. The Trust has two link midwives with a special interest in special needs. They offer home visits where the link midwife meets the woman to discuss and plan for any particular needs or worries that may arise during pregnancy and childbirth. From this meeting, an individual plan of care is formulated, which is then kept with the woman's handheld notes so that all those involved with her care can access it. This whole process helps to provide women with physical disabilities a quality service.

10.13 The RCM would endorse the approach outlined above for how maternity units should approach the delivery of maternity services for women with severe learning disabilities and women with severe physical disabilities. As before, this has clear implications for the level of funding received by maternity units.

XI. MATERNITY SERVICE LIAISON COMMITTEES

11.1 All local Health Authorities had a statutory obligation to establish Maternity Service Liaison Committees (MSLCs), a multi-disciplinary maternity services forum with professional and lay membership. The Winterton Report recommended that, "the Government strengthens the role of MSLCs which have a potential at local level to channel more effectively users' views into the planning and monitoring stages of service delivery". Although this recommendation was made 11 years ago, it is still very much in line with current Government policy on public and patient involvement and the creation of local services to meet local needs.

11.2 MSLCs also have an enormous part to play in reducing inequalities in maternal health at a local level by engaging with disadvantaged populations. Despite their importance and relevance to current Government agendas—patient and public involvement, reducing health inequalities, and devolvement of power to the local level—Strategic Health Authorities have no obligation to continue to fund MSLCs. The result to date has been the disbandment of many MSLCs without consultation leaving local maternity service users and professionals with no vehicle for communication. This situation has the potential to undermine the ability of the maternity services to respond to need and tackle inequalities in care provision.

XII. CONCLUSION

12.1 We have outlined above our responses to the issues raised by the sub-committee with reference to specific groups of women. These groups are diverse and have their own particular needs, but like all women their pregnancies are individual to them and how they are treated by maternity services should be governed by the principles of choice, continuity and control.

April 2003

1 Information on ethnicity published by National Statistics on 13 February 2003, accessible at "www.statistics.gov.uk/cci/nugget.asp?id=273". Back

2 Commission for Racial Equality (1994) Race Relations Code of Practice in Maternity Services. London: Centurion Press. Back

3 Neile E (1998) Control for Black and Ethnic Minority Women: A Meaningless Pursuit. In Kirkham M, Perkins E, eds. Reflections on Midwifery. Back

4 Department of Health NHS Hospital and Community Health Services Non-Medical Workforce Census England 30 September 2001, available at www.doh.gov.uk/public/nonmedicalcensus2001.pdf. Back

5 Beishon S, Virdee S and Hagall A (1995) Nursing in a Multi-Ethnic NHS. London: Policy Studies Institute. Back

6 Statistic from the Refugee Council, www.refugeecouncil.org.uk/news/myths/myth001.htm. Back

7 Details of those seeking asylum in the UK during 2002 taken from BBC News Online report, Asylum figures at record level, http://news.bbc.co.uk/1/hi/uk-politics/2806085.stm. Back

8 McLeish J (2002) Mothers in Exile: Maternity Experiences of Asylum Seekers in England. London: Maternity Alliance. Back

9 Information obtained directly from staff at Bradford Hospitals NHS Trust. Back

10 Statistics taken from www.poverty.org.uk, a website produced by the New Policy Institute with support from the Joseph Rowntree Foundation. Back

11 Rogers C and McLeod M (2002) Supporting Poor Families-Briefing Paper. London: National Family and Parenting Institute and End Child Poverty. Back