APPENDIX 19
Memorandum by Saint Mary's Hospital for
Women and Children, Manchester
BACKGROUND
1. Saint Mary's Hospital is a women and
children's division within one of the largest teaching Trusts
in the country. With an income of £25 million per annum and
800 staff, it has a national and international reputation as a
centre of excellence and prides itself in offering a range of
services, not only to the local communities within Central Manchester
but also to the wider population of the North West region.
2. The maternity unit delivers approximately
4,100 women per year with a normal delivery rate of 74% including
a 1.6% home birth rate for the local population. Central Manchester
has a diverse ethnic minority population, which accounts for 39%
of all women who book at Saint Mary's Hospital. The current model
of midwifery care is traditional but includes choice for home
birth and DOMINO delivery. Within this model the majority of women
living in Central Manchester have midwifery led care both antenatally
and postnatally but there are insufficient community midwives
to provide intrapartum care for a greater number of these women.
3. Obstetric services are provided both
at a secondary and tertiary level, with the majority of consultants
being subspecialty trained or university joint appointments. At
a tertiary level Saint Mary's offers an extensive Regional Fetal
Medicine service which is supported by the onsite Regional Neonatal
Medical and Surgical units and the Regional Genetics service.
There are also dedicated specialist antenatal clinics including
diabetic and endocrine, combined obstetric haematology and haemoglobinopathy,
hypertensive / renal disease and teenage pregnancy The unit also
supports the regional population accepting in utero transfers
from across the North West region.
CHOICE AND
CONTROL
1. All women attending St Mary's Hospital
for maternity care have total control and choice regarding the
care they receive. Women and their families are partners in care
and the ethos of the multidisciplinary team is to ensure all women
are given the appropriate information to enable them to make informed
choices regarding the type and place of care, screening and treatment
they receive.
42. Women can choose to access pre conception
care eg women with diabetes or who have had recurrent pregnancy
loss. Access may be via General Practitioner (GP) referral, referral
from other specialists or a self referral because a woman is already
known to the service.
3. Becoming pregnant often involves a choice
in itself and a number of women require support to make a choice
whether to continue with a pregnancy or not. Women can access
counselling support via St Mary's Hospital to assist them with
this decision making process eg young parents, women who have
fetal abnormality. Both of these are easily accessible with little
if any delay.
4. Access to St Mary's Hospital maternity
services is usually via the GP referring to a consultant obstetrician.
Whilst the midwife can and does provide the majority of care,
in low risk cases, the consultant obstetrician remains the lead
professional. Work is underway and discussions are taking place
with the PCT to develop true midwifery led care so women can book
directly with their midwife. There are a small number of women
who are referred directly to the consultant obstetrician by their
midwife eg vulnerable, hard to reach groups.
5. At the first point of contact with the
maternity services, whether it is through the GP or at the hospital,
all women are given information regarding the choices available
to them within all the maternity units in Manchester and the options
of care eg homebirth. Women are regarded as low risk unless factors
dictate otherwise. The initial meeting between the midwife and
the woman is to discuss these options, and choices made are documented
in the hand held records. Women may ask for a homebirth, DOMINO
delivery, water assisted labour and delivery or hospital delivery.
The only limitation to this choice is for women booked at St Mary's
Hospital who live outside Central Manchester. Those women who
want a home or DOMINO birth are referred with their consent back
to their local maternity unit.
6. Women are reassured that the choices
they make can be changed at anytime and at all times they will
be kept informed of progress. Women carry their own hand held
maternity records.
7. Central Manchester has been at the forefront
of offering screening to women and receives approximately 50%
of referrals from outside Central Manchester, many of which are
for tertiary level care eg in the Fetal Management Unit, women
with diabetes or haematological conditions. Information giving
is an essential requirement to enable women to make informed choices
and be in control. All women are given a booklet explaining the
facilities available at St Mary's Hospital, which contains basic
information regarding screening and diagnostic tests. This booklet
is updated annually but it was recognised that antenatal screening
required a more comprehensive document. We have now produced a
booklet which explains to women the difference between screening
and diagnostic tests and what is available both within the unit
and externally. The information within the booklet will be reinforced
verbally by both midwives and obstetricians and interpreted for
women whose first language is not English. The written information
has taken into account national guidelines and recommendations
eg Downs Syndrome screening, sexual health and haemoglobinopathy
screening. As the requirement for midwives to provide information
and counselling increases, this has a serious resource implication.
National guidelines have recommended that maternity units have
a dedicated antenatal screening co-ordinator a fact which was
also included in the Birth rate Plus report 2002. However, Birthrate
Plus also revealed an overall shortage of midwives and there has
been no additional funding to increase the current establishment
to date.
8. With regard to screening women are asked
how they would like the results to be relayed to them and many
results are given via the Fetal Management midwives. When women
receive abnormal results ie the screening highlighted an increased
risk of a fetal abnormality or a diagnostic test confirms this,
they have a choice whether or not to continue with the pregnancy.
As documented earlier counselling is available to assist the women
and their partners make their choice. Regardless of the choice
made, total support is given to the women and her family.
9. Public health issues are high on the
agenda for pregnant women. The whole pregnancy continuum is a
time when women need to be given information in order that they
may make healthy decisions. All pregnant women at St Mary's Hospital
are given advice and support regarding smoking cessation and infant
feeding. Women have access to health educators who are trained
to help them make informed choices eg NRT for smokers, breastfeeding
workshops. There are healthy activities offered eg exercise in
water and Get Fit For Baby classes, both of which are run by midwives.
10. The Maternity Day Unit is an assessment
facility for women attending on an outpatient basis who require
greater maternal or fetal surveillance. There are a small number
of women who choose to attend the Maternity Day Unit who for personal/
family reasons do not want to be admitted to the antenatal wards.
Women whose pregnancies are overdue can opt to attend the Maternity
Day Unit for assessment and monitoring rather than induction of
labour.
11. As already highlighted, Central Manchester
has a diverse ethnic community and for women whose first language
is not English, choice and control can be difficult. Use of a
24 hour interpreter service is imperative to enable informed choices
to be made. There are occasional difficulties in accessing link
workers/ interpreters; however every effort is made to do so.
12. Labour and delivery causes anxieties
for many women, but if women are well informed and their views
listened to and respected, anxiety levels can be reduced. St Mary's
Hospital offers parent education courses and active birth workshops
to inform women of available choices. These are frequently over
subscribed within the maternity unit; however, additional groups
have been started within the community to facilitate greater access.
In labour, all women are free to mobilise, use aides in labour,
adopt different delivery positions and have access to a variety
of methods of pain relief. At any deviation from the normal, women
are informed and given appropriate advice. The women, however,
remain in control and informed consent is always obtained.
13. The length of hospital stay following
delivery varies and is dependent upon the women's wishes and needs.
Some women go home after a few hours whilst others remain for
several days. There are occasions when a woman's choice to stay
longer cannot be facilitated due to the pressure on postnatal
beds ie when there are no medical indications to remain in hospital.
Women in hospital have a choice of access to amenity rooms and
a varied multicultural diet. Postnatal visiting in the community
is agreed between the community midwife and the woman on a flexible
basis according to need. The length of time a midwife continues
to visit, up to 28 days, is also agreed individually. When babies
have been admitted to the neonatal unit and subsequently discharged
they are followed up at home by a team of community special care
midwives who continue to ensure women are given appropriate advice
and support enabling them to feel confident in the care of their
neonate.
14. Neonatal screening is an area currently
undergoing development. Women are given both written and verbal
information explaining the screening tests available and asked
to consent to the tests they wish their baby to have. This includes
PKU and hypothyroidism, neonatal hearing screening and haemoglobinopathy
screening. St Mary's Hospital is a tertiary referral centre and
so women are receiving care from specialist obstetricians and
physicians, and their neonates from consultant neonatalogists.
Additional treatments may be required postnatally so women and
their neonates are referred to the appropriate professional to
obtain the requisite information to make the treatment choices
eg Geneticists, neonatal surgeons.
15. As a university teaching hospital, students
from a variety of backgrounds have their clinical placements within
St Mary's Hospital. Women are informed about students being an
integral part of the unit, in the St Mary's Hospital booklet,
however, they are asked at all times for their consent for students
to be involved in their care. All students remain under the supervision
of a qualified professional.
16. There is an active research programme
within the maternity unit, which is also home to the Tommy's Centre
for Maternal and Fetal Health. Again all women are given written
and verbal information regarding research projects with written
consent being obtained if they wish to participate in any of the
ongoing research projects in the department. Women are reassured
that if they decline to participate this does not affect the care
they receive.
17. The services available for women at
St Mary's Hospital, a tertiary referral centre, are wide ranging
and so it is imperative that information is available for them
in a format they understand to enable them to make choices, whether
it be for low intervention maternity care or specialist obstetric
and midwifery care. Women are treated equally and access to services
is available according to need. Vulnerable and difficult to reach
groups are catered for by locating services in the most appropriate
areas. This enables these groups of women to take control of their
pregnancy eg Young Parents Group located in a local library, community
services for women who misuse drugs and alcohol, outreach services
following closure of a local maternity unit.
18. National guidelines continually inform
service provision, policies and guidelines. St Mary's Hospital
is currently developing business plans for routine antenatal Anti-D
prophylaxis, universal neonatal screening for haemoglobinopathy,
and improved Down Syndrome screening. Availability of these services
will increase women's choices and ultimately their control over
their own pregnancy.
19. Saint Mary's Hospital has a dedicated
team of professionals continually striving to improve and modernise
services for women. We recognise women are essential partners
in this work and so we are actively seeking their views on how
to improve the service. This is through the local area groups
(PCT), Sure Start programmes and feedback from the parent education
groups. We also have user representation on the clinical forum
for the central delivery unit. Incorporating women's views will
ensure we provide choices for women, which in turn will enable
them to be in control.
June 2003
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