APPENDIX 20
Memorandum by North Middlesex University
Hospital NHS Trust
Re: The Sub-committee will examine the degree
of evidence of choice and control a woman has over her maternity
care.
The evidence submitted for consideration by
the Health Committee Maternity Services Sub-committee has been
submitted on behalf of North Middlesex University Hospital NHS
Trust. Ms Rose Gibb Chief Executive and Barbara Beal Nurse and
Patient Services Director have made the submission.
INTRODUCTION
North Middlesex University Hospital NHS Trust
has since 2002 made significant progress to ensure the Modernisation
of Maternity Services within the national and local context. The
aim being to ensure the provision of choice and effective maternity
services that meet the needs of the diverse population of women
and the families that the Trust serves. Indeed over a 146 languages
are spoken by the community the Trust serves who access maternity
services every day.
THE POLITICAL
CONTEXT
The changes that have been introduced have been
done so in partnership with key stakeholders including local MPs
Barbara Roche and David Lammy, Commissioners Haringey Teaching
PCT, the Maternity Services Liaison Committee, users and in particular
a local constituent group Haringey Home Birth Campaign Group.
Whilst the local political context around home birth remains unstable
the North Middlesex University Hospital NHS Trust is committed
to deal with the issues sensitively to ensure that the totality
of the service delivery reflects the needs of the whole population
who access and use maternity services at the Trust.
In the intervening time the Trust has participated
in the local borough Haringey Local Authority Overview and Scrutiny
Committee who have completed a review of Maternity services within
the borough and are due to publish their findings in July 2003.
BACKGROUND
Since 1993 due to a changing national and local
context there have been significant changes to maternity services.
During 2000 Maternity Services at North Middlesex University Hospital
underwent significant change, due to a number of factors that
were placing a significant risk to the care of women and their
babies and changes to local commissioning of services:
The midwifery vacancy was 25%, therefore creating
a lack of midwifery cover to care for women and their babies,
making the provision of maternity services unsafe.
Following consultation and approval by the Haringey
and Enfield Health Authority and Maternity Service Liaison Service
(MSLC) in 2000 a contingency plan was put into place to ensure
the safety of women in labour at North Middlesex University Hospital
NHS Trust.
PCTs, commission maternity services, including
Home Birth, only from their local population, ie loss of GP fundholding
income.
The Home Birth Team that existed at the time
needed to work in line with Trust Clinical Governance framework,
Caldicott and EU directives.
MATERNITY SERVICES
FAILING TO
OFFER CHOICE
TO WOMEN
OF ALL
ETHNIC MINORITIES.
Trust services needed to reflect modernisation
agenda.
During 2000-01 following the Strategic Review
of Maternity Services at North Middlesex University Hospital NHS
Trust, a Maternity Service Review Implementation and Monitoring
Group, with clear terms of reference and membership were established
to monitor and report on progress.
In 2002-03 the Midwifery Led Teams were phased
in, to ensure the provision of effective midwifery services and
improved choice and control, including midwifery led care and
home birth. The Emerald Team was the first group to be introduced
in October 2002. The information that follows outlines the evaluation
of the first six months benchmarking exercise. It should be noted,
however, that the volumes covered are small.
Aims of New Service Model:
HB rate of 2.9%, eg 2003 numbers = 87
ETHNICITY OF
WOMEN SERVED
TO BE
REFLECTED IN
CHOICE.
HB rate to be within commissioning catchment.
Midwife vacancies down.
Improve all aspects of maternity care.
14% of women to be offered midwifery-led care.
Service model to ensure women's choice, and
safety.
This was presented to the MSLC by the Chief
Executive Rose Gibb and Kanta Patel Head of Midwifery on the 12
May 2003.
Evidence of Progress 2002-03
INTRODUCTION
Pattern of referral at North Middlesex University
Hospital NHS Trust
|
| 2000
| 2001 | 2002
|
|
| Booking | 3,056
| 3,029 | 3,111
|
| Referral | 2,976
| 2,918 | 2,995
|
|
TABLE 1
TABLE 2
Table 2 reflects the ethnic origin, of women and their families
whom access and use maternity services at the Trust plus 8% of
women are from ethnic minority group. Included in the modernisation
of maternity services is the need to ensure continued and improved
access and a safe, effective service to the diverse population
the Trust serves. Many of who have "high risk" pregnancies,
complex medical conditions and experience social deprivation and
exclusion. Indeed many of these women are admitted in labour without
ever seeing a doctor and midwife. An issue the North Middlesex
University Hospital NHS Trust is committed to improving.
Key findings:
78% of women presenting to the maternity services are from
ethnic minorities. 15% are British white.
BIRTH OUTCOMES
AT NORTH
MIDDLESEX UNIVERSITY
HOSPITAL NHS TRUST
|
| Outcomes | 2000
| 2001 | 2002
| National Rate |
|
| Normal Births | 74%
| 73% | 76%
| 69% |
| Caesarean Section | 18.6%
| 19.7% | 18%
| 21% |
| Instrumental Delivery | 6.4%
| 7.5% | 6%
| 8% |
| Homebirth in Boundaries | 87
| 53 | 65
| |
| (2.9 %)
| (1.8%) | (2.1%)
| |
| Homebirth out of Boundaries | 22
| 19 | 3
| |
Total Homebirths
(average 2.9%) |
109 (3.6%) | 72 (2.4%)
| 68 (2.3%) | 1-4%
|
|
TABLE 3
The data in Table 3 demonstrates that in comparison to the
National Rate for Birth Outcomes, and as reported in Dr Fosters
Guide 2003 the Trust has excellent birth outcomes for women and
babies. These are summarised as follows:
The Normal Birth Rate has steadily increased since 2000 and
in 2002 was 76%, significantly higher than the national rate of
69%.
The Caesarean Section Rate has not increased since 2001 and
at 18% is lower than the national rate of 21%. This is of particular
note given concerns nationally about increased intervention and
caesarean section rates.
The home birth rate has remained consistent and it is anticipated
will rise as the midwifery group practices are established.
EVALUATION CRITERIA
As part of the Maternity Service Review Recommendations it
was agreed by the MSLC and the Maternity Services Monitoring Group
to use the following evaluation criteria:
| 1. Transfer Rate | 5. Religion
|
| 2. Continuity of Carer | 6. Breast Feeding on Discharge
|
| 3. Post Code | 7. Women's Satisfaction
|
| 4. Ethnicity | |
EVALUATION OF
THE FIRST
COMMUNITY TEAMS
AGAINST BENCHMARK
CRITERIA
|
| Criteria | Homebirth Audit 01
| Midwifery Led Care Audit 03 Oct-Dec '02 Emerald Team
| Midwifery Led Care Audit 03 Jan-Mar '03 Emerald Team
|
|
| Total women in a sample | 98 out of which 76 had homebirth
| 17 | 21
|
|
| Gestation at booking | 11% over 28 weeks. 25% transferred from other team at >29 weeks gestation. 26% (20 women) transferred from other hospitals between 20-29 weeks gestation
| 11%>80% <24 weeks 11% >24 weeks
| 90% <24 weeks 10% >24 weeks
|
|
| Continuity of Care (Antenatal) | Not formally measured
| 63% saw 1-3 midwives 31% saw 4 midwives 6% saw 5 midwives 0% saw 6 midwives
| 63% saw 1-3 midwives 36% saw 4 midwives 0% saw 5 midwives 0% saw 6 midwives
|
|
| Antenatal Transfer from Midwives to Consultants
| 13% | 23%
| 16% induction of labour |
|
| Intrapartum Transfer | 8%
| 5% | 5%
|
|
TABLE 4
KEY POINTS
OF NOTE
62% of women booked at 28 wks + in HBT having transferred
from other staff or units showing a level of discontinuity of
care.
Continuity of care is achieved in Emerald Team.
80%-90% of women booked at less than 24 wks in Emerald Team.
Higher antenatal transfer rates are evident in Emerald Team
in relation to RCOG guidelines, but interpartum transfers are
lower.
EVALUATION OF
THE FIRST
COMMUNITY TEAMS
AGAINST BENCHMARK
CRITERIA
|
| Criteria | Homebirth Audit 01
| Midwifery Led Care
Audit 03 Oct-Dec '02
| Midwifery Led Care Audit 03 Jan-Mar
|
|
| Continuity of Carer (Postnatally) | Not formally Audited
| 73% saw 1 midwife 13.3% saw 2 midwives 13.3% saw 3 midwives 0% saw 6 midwives
| 76% saw 1 midwife 24% saw 2 midwives 0% saw 6 midwives
|
|
| Ethnicity (See Pie Charts) | 61% White 39% All other Ethnicity (improvement from '00 figures which was 81% white)
| 6% white 94% All other Ethnicity
| 14% white 86% All other Ethnicity
|
|
| Social Class | Not recorded (61% professional women in 2000)
| 11% Professional 29% Housewives 29% Non- Professional 31% Not recorded
| 5% Professional 66% Housewives 24% Non- Professional 2% Not recorded
|
|
| Breastfeeding at Discharge from Community Midwives
| Only 60% recorded (Record keeping is an issue)
| 87% | 90%
|
|
| Religion | Not recorded
| Multi-faith (see pie chart)
| Multi-faith (see pie chart)
|
|
ETHNICITY OF
WOMEN IN
MIDWIFERY LED
CARE OCTOBER—DECEMBER
02
The number of women from ethnic minority groups who have
chosen midwifery led care is outlined in the Table 5 & Table
6. This is an increase on those who previously booked for home
birth in 2000, and 2001. "Table 7 & 8"
TABLE 5
TABLE 6
TABLE 7
TABLE 8
HOMEBIRTH NUMBER
IN EACH
TEAM AREA
AND FUTURE
PROJECTIONS—2000/2002-2003
P.A.S:—Patient Administration System.
NB: Also total antenatal and postnatal care for women delivered
in other unit—living in our area.
TABLE 9
These are projected figures for home birth and are anticipating
at the end of 2003-2004 that the average home birth rate of 65—67
will be achieved. Therefore this team is on target to maintain
the homebirth rate.
RESULTS OF
WOMEN'S
SATISFACTION SURVEY
IN EMERALD
TEAM—MIDWIFERY
LED CARE
FINDINGS
| Questions | Yes
| No | Other
|
| | |
|
| 1. Where you given a choice of place of birth (hospital/home)?
| 6 | 1
| |
| 2. Care during pregnancy—pleased with care and treated with respect
| 7 | |
|
| 3. Staff kind and understanding | 7
| | |
| 4. Where you involved in decision-making? |
5 | | 2-Some of the time
|
| 5. Have you met some of the midwives who looked after you in labour?
| 3 | 4
| |
| 6. How important is it to have met the midwives before labour?
| 3 | 4
| Those who had not met midwives in labour—not important to them.
|
| 7. Breastfeeding supports? | 6
| | 1-Bottle Feeding
|
TABLE 10
PROCESS
A total of 15 questionnaires were distributed with stamped
addressed envelopes on the 14 April 03. Followed up by telephone
calls from the Patient Advice Liaison Service.
At the time of the presentation of the evaluation report
to the MSLC on the 12 May 2003, seven (7) questionnaires had been
returned.
FINDINGS
The findings outlined in table 10 suggest that women in general
are satisfied with the choice of birth and care during pregnancy.
However they identified a number of areas that require improvement.
These were:—
Improved standard of hygiene
Improved facilities on the labour ward
Choice of Birth Partners
The Trust is putting into place mechanisms to address these
concerns, and progress will be monitored through the Maternity
Services Monitoring Group, and Patient, Public and Staff Involvement
Group.
The women highlighted that they chose to give birth at North
Middlesex University Hospital NHS Trust because it was convenient,
they were scared to have their baby at home, had their previous
children at the Trust, and liked the structure of the midwifery
team.
Whilst it is acknowledged that implementation of the changes
are at an early stage, and the sample size was small, the views
of women and birth outcomes are encouraging. There will be ongoing
evaluation and the views of women and their families will be monitored
and views incorporated into service provision.
IN CONCLUSION
The evaluation of the first six months of implementation
suggests that significant progress has been made. The choice of
midwifery led care (which includes the choice of home birth) has
increased drastically. Continuity of antenatal care has improved
and will be developed further. This is of considerable importance
given the high-risk obstetric profile of the women who access
maternity services at the Trust. Continuity of postnatal care
is in line with "best practice", and breast-feeding
rates are high.
The home birth rate is static, although the ethnicity and
professional grouping of women is markedly different than in 2000
or 2001. It is important to give recognition to the period of
transition and the major changes being introduced.
NEXT STEPS
Undertake further evaluation of service in November 2003.
Work with women to listen to, understand and to continue
the degree of choice and control women have over their maternity
care, including home birth.
Restructure questionnaire, which is too complex.
Monitor informal/formal complaints.
Understand the catchment area for women now excluded by Whittington
and NMUH as a result of commissioning changes (this area has been
identified by the HBC).
Review Home Birth criteria against centres in London to ensure
it is not too stringent.
Monitor/report critical incidents to staff and women and
babies as a result of changes.
RECOMMENDATION
To continue with current strategy
To implement next steps
To review service in November 2003
June 2003
| 
