COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Maternal Deaths at Antrim Area Hospital
4 December 2008
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Ms Breedagh Hughes ) Royal College of Midwives Northern Ireland
The Deputy Chairperson (Ms O’Neill):
Breedagh, you are most welcome. After your presentation to the Committee, members will put questions to you.
Ms Breedagh Hughes (Royal College of Midwives Northern Ireland):
Thank you. I will concentrate on the executive summary in the report and take the Committee through the sequence of events that led to the external review team making its recommendations.
Page 3 of the report outlines the background to the appointment of the review team. The team was appointed between February and June 2008 by the Northern Health and Social Care Trust, and, as its members are from England, they are external to, and independent of, the trust.
The team was tasked to review the maternity services provided by the trust, focusing specifically on organisational, management and performance issues. It was conducted in parallel with a review of governance issues, the need for which arose after two maternal deaths. However, that review is separate and sits alongside this one. My evidence will focus on the organisational, management and performance issues in the trust — the governance issues will be addressed elsewhere.
For much of the period examined by the external review, Antrim Area Hospital and the Causeway Hospital were part of separate legacy trusts — Antrim Area Hospital was part of the former United Hospitals Trust, and the Causeway Hospital was part of the Causeway Trust. The review of public administration (RPA) brought both hospitals under the management of the new Northern Health and Social Care Trust from 1 April 2007. Subsequently, a women and children’s services directorate was formed, which established a new single management structure.
The review was set in the context of the significant organisational change that took place in all five new trusts. The review team examined differences in risk-management arrangements between Northern Ireland and other parts of the UK, in addition to national guidance on, and best practice in, models of care.
As my presentation continues, the absence of any specific strategic direction, standards or policies for maternity services in Northern Ireland will become apparent. Consequently, the external review team had to base all its assessments on standards in the rest of the UK and measure Northern Ireland against them.
The team based part of its inquiry on recent findings by the Healthcare Commission in England and on other reports, produced in England, on failings in health services. It also examined the demographic changes in Northern Ireland, including the rising birth rate, which, given the 10% increase in the past three years, is a significant factor.
In its key findings on standards and performance, the review team concluded that the maternity services at Antrim Area Hospital and the Causeway Hospital were safe — and that is one of the underlying messages that we want to publicise. Maternity services are provided by our members, and their confidence and morale have been greatly dented by suggestions that those services are not safe.
So far this year, in Northern Ireland, 10 women have died in childbirth — five from suicide and five from physical complications associated with their pregnancy. It is impossible to eliminate all of the risk from childbirth, but it can be identified and managed.
Although the review team found that the services are safe and can be measured against the top quarter of similar-sized units in the UK, it also found high levels of medical intervention and an overall model of care that appeared to be medicalized in comparison with national models of good practice. The Committee must be aware that, during pregnancy, every woman needs and receives care from a midwife, but not every woman needs medical care.
Culturally, Northern Ireland has been slow to implement that approach and has, therefore, ended up in the current situation, whereby practically every pregnant woman is seen by a doctor, whether or not that is necessary. That has a two-fold effect; it medicalizes childbirth, which, for most women, is a normal physiological life event, and it means that doctors’ precious time is taken up seeing healthy women with normal pregnancies. If doctors’ time was freed up, they could spend more time with women who have problems and need to see a medic. The review identified a medicalized model of care with high levels of medical intervention.
The review team found that funding in the Northern Trust was at the low end of the Northern Ireland range. We constantly hear that maternity services in Northern Ireland are overstaffed, particularly in comparison with England. At last week’s Committee meeting, I stated that we do not wish to be benchmarked against England, where there is a staff shortage of between 4,000 and 5,000 midwives. In many instances, maternity units in England are unable to provide a safe service.
Anyone from England who visits Northern Ireland will look at our funding and the fact that every woman in labour is attended by a midwife — rather than one midwife running between two or three women — and conclude that women here receive a luxury service. However, consider the situation that pertained in the Northern Health and Social Care Trust; in a Northern Ireland context, it was at the lower end of funding, although it probably appeared to be well funded in comparison with places in England.
The external review team was presented with evidence about the widespread ambition of management and staff to take part in more training, risk management and clinical audit. As I take the Committee through the rest of the report’s findings and recommendations, we will find out why that was an ambition rather than a reality.
The team found that the legacy trusts had comparatively weak application of their organisational and clinical governance structures. Strategies, policies and guidelines frequently appear to have been developed uniprofessionally and were not regularly reviewed. In practice, that meant that medical staff would draw up a policy on, for example, the induction of labour, but they would not necessarily consult the midwifery staff, who might also have drawn up a policy for the induction of labour. There was little evidence of multi-professional working.
The longstanding history of medical dominance, which recurs throughout the report, led to a lack of multi-disciplinary working in areas where such an approach would definitely have worked to the advantage of the staff and the women in Antrim Area Hospital and the Causeway Hospital.
Some of those interviewed by the review team perceived the culture as not conducive to learning — and I will return to that point.
There were limited ongoing mechanisms for seeking, or responding to, user feedback. Over the past few months, the Committee will have become acutely aware of the importance of working with the women who use the services, listening to their needs, and subsequently tailoring, planning, commissioning and delivering the services to meet their needs. At the time of the review, no such system was in place.
In response to some of those issues, the trust was already developing a risk-management strategy and new governance structures, and I am sure that the Committee will hear more about that when the trust gives evidence.
The review team found a historical lack of clear clinical and managerial leadership. That was partly caused by the dissonance between midwifery and the medical management structures. It was also partly an inherited situation, because the previous midwifery manager, for the last couple of years of her career, spent much of her time acting up for the director of nursing who was on sick leave. That left a vacuum, and there was no clear leadership from a midwife in the maternity services.
The trust has put in place a new structure to strengthen midwifery leadership and the management of maternity services, and, in common with the other four trusts in Northern Ireland, it has appointed a trust-wide head of midwifery. The Royal College of Midwives is pleased that each new trust has appointed a clearly identifiable trust-wide head of midwifery to lead the midwifery services in the overall context of a maternity service.
The trust has also appointed several clinical services managers, but some concerns remain about the scope of the new management team and the huge task that it faces in the short term. It is a bit like turning a tanker — when there is a long traditional cultural history of working in a certain way, it is difficult to start the process of turning that around.
Over the past few weeks and months, the trust has been working closely with us to consider the best ways of doing that. All the formal and informal recommendations that we made to the trust have been taken on board, and many measures have been implemented. Other measures are planned, and I am sure that the trust will tell you about those.
There is a need to ensure appropriate support for the new service managers, and that that support is provided in many different ways from all sorts of people, including the Royal College of Midwives. The trust is working to improve the integration of maternity services into the wider leadership structures, and statutory midwifery supervision is also improving.
Statutory midwifery supervision is a requirement of a law that goes back to 1902. Each of the four board areas employs a supervisor of midwives, whose only responsibility is to protect the safety of the public. In the past couple of years, we appointed a single midwifery supervisory officer to cover all four board areas, and that is an excellent and sensible way to move forward. However, below that officer is a huge local network of supervisors of midwifery, and their only remit is to protect the public. They are accountable to the Nursing and Midwifery Council, which is our regulatory body and our equivalent of the General Medical Council.
For a long time, Northern Ireland lagged behind its counterparts elsewhere in the number of supervisees for which each supervisor had responsibility. Indeed, the numbers were huge, and the supervision arrangements were quite ad hoc. Ideally, each supervisor of midwives should have about 12 midwives whom they should meet individually every year. The supervisor should examine their training needs and provide them with anything that they need to enhance their practice. Since the appointment of the single supervisory officer, that objective is slowly beginning to be met across Northern Ireland
From 2005-07, the review team found little evidence of clear training and education strategies, of systems to identify training need or of data systems that captured the training that had been provided. They found little evidence on the uptake of training or an audit of training, and no designated person in the maternity unit kept information on all planned and completed training to provide quality assurance.
In practice, that meant that individual midwives did not have their training needs identified regularly, and they did not receive regular appraisals. There was no mechanism in place to audit their training needs to ensure that the necessary training was provided, nor was the impact of that training assessed.
Training was provided on an ad hoc basis. A midwife who volunteered to go on a study day or attend a conference might have gone in her own time, or she might have received some funding from the trust. However, it was not structured.
There was some structure in the basic, mandatory training, such as fire drills, and manual lifting and handling, which applies to all trust employees. However, further professional development was extremely ad hoc, and there was no systematic way of identifying and addressing training needs.
Part of that was due to a chronic shortage of staff, which persists to this day. In May 2006, at the time of the proposed transfer of the maternity service from the Mid-Ulster Hospital in Magherafelt to the Antrim Area Hospital — although some of the service went to the Causeway Hospital and Craigavon Area Hospital — the Royal College of Midwives identified that the proposed transfer would put Antrim Area Hospital under pressure, as we did not think that it had enough beds or staff. However, the legacy trust assured us that the hospital would be fine; it did not need extra beds, it could enhance efficiencies, and it could take whatever deliveries came its way from the Mid-Ulster Hospital.
As it turned out, Antrim Area Hospital could not handle the increased number of deliveries because it had neither the staff nor the capacity. In some ways, the number crunching contributed to the staff’s difficulties in accessing continued professional development, because not enough staff were available to free up the midwives to receive any necessary training.
On the other hand, the midwifery students interviewed by the review team spoke highly of the midwives and their ability to meet the needs of learners and the needs of the service. In fact, earlier this year, the HSLP, which is an outside assessment body, came into Antrim Area Hospital to assess the standard of clinical support and mentoring given to student midwives, and found that it was excellent. The students are being well taught academically in Queen’s University and well supported clinically as they learn their profession as midwives in Antrim Area Hospital. Students in Antrim have never brought any concerns to the attention of the Royal College of Midwives — it is a good teaching unit.
The issues of capacity and capability go back to what I said about the maternity services struggling to cope with an increase in deliveries and “a perceived shortfall in capacity”. The report states a “perceived” shortfall in capacity, but members must bear in mind that the team was from England, and it was benchmarking against capacity there. The capacity issues appeared to apply to both midwives and obstetricians, and that least partly because the service and workforce design did not fit the needs of the staff, the users or the organisation.
The trust has just finished a workforce planning exercise and has identified ways in which midwives could be better used. It could introduce maternity support workers to assist midwives and free them up to do midwifery. Rather than a midwife scrubbing in to assist at a caesarean section in theatre, that job could be carried out by a nurse. Instead of every anxious pregnant woman taking a midwife out of the ward to look after her, a single dedicated unit could be set up — similar to a triage unit — where all women could go to see one midwife, and precious staff would not be taken off the wards. Those types of options are being considered, and they have been implemented in other areas of Northern Ireland. Having a proper workforce, therefore, is not only about having a sufficient number of staff; it is a question of the right people being in the right place at the right time to do the right things.
I had a similar discussion with the Committee last week. It is not appropriate to have midwives answering the phone, doing clerical or domestic work, or washing beds. They should be freed up to work as midwives. Quite often, it is a matter of working differently, not simply about having more staff on the ground. However, the review team found that a combination of those two factors — working in inappropriate ways and not having enough staff on the ground —added to the difficulties.
The review team’s opinion was that adopting a less medicalized model of care and deploying the staff differently would enable the service to address the perceived shortfall in the longer term. The Committee will hear today that some moves have been made in that direction. Furthermore, the team sought new funding for the appointment of a specialist midwife to take responsibility for managing risk and governance issues. As I said earlier, risk cannot always be eliminated from childbirth, but it can be identified and managed. Moreover, the team stated that additional, transitional funding would be required in the short term to effect the beginning of the process of change.
The team felt that despite the pressures of the current focus on maternity services — and the adverse incidents received much press coverage because of their high profile — the general feeling among staff, users and other stakeholders was that staff in both the Antrim Area Hospital and Causeway Hospital provide a good level of service given the structures and constraints within which they work.
Such pressures and constraints included the recent reconfiguration of the trusts, and the negative impact on morale of the serious clinical events. Not one healthcare professional sets off in the morning to work in maternity services expecting that a mother will die. A maternal death is rare and extremely traumatic for the midwives, and the ripple effect on morale throughout the unit is inescapable. The increasing birth rate is putting pressure on capacity, and the current model of care does not facilitate the best use of staff in the unit.
The review team’s main recommendation was the creation of a multi-professional environment in which the entire maternity services team works together to develop a shared vision of the way forward. Any maternity services team is massive, and the report’s authors named some of those involved: obstetricians; midwives; neonatologists, who look after the sickest babies; anaesthetists; nurses; managers; social workers; dieticians; general physicians and obstetric physiotherapists. However, although a huge number of people are involved, the review team found that everyone undertook their own role in isolation. That finding explains why the team’s first recommendation is the creation of a multi-professional environment in which people work collectively to develop that vision.
From that vision, the team suggested that the professional staff should produce a clear, trust-wide maternity services strategy and proposed that it be implemented by the end of 2008. That timescale is not realistic for several reasons; not least because the senior midwifery team was appointed only a couple of few weeks ago. However, more importantly, it goes back to what I said earlier: Northern Ireland does not have an over-arching maternity services strategy that emanates from the Department. Indeed, the most recent document on such a strategy was published in 1996, when guidelines on the commissioning of maternity services were issued to the four boards.
A major piece of work has started on the review of maternity services in the Eastern Trust area. The Committee knows about the provision of perinatal mental health services for women in Northern Ireland, and another piece of work is about to commence on that.
Therefore, having lagged behind other services for so many years, maternity services have now shot up to the top of everyone’s agenda, and the Department will soon produce major pieces of work. However, until those projects are completed, it is somewhat unrealistic to expect the trust to develop its own strategy without knowing how that will fit into any over-arching departmental strategy. However, a strategy of some sort must be produced, and everyone must have a clear vision of what they are working towards.
In line with that vision and strategy, the team recommended that an agreed overall patient pathway, or service design, should be put in place to address the identified weaknesses in efficiency and safety. In Wales, for example, every woman who becomes pregnant treads a “normal care pathway”. Unless information to the contrary is known at the outset, all the women are presumed to be normal and healthy.
At any point on the journey through pregnancy, if a woman develops a health problem, whether related or unrelated to the pregnancy, or if her baby develops a problem in utero, she may have to be diverted from that normal care pathway. However, to work from the assumption that every woman needs medical attention from the word go is incorrect: it is akin to looking through the wrong end of a telescope. The team wants the best use to be made of staff: a woman who is young, well and has a healthy pregnancy should be cared for, as far as possible, by midwives. That frees doctors to look after those women who develop complications.
All trusts in Northern Ireland — not only the Northern Trust — struggle to develop an overall patient pathway. Historically, Northern Ireland has had an extremely medically focused culture. As was mentioned in last week’s meeting, in the first instance by the physiotherapist, people can refer themselves directly to a physiotherapist. Why should a pregnant woman have to wait for an appointment to see a GP; why should she not see a midwife as her first point of contact? After all, a GP does not look after a woman during her pregnancy. That may sound like a simple idea, but putting in place structural changes to facilitate it is more difficult than one might think.
As part of developing the vision, strategy and service model, further consideration must be given to the structure and style of the service’s leadership and management. In the past couple of months, much thought has been given to the structure and style of maternity services. The senior midwifery management team is now almost complete, and several other key posts have been identified that will help to consolidate that position.
Clear links and robust monitoring must be developed as a part of the trust’s efforts to improve safety and risk management. However, there must be targeted support, encouragement and resources to allow for multi-professional meetings, a sharing of information and a dedicated risk manager. That requires a cultural change, as much as anything else. There will be some resource implications, but it is mainly a question of a willingness to learn the lessons of the past and move forward collectively to provide a service that meets women’s needs in the future. The review was not commissioned to meet the needs of midwives, medics or trusts. Its recommendations are designed to ensure that the needs of the women who use the service are met, and that is fundamental to the review.
We must follow through on the current suggestions for multi-professional continuing professional development and on-site training: that is now happening. We had a slight hiccup earlier this year, when the Chief Nursing Officer and the Chief Medical Officer jointly wrote to the trusts to the effect that all midwives in Northern Ireland were to be trained in the interpretation of continuous cardiotocography (CTG) tracings: a method of assessing the progress of labour. We stated at the time that our medical colleagues could do with such training too: a couple of weeks ago, the coroner, Mr Lecky, picked up on that that up and agreed that the trusts should train midwives and medics together on an issue that affects them both. We are delighted that that has happened.
The trust needs to develop local arrangements for an effective maternity services liaison committee. The Committee has met the Royal Jubilee Hospital’s maternity services liaison committee, and most members know what user power can do. That model will be rolled out throughout Northern Ireland. The Minister has just finished a consultation exercise on establishing maternity services liaison committees. The responses are being considered, and early in the new year, we expect guidance to be issued to instruct all the trusts to have at least one maternity services liaison committee.
The Northern Health and Social Care Trust has a split-site service, and we are still waiting on the detail as to whether Antrim Area Hospital and Causeway Hospital should have separate liaison committees, but the finer details will emerge when the Minister has made his recommendations. The Royal College of Midwives, the National Childbirth Trust and the existing maternity services liaison committees have worked together for several years to try and get this issue on the departmental agenda. It has been a very successful outcome, because arrangements that exist in some places will be formalised, and the model of best practice that involves service users will be rolled out right across Northern Ireland.
It must be ensured that all stakeholders are given the support and the facilitation that they might need to shift the culture and the style of maternity services. The need to change historical culture is a recurring theme throughout the review. That takes a lot of goodwill.
I am happy to answer questions on what I have said. We have had ongoing and sustained contact with our members — the midwives — at the coalface in Antrim Area Hospital and also at Causeway Hospital, because there has been a trust-wide dampening of morale. The shortage of staff applies equally in both units, and that must be addressed, but we are concerned by the fact that there is no such thing as an unemployed midwife in Northern Ireland.
Having identified the shortage of staff, I am not quite sure where additional staff will come from. That was discussed last week when I talked about agency midwives — the baby should not be thrown out with the bath water. If our colleagues from Glasgow and Liverpool — who are otherwise unemployed — are needed to support us in the short term, we have no option but to accept their help. If there is a resourcing issue, please be sympathetic, because there are no unemployed midwives in Northern Ireland, and every trust is struggling because of staff shortages.
The morale of midwives has hit rock bottom and beyond. It was humbling to meet them and to hear what they had to say. However, over the past couple of weeks, they have told me that they detect a light at the end of the tunnel. The most recent phone call that I received was at 9.20 pm on Monday night. They feel that the trust is now committed to trying to turn the tanker, but they know that that will not happen overnight and that many of the problems that were identified by the review team will persist in the short term. Midwives want to be part of the process of putting that change in place. We will continue to work with the trust so that it gains the benefit of our professional workforce-planning and trade-union expertise. It will also be tied into our wider networks across the UK, which could be helpful.
For the first time, over the past couple of weeks, we have begun to detect a slight lift in the midwives’ morale. They remain short-staffed and they still feel under pressure, but they are now beginning to see some light at the end of the tunnel. The stabilisation of the management structure was a huge step forward in itself, as was identifying and appointing a clinical risk and governance midwife. My understanding is that the Northern Health and Social Care Trust has freed up resources so that a practice development midwife can be appointed. That midwife will take a lead in the continuing professional development that is so sorely needed in the trust.
There should be an impetus on recruiting staff on a level that is slightly ahead of planned retirements, so that when people retire, there are not gaps before others can replace them.
Furthermore, there must be a commitment, supported by the board of the Northern Health and Social Services Trust, to appoint three additional midwives to try to put in place — even on a nine-to-five basis — a triage system to deal with women who appear at the unit because they are concerned about something relating to their pregnancy and who, therefore, must be seen. Often, such women just require reassurance, and the vast majority of them are sent home.
Nevertheless, if one is running a busy ward or labour ward, dealing with such matters detracts from staffing levels. Therefore, even a part-time admissions and assessment unit would be a start — half a loaf is better than no bread. Those facilities are being put in place, and midwives are being kept informed of progress; they feel that, although it will take time, money and willingness, they have been given a clear steer of the direction towards which they are working.
The Deputy Chairperson:
Thank you very much for that, Breedagh. We are also concerned about staff morale, which is why we invited you here. The Committee wishes to ascertain what it can do to support midwives as they carry out their important roles.
You said that there appears to be a more medicalized approach to pregnancy. Were you referring only to the Northern Health and Social Care Trust, or is it a more general problem?
Ms Hughes:
Although it is a general problem throughout Northern Ireland, it is much more pronounced in the Northern Trust. The review team discovered that Northern Ireland has very high levels of medical intervention — most trusts have a caesarean-section rate of 33%, which means that one in every three babies is delivered by caesarean section. The World Health Organization and the International Federation of Gynaecology and Obstetrics recommend a figure of approximately 12%, and the rate in England is 23%.
The Deputy Chairperson:
What can be done to change those outcomes; presumably, something along the lines of the care pathway that you were talking about?
Ms Hughes:
Yes, working on the assumption that every woman’s pregnancy is normal until proven otherwise would, in itself, address the problem. In addition, having midwives as the first point of contact for women to discuss care options would help.
There is also a cultural issue with women here. There is a body of women who feel short-changed if they do not see a doctor at each and every visit, and we are working on that problem with service users. In Belfast, as you know, the campaign is focused on having a new hospital, and much of that new hospital is designed to facilitate women who require midwifery, but not medical, care.
However, the Northern Trust does not have a system of midwife-led care; whereas, in most other trusts, care for women can be provided by midwives. Women book in with a midwife, who looks after them during pregnancy, during labour and after the baby is born — unless it is deemed essential, they never see a doctor. In the Northern Trust, a clearly identified system to access such care does not exist, although it would be one positive way to make progress in lifting midwives’ morale, and it would give them the opportunity to practice fully as midwives, the role for which they trained. Moreover, such an arrangement would be a good place from which to start to restore some professional pride and optimism.
The Deputy Chairperson:
That is a matter for the Committee to take up with the Northern Trust. It is a question of choices for women, and that leads us back to the care pathway.
You said that despite the short-term chronic staff shortage, in the long term, you can see light at the end of the tunnel. Is there anything that we could do to help in the short term?
Ms Hughes:
Keeping an eye on the situation would help. In May 2006, when the Mid-Ulster Hospital was proposing to transfer its maternity services to the Antrim Area Hospital, we said that we had huge concerns; however, the legacy trust did not share that opinion. At the time, although we asked for a workload analysis of staffing levels, it was not done. Now, it has been done, so we know clearly where the shortfall is, and there is a commitment from the trust and the board to fill the gap.
Nevertheless, I am concerned that we do not know from where the midwives will come. Members will know that, in the past year, there has been a 60% increase in the number of midwives in training. However, 12 of those trainee midwives have been earmarked for the Southern Health and Social Care Trust, which got its spoke in first, saying that its shortage was worse than everyone else’s’ and producing figures to back that up. The Northern Trust is now in a similar position and might bid for extra training places in 2009.
The Deputy Chairperson:
Are midwives involved in drawing up the risk-management strategy?
Ms Hughes:
We have appointed a risk and governance midwife who will be involved in that.
Ms S Ramsey:
I appreciated your presentation, and I am sorry that I will miss the trust’s presentation. I have questions that you would, probably, love to answer but are unable to. However, I will try to tease out those answers. It is sad that the Committee is discussing the shortage and lack of resources in midwife services. You said that, so far in 2008, 10 women have died, five of whom committed suicide. We need to examine that issue.
Your presentation was useful. The report states that maternity services at the Antrim Area Hospital and the Causeway Hospital are safe, but that there are “high levels of intervention” and that the overall care model “appears medicalized”. You quoted the statistic that 33% of women here opt for a caesarean section, whereas the recommended figure is 12%. Although the report is overarching, have the Royal College of Midwives, the trusts or the Department made any proposals to challenge those issues?
There seems to have been a lack of joined-up thinking, joined-up strategy and joined-up work at all levels of midwifery services. Will the report change that situation? Will the independent review improve the situation for staff, patients and the trusts? Have the Department or the trusts committed money to implementing those recommendations? The situation could arise again within a year, and I want to bring that into the public domain.
Ms Hughes:
The report is robust. The external review team included Kate Sallah, who is a well-known and respected midwife. She has clinical, educational and management experience and has advised the Department of Health in England. Moreover, the team included a well-respected obstetrician and a management consultant whose expertise centred on management and cultural issues, which were important to the report.
Many of the report’s comments about the Northern Trust could be applied to other trusts. Every maternity unit and maternity service in Northern Ireland can learn a great deal from the report. That process has already started in other trusts. Furthermore, we are establishing guidance on the maternity services liaison committees and on the recognition of women’s needs and rights. Maternity services in Northern Ireland are ripe for change.
The question about caesarean sections is difficult to answer. That procedure has, historically, been hazardous to women because of the general anaesthetic. In the past 30 years, use of epidurals has increased and, therefore, the anaesthetic aspect of a caesarean section has become safer. That does not mean that a caesarean section is safe; it is major abdominal surgery, and every three years we publish a report from a confidential inquiry that examines why women die. That report continually concludes that women who have had a caesarean section are much more likely to die. It is a well-known fact.
A caesarean section is absolutely necessary for some women. A caesarean section may be indicated for babies who need to be delivered in a hurry or in a particular way on a particular day, because they need expert neonatal input.
Over the past few years, the difficulty for us has been that an abnormal procedure has become the norm, and that procedure is not without risk to both mother and baby. Last week, a piece of research was published that shows that babies who are born by caesarean section are approximately 10 times more likely to develop childhood asthma. We are beginning to learn more about the negative impact of the caesarean section. Women who have a caesarean section are much more likely not to be able to get pregnant in the future. They are much more likely to have an unexplained still birth in the future. They are more likely to suffer from a ruptured uterus and a massive haemorrhage in the future.
It is incredible to us, as midwives, that the more that we learn about caesarean sections that is not good, the higher the rate of the procedure in Northern Ireland, where instances of the procedure have steadily crept up each year. The average proportion of babies born by caesarean section in Northern Ireland is 28%. That is a distorted average, because Lagan Valley Hospital has a caesarean section rate of 15%, which pulls the overall average down. Apart from Lagan Valley Hospital, every unit in Northern Ireland has a caesarean section rate of over 30%. As I said earlier, some women and some babies absolutely require it, but it is not required by one in three women.
One of the complicating factors for midwives in Northern Ireland — and indeed our colleagues in the South of Ireland — is the culture of private antenatal care. Women pay to see a consultant obstetrician privately, who cares for them during their pregnancy. Many women think that that entitles them to a caesarean section if that is what they want.
Midwives face a moral difficulty, and those who are trying to balance budgets face a financial difficulty. From the moment that a woman comes through the door of a maternity unit, she stops being a private patient and becomes an NHS patient. The NHS picks up the bill for her caesarean section, which costs approximately three times as much as a standard birth, even before consideration is given to the costs that are attached to the fact that a baby who is born by caesarean section is more likely to end up in a special care baby unit. Moral and public-health issues are involved in women being subjected to — or often subjecting themselves to — unnecessary major abdominal surgery.
There is also a financial consideration, and the Royal College of Midwives is working with the Chief Nursing Officer on that. Some members will know that, a few years ago, a large value-for-money exercise was carried out by PricewaterhouseCoopers. That exercise identified factors that cost the Health Service in Northern Ireland money, one of which was the length of stay in maternity units. Women are staying for longer in maternity units because those units are like a surgical ward. In any post-natal ward in Northern Ireland, there are hardly any women who have had a normal birth; they are full of women who are recovering from a caesarean section. The women who have had a normal birth go home in the first few hours after the birth. That is a major issue.
With the Chief Nursing Officer, we are trying to introduce an electronic maternity data system to pin down why and where caesarean sections happen so that the issue can be addressed. That issue is being taken seriously.
I am not sure that our obstetric colleagues would share our views on the matter. They think that as midwives are always mouthing off about women’s choice, the choice to have a caesarean section should also be afforded to women. I agree that women should have that choice, provided that it is a fully informed choice and that women know what they are letting themselves in for, now and in the future. Decisions must also be made about who pays for a caesarean section that is not medically indicated. The issue is being addressed, but it is another tanker that must be turned.
The Deputy Chairperson:
More education is needed on the caesarean section and on its long-term implications. Many people, including me, would not have some of the information that you provided. A clearer message must be sent out about caesarean sections.
Mrs Hanna:
Good afternoon, Breedagh, you are welcome. The review is relevant, timely and much-needed by all trusts, but it is sad that it has come on the back of safety issues. I look forward to hearing the presentation by the Northern Health and Social Care Trust.
The main issue is the culture shift that is required. You said that there will be a new maternity manager and a dedicated risk manager — will one person do both jobs?
Ms Hughes:
No; the head of midwifery will take the overall lead on maternity services in the trust and will work with the lead obstetrician and the senior management of the trust to examine overarching strategies and policies to be adopted in the trust. The position of risk and governance midwife will be held by a separate person, who will be responsible for trying to identify areas of risk; implementing measures to reduce or manage the risks; ensuring that staff are adequately trained; working with the practice-development midwife when he or she is appointed; and identifying good and bad practice. The risk and governance midwife also will also conduct a regular audit and a review, but not only of serious adverse incidents because it is too late by then. A robust review of near misses is also required. The value in having a risk and governance midwife is what can be learned from near misses.
Mrs Hanna:
We can all analyse and identify what should be changed, but the proof of the pudding is in making the changes. To get that change of culture off the ground, will there be a team comprising someone from each discipline? It is a matter of working together and, as you said, when many individuals are talking, for example, about the need to induce labour, that situation requires teamwork, and it requires everyone to work to their strengths.
Ms Hughes:
That is a question for the trusts, because they will be able to tell the Committee about the plans that they have submitted. We have said that we agree with the review team that such a team is necessary, but I am not sure how it will be developed.
Mrs Hanna:
A team would demonstrate the practical workings — that is the change that we need. From my background in midwifery, I know that the left hand does not always know what the right hand is doing. Sometimes, professionals — particularly midwives — are not working to their strengths when they should be totally dedicated to the pregnant woman and midwifery. The Committee will be interested to hear how that works out, because it would benefit everyone.
You also mentioned, and gave plenty of detail on, the levels of intervention and the medicalized model. You need to talk to some of the obstetricians, because they are promoted —
Ms Hughes:
There is a cascade of intervention — if a woman comes in to have her labour induced, her waters are broken and a drip is put up, which leads to very strong early contractions. If a woman arrives at hospital in labour, there is a gradual build up of contractions, and her body can cope with the increasing intensity of the labour. Many of the women who arrive at hospital in spontaneous labour will manage very well if left to their own devices. A woman who has an induced labour is hit with intense pains from the start, and the next step is an epidural.
After an epidural, a CTG monitor is required, because the woman cannot move, and the ways in which the midwife can assess the progress of labour are limited. Once the CTG monitor is in place and the woman becomes fully dilated and is unable to push, because she cannot feel anything, which means that she is more likely to have a forceps delivery. Alternatively, there will be CTG tracing in place, which is more likely to lead to a caesarean section.
There is an ongoing discussion about the benefits, or otherwise, of CTG tracings. All of the evidence over the past 30 years shows that they increase the caesarean section rate, but they do not decrease the neonatal morbidity. Therefore, stopping a woman from putting her toe on that pathway, which begins with the induction of labour, would be a good way to go. However, as with caesarean sections, there are women whose labour will have to be induced.
Mrs Hanna:
You explained that extremely well. You mentioned the power of service users and involving women, but we must be aware that having a caesarean section is a lifestyle choice for many women — people decide exactly when they want it and think about it being over in hour, without considering the following few weeks.
I did not expect a policy on breastfeeding policy to be included in the report, but I would like to hear about the breastfeeding policy in all units. It may be an issue to discuss another day, but I know that work is ongoing on that issue, and, if we are looking holistically at the journey of pregnancy, that should be part of it.
Ms Hughes:
That ties in with the Minister’s commitment to improve public health. Breastfeeding a baby is the best thing to do to prevent childhood obesity and reduce susceptibility to ailments such as asthma and eczema in later life. That involves a big public health issue about which I will be happy to talk to the Committee another time.
Mr Gardiner:
Thank you, Ms Hughes, for your professional and in-depth presentation.
Do you have a breakdown of the people who have undergone caesarean sections to show how many attended their doctor or gynaecologist privately and ended up having a section because their physician had gone off on holiday on the date on which the mother was called into hospital? I must declare that my wife was a midwife.
Ms Hughes:
She may have a particular perspective on that.
Mr Gardiner:
She did not brief me, and I did not discuss the matter with her.
Ms Hughes:
The most recent solid data that is available relates to early 2000, when a national audit of caesarean sections was carried out across England and Wales; Scotland had already carried out an audit in 1999. The Health Minister at the time, Bairbre De Brún, was asked to include Northern Ireland in the national audit, and she did so. The Royal College of Midwives realised that antenatal care in Northern Ireland probably affected the rate of caesarean sections rates. Therefore, a question was added that asked women what type of antenatal care they had experienced.
It was discovered that women who had received NHS care had a caesarean section rate of about 22%, and those who had received private antenatal care had a section rate of 40% — almost double. The question is how many women had received private care. The study positively identified that 8% of women had received private ante-natal care, and the data in the one relevant box was missing in a further 9% of cases. Therefore, it was certain that 8% of women, and anything up to another 9% of women, had received private antenatal care in Northern Ireland.
It is suspected, anecdotally, that in some units as many as one in five women receive private antenatal care. The Royal College of Midwives would like another piece of research to be conducted. The means to capture that information is available as the new system is in place, but no one at departmental level is willing to ask the question.
Mr Gardiner:
Perhaps the Committee could ask the Department on your behalf. We are here to work in the interest of the people who elect us and whom we represent. Members want the best for the Health Service and its patients.
Ms Hughes:
That would be most helpful. We already know that there is a direct link, but we do not know the extent of it, and we would appreciate having that information.
Mr Gardiner:
Will the Chairperson note that suggestion and follow it through?
Mr Buchanan:
To follow up on that point, Ms Hughes, you talked about the percentage of women who opt for private antenatal care. Those women are obviously being advised to go private. What drives so many of them to do that? Is it because of a lack of confidence in hospital services? There must be some reason for those women to take the private-care route rather than using the Health Service. If more women used the NHS, the proportion of caesarean sections might decrease.
Ms Hughes:
There are many factors, but the main one is probably cultural and is common to the entire island of Ireland. The trend to go private is unique to Northern Ireland and the Republic of Ireland. The question asked is not where a woman is going to have her baby; but which consultant she is attending. That applies to a certain class in our society; wee lassies from Ballybeen and Turf Lodge do not go private, because they cannot afford it — the cost of private antenatal care is approximately £3,000.
As midwives, we must address the issue of convenience. Women are generally seen by consultants in the evenings in their private rooms. They are seen at a time that may be regarded as convenient for the women, but in reality, it is convenient for the obstetrician. If a woman requests an appointment at 6.00 pm on Tuesday, the consultant may say that he or she has a dinner engagement at that time and tell her to come on Wednesday instead. The woman may have to change to Wednesday, but she still gets a 6.00 pm appointment, and many regard that as important.
By law, everyone is entitled to time off work for antenatal care, but some pregnant women still get sacked or passed over for promotion for exercising that right.
For some women, the flexibility to choose when to have an antenatal appointment is very important. We must address the fact that NHS maternity services do not provide any evening antenatal clinics and ask ourselves why.
The factors of class and culture have almost become an established tradition. However, we must hold our hands up to the fact that convenience for women is a factor.
Mr Buchanan:
Whether a woman opts for private care is a matter of choice. However, in my West Tyrone constituency, there are no maternity services, which is an absolute disgrace. Youngsters cannot be born in County Tyrone unless they are born on the kitchen floor. It is important that women have a choice; in County Tyrone, they have none.
The Deputy Chairperson:
Every MLA who represents Tyrone makes that point at Committee.
Breedagh, thank you very much for coming today; the Committee has an open-door policy and is here to support you. We have received a report from the trust that maps out how it will implement the recommendations in the review. We will monitor that implementation and keep in touch.
Ms Hughes:
That would be very helpful. The review provides a foundation and a clear place from which to start. We have been engaged in discussions with the trust on how to move forward, and I hope that that momentum will continue.
A certain amount of pump-priming is necessary to obtain the immediate extra resources that are required. I hope that, in the long term, when that initial block of money is gone, we do not find ourselves slipping backwards. I want this to be a positive and sustained process.