1. PROMOTING NORMALITY A WOMAN CENTRED APPROACH TO MATERNITY CARE. by Amanda Lucas Matron Maternity Services/ Supervisor of Midwives EAST CHESHIRE TRUST

2. W HY PROMOTE NORMALITY ? DH documents (1993, 2004 & 2007) advised woman centred approach, access to high quality maternity services and choice, access and continuity of care for all women Other drivers for normality include documents from the NCT (2007 & 2010) which suggest the normal birth rate could be used as an indicator of quality in midwifery care

3. NICE Intrapartum guidance promotes intervention only when necessary High Impact Actions (NHS Institute for Innovation & Improvement, 2010) has a focus on promoting normal birth and reducing the caesarean section rate CMACE report 2006-2008 Saving Mother’s Lives advises a back to basics approach with teamwork and improved communication

4. I N REAL TERMS ……

8. F ROM A QUALITY PERSPECTIVE Women are more likely to feel in control requiring less pharmacological analgesia (Hildingson et al, 2003) Women are more likely to breastfeed (Hatem et al, 2008) Better outcomes for mothers and babies (Wagner, 2002; Johanson et al, 2002 & Edwards & Byrom, 2007) Women have the choice of place of delivery The midwife will be the lead professional, continuity of carer, holistic care Increased job satisfaction for midwives

9. F INANCIAL IMPLICATIONS Reduction in cost pressures (Newburn & Singh, 2003) Reduced length of stay in hospital (£2630 BY 1 DAY ) Reduced medical staffing & post operative nursing costs (£820 per case NHS INSTITUTE FOR INNOVATION & IMPROVEMENT ) Less outlay on medical equipment as midwives utilise clinical skills Possible financial bonus when targets met (locally agreed) Possible financial penalties when targets not met (locally agreed)

10. C HALLENGES TO NORMALITY AT ECT

11. Previously medically dominated Midwives de-skilled and reliant on obstetricians Increased intervention due to the fear of litigation Negative publicity and the ethos of “too posh to push” Affluent area and rise in maternal request caesarean sections No clear pathway for vaginal birth after caesarean section Reluctance to perform external cephalic version

12. S UCCESSES

13. P ROMOTING N ORMALITY P ROVISION OF A QUALITY SERVICE Commencement of a normal birth strategy group Implementation of a stand along side midwifery led unit 1:1 care in labour (achievement of 97% in 2010) Implementation of maternity dashboard (monitoring tool) Introduction of a second pool for hydrotherapy and water birth Development of new care pathway for vaginal birth after caesarean section Home from home delivery rooms

14. P ROMOTING NORMALITY P ROVISION OF AN INNOVATIVE SERVICE Supervisor’s clinic Development of new supervisor of midwife clinic Dedicated time to debrief, discuss VBAC and devise individualised plans of care in partnership with women and their families Weekly Pathway of referral “Bottom up” approach to change (DH, 2010)

15. R OBUST SUPERVISION

16. P ROMOTING NORMALITY W ITH EMPHASIS ON PREVENTION Strong leadership in the clinical area Skills & drills training in the clinical area Presentations and audits on reducing caesarean section (CNST & maternity dashboard) Robust multi-disciplinary maternity training programmes (94% compliance, 2010) Dedicated breastfeeding midwife and attainment of Baby Friendly Level II Robust risk management including midwifery involvement in guideline development/evidence based practice

17. P ROMOTING NORMALITY P ROVISION OF A PRODUCTIVE SERVICE Reduction in the C/S rate of 0.8% (2% in emergency C/S) from 2009/2010 Normal delivery rate which is currently 70.3% Published work on midwifery led care, accountability, change management and an infection control initiative Practice Development Midwife who was successful in being named national midwife of the year 2009/2010 in BJM awards in London LW Lead midwife who was successful in being name ECT nurse/midwife of the year 2010

18. D EDICATED LEADERSHIP

19. Y OU DON ’ T HAVE TO BE A SUPER - MIDWIFE TO MAKE A DIFFERENCE …

20. J UST A WE CAN DO IT ATTITUDE !!.

21. R EFERENCES Department of Health. (1993). A Report by the Expert Committee on the Maternity Services Part 1 Changing Childbirth report. London: DH Department of Health. (2004). National Service Framework for Children, Young People and Maternity service. London: HMSO Department of Health. (2007). Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. London: DH Department of Health. (2010). Equality and Excellence: Liberating the NHS. London: DH Edwards, G., Byrom, S. editors. (2007). Essential midwifery practice: public health. Oxford: Blackwell Publishing Hatem, M., Sandall, J., Devane, D., Soltani, H. and Gates, S. (2008). Midwife- led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No: CD004667. DOI:10.1002/14651858.CD004667.pub2

22. Hildingson, I., Waldenstrom, U. and Radestad, I. (2003). Swedish Women’s Interest in Home Birth and In-Hospital Birth Centre Care. BIRTH 30(1): 11-22 Johanson, R., Newburn, m., Macfarlane, A. (2002). Has the medicalisation of childbirth gone too far? British Medical Journal 324(7342): 892-895 Maternity Care Working Party. Making normal birth a reality. Consensus statement from the Maternity Care Working Party: our shared views about the need to recognise, facilitate and audit normal birth. National Childbirth Trust; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists; 2007. Available from: http//www.nct.org.uk/about-us/what-we- do/policy/normalbirth

23. National Childbirth Trust. (2010). Normal birth as a measure of the quality of care. NCT: London Newburn, M., and singh, D. (2003). Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey. London: NCT (accessed at www.nct.org.uk/about-us/what-we-do/campaigning/better-birth- environment) NHS Centre for Innovation and Improvement. (2010). High Impact Actions for Nursing and Midwifery. NHS Institute for Innovation and Improvement, Coventry NICE Intrapartum guidelines, 2008. National Institute for Clinical Excellence Wagner, M. (2002). Critique of the British RCOG National Sentinel Ceasarean Section Audit Report of October 2001. MIDIRS Midwifery Digest 12(3): 366-370