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Posts Tagged ‘postnatal care’

Over the past few years there has been an escalation in the erosion of the midwifery care provided at home after birth. I have complained, wrung my hands, and generally played the prophet of doom about the impact this could have but, unfortunately, postnatal care is the easiest way for Trusts to cut staffing costs so the resources for this area have been torn away with relief by struggling maternity services. It is the area less likely to produce litigation, and the area where any successful litigation would probably decide on far smaller awards to the claimant so, in the mind of a budget holder, is the safest area to cut services back to the bone.

I was at a governance meeting a while back where the topic of community postnatal care came-up, and I was surprised to hear a consultant midwife back the reduction in care whilst supporting her approach by mentioning ‘a study in the Netherlands’ which found no difference in outcomes between those who had care at home after birth and those who didn’t. Well, I think I’ve found the study, Costs and effectiveness of community postnatal support workers, and if this was the study then she was in error using it to support the discussion as the visits by midwives were not changed, more and longer visits were provided by maternity support workers. Well, today I learned that there is to be a study conducted initially in Scotland by Sterling University into postnatal care. Am I hopeful it will be a positive thing? Not really as I’m not entirely sure that it will be woman centred. At the moment all I have to go on is the BBC report,and whilst I love ‘Auntie’ I am aware that reporting on this topic, maternity care, is not always accurate so I’m just going on their take on the information. What concerns me is that NICE have already issued their guidance on Postnatal Care, which Trusts have interpreted to mean that care is taken away from the home and provided at clinics and this study are also going to ‘develop a best practice package’… ‘which individual health authorities could then adapt to their needs’, (their needs being to cut costs). I will be interested to read their results but I’m really not going to hold my breath.

My previous musings on this topic include; Letting women and babies down? (2010); The Demise of Community Midwifery – part 2 (2010); What now? (2009); A step backwards (2008); An embarrassment (2007). When reading these offerings prior to linking it was interesting (depressing) to chart the real demise of the postnatal care provision in my area, especially my ’embarrassment’ at the care I was not providing in 2007 when we were still visiting at home. Now we ‘triage’ on the first day home and basically, if the woman answers all the questions on our pro forma correctly, she won’t get to see a midwife until Day 5, and then the likelihood is that it will be at a clinic, one of which is 12 miles away. I’m not embarrassed now, I’m ashamed.

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I’m fed-up with constant repetition, my constant repetition. I’ve lost track now of how many times I’ve blogged about the reduction in postnatal care and how potentially damaging that I believe it is – Two minds; Do women have a right to a homebirth? ; The Demise of Community Midwifery  – part 2 and, perhaps the most pertinent and written nearly 3 years ago, ‘An embarrassment’ .

Well, now it’s official and it’s in the news – ‘New Mothers let down by postnatal care’ (BBC). The NCT have completed a survey and have discovered that women feel unsupported following the birth of baby and have summed up the lack of care in one word, ‘shocking’. They go on to say that ‘ Many of these problems the women highlight seem to be due to staff shortages or lack of visits once they have left hospital’. Actually NCT it is not 2 problems but one, the staff shortages cause the lack of postnatal visits. Sorry, repetition as this is one of my familiar themes and, rather than conduct a survey,  all you needed to do was read my blog. I’m just a midwife though, what do I know? But you do know my thoughts as we had a brief email exchange, it was exactly a year ago, I published the mail from the NCT and my response in An email to the NCT and  ‘NCT – A reply’.

I am a Cassandra, ‘ no one would ever believe her predictions’. I’ve got another prediction, it’s going to get worse unless there is a step back and an honest consideration of what is really important in maternity care. Times are hard and the approach should be to consider what part of the maternity services should not be ignored, can we really afford to be touchy, feely? Should monies be spent on staff or surroundings? Homebirths or home visits? If the finances do not routinely allow for both what is important, a live and healthy mother and baby or an empowering experience?  

Other sources which report on the NCT survey – Sky News, Telegraph (the comments are incredible) and the Observer.

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I’ve learnt from long experience never to take what is said by hierachy at face value, so it is with fingers crossed that I write that the ’emergency’ meeting last week was reassuring. Certainly the head of midwifery acknowledged that community has been bearing the brunt of the staff shortages, that cracks are showing and that complaints have increased. The point was reinforced though that, even when the situation has improved staff-wise, postnatal visits must be kept to a minimum and that all our efforts must concentrate on the booking appointment and the antenatal care. Grrrr, so short-sighted, it is true that postnatal care is now the Cinderella component of maternity care.

There has been lots everywhere about the midwife who was struck off at the beginning of last week, the headlines were eye-catching, Midwife banned for God quip after couple’s newborn baby diedMidwife banned after telling grieving Mother ‘ God knows best’ but that is just what they were, eye-catching, but they were not actually correct as the midwife was struck off for misconduct in that she failed to provide appropriate care, behaved dishonestly with regard to her record keeping etc. This midwife broke numerous rules, breached standards and then attempted to cover her ommisions up, and for this this she deserves to be sanctioned,  but, with regard to he God comment the NMC acknowledge that the words were spoken at an emotional time and were not meant to be deliberately insensitive. This is not the reason she was struck off. Read the full findings on the NMC website.

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Previously in ‘The Demise of Community Midwifery :-

The PCT’s, in some areas, are with holding the government monies which were supposedly ring-fenced for the improvement of the maternity services. The result is that the maternity care providers, the hospital trusts, have increased consultant availability, improved facilities and employed (in some cases) more midwives in line with recommendations but the promised monies have not been forthcoming from the PCT’s, so they are now having to make cut-backs.

Next on my list of ‘those responsible’ are the ‘user’ and ‘interest’ groups. Within maternity care the focus, their focus, is on the birth itself. Fair enough, that is what is most important, a healthy baby and Mum. Childbirth is not an isolated event though, there are 40 weeks leading up to the birth of a healthy baby, the antenatal period. Traditionally this care is provided in a variety of ways but, within the NHS, the majority of care options will involve a midwife to a greater or lesser extent. G.P’s may also be involved, if the G.P is registered as providing maternity care s/he will receive extra funding from the PCT for each of his pregnant women, regardless of how much input s/he actually has and, surprise, surprise, the PCT’s are still paying G.P’s this.

Back to the interested parties and why I point a finger at them. They lobby, they lobby for women’s choice. Women’s choice in where they give birth. Nothing against this, in theory, but everything against it when it appears that they place more emphasis on this than on antenatal and postnatal care and so this is where the money and focus is. Wonderful for a woman to give birth in a friendly, tastefully decorated, home-from-home room, littered with birthing balls, fully equiped with a birthing-pool and aromatherapy diffusers. Is it still wonderful though if, after the birth of her choice to a healthy baby, baby fails to thrive, develops jaundice and is, eventually, readmitted to hospital for IV fluids and phototherapy? This happens now, how much more often will this happen when community midwives no longer visit? G.P’s will see an increase in visits by, or to, newborns and their Mothers. Why the Mothers? Well, wounds become infected. Presently a midwife will visit, suspect an infection, take a swab and then phone the G.P to request that a prescription be issued for antibiotics. The infection will be caught early and the wound will, in most cases, heal well. If an infection is not treated promptly then it will ‘break down’ leading to a longer healing period or a readmission to hospital for re-suturing. I’m not even going to discuss the effect that reduced domiciliary visits will have on breastfeeding rates, all at a time when WHO are emphasing the importance of community support. Much is written about the detection of postnatal depression, as a community midwife I may suspect that a woman is likely to suffer PND, but serious PND generally shows after I have finished visiting. My role in this is to ensure that women know where to access help and to not  be ashamed, as many women are, of admitting that she is suffering from depression. Then there is an illness which does present whilst community midwives are visiting, puerperal psychosis, yes, it is rare but when a woman does begin to suffer from it early detection is beneficial as this illness can have tragic outcomes, as recognised in Why Mothers Die.

The essence of my argument with the ‘interest’ groups, who concentrate so single-mindedly on the ‘birth day experience, is ‘what point an ecstatic birth if, as the result of poor follow-up care, the mother and/or baby are unnecessarily ill, or die?’ It is wonderful that there are groups out there who apply pressure to government and care providers to improve care within the maternity services. Come on though, widen your focus from the glamour, headline catching time of birth and acknowledge the importance of good care before and after birth

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I’ve debated writing about this, at the moment it is still rumours, pretty strong rumours but it has some pretty hefty mongers instigating the whispering. If there is truth behind the words then the maternity services in one area will be stopping a service which has been provided for decades, that of domiciliary midwifery visits. If one region stops this care then eventually all Trusts will see the savings which can be made and community midwifery as we know it now will disappear.

Apparently a Trust has employed a cost-saving guru who has scoured the services and discovered that community midwives are an expensive item. They drive around the area, visiting new Mums and babies at home and this is obviously not cost effective to an accountants mind, after all, not only do they have to pay the midwife’s travelling time  but also her mileage. To any sensible person it is logical that, rather than the midwife travelling to the patient, the patient should travel to the midwife. This does happen already in some areas over weekends and this has allowed the Trusts to reduce the numbers of midwives working and being paid unsocial hours.

So, the benefits are that a midwife can see double the number of women and doesn’t have to be paid mileage. There are drawbacks, none of which are obviously financial so probably not of interest to an accountant employed to advise a Trust on cost-cutting. Women are now being discharged earlier and earlier from hospital following the birth, even those who have had caesareans now come home on day 2. In the future will they be expected to return the next day to the hospital, often having to travel over 15 miles due to the closure of the smaller maternity units? What about those families who do not have transport, or have other children? There are so many ‘what ifs’, many seemingly trivial but which will impact upon the welfare of mothers and babies.

Links identifying the role of the midwife in postnatal care

NCT

Maternity Matters

Community postnatal care provision in Scotland : the development and evaluation of a template for the provision of woman centred community postnatal care

The Lancet

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Dr C, the conundrum that he is, has had me shouting at my computer screen about one of his pithy entries involving ‘madwives’, and then had me thanking him for alerting me to a wonderful entry by Good enough Mum.

Now he is ranting about ‘polyclinics‘. What do I think? Well, on the face of it, and given the expectations of the public courtesy of this government’s promises, I think that they will be the only way midwives will be able to cover their workload. That is not to say though that they should be way forward in maternity care, they are a centralisation which I fear will lead to a de-personalisation of the care that I am currently striving to provide. Looks like they are the way we will be going though as the definition of a polyclinic states that ‘In terms of the clinical working groups’ recommendations, polyclinics will offer access to antenatal and postnatal care’. So, if the dream (nightmare) comes true it won’t just be pregnant women attending the polyclinic, it will be newly delivered Mums and babies. Combine the 24% caesarian section rate, with the fact that most post-section women are discharged on Day 2 or 3, and then mix in the fact that they will have to access their postnatal care at the polyclinic and I have difficulty seeing anything positive about this proposed reform. It’s not long ago that we would visit all women daily for the first 3 days, twice a day for the first 2, then we would visit at least another 3 times before we discharged Mum and baby, soon the roles will be reversed. I believe that home visits are important, so much can be incorporated. Practical advise, is the room temperature within normal limits? Demonstrating how the baby should be put in it’s crib/cot according to the SID’s recommendations. How is the Mum coping? Easier to judge if she is in her own environment. If a relative is there to help how supportive is s/he being, some can be quite undermining. I am not going to be able to see, sense any of this if I’m not ‘popping’ in for a chat to see how things are going.

I’m going now because I’m just depressing myself. It’s hard being involved with a service which is falling apart around you. 

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