Northern England Strategic Clinical Network Conference

15th May 2015

Five Year Forward View and Maternity

Five Year Forward ViewMaternity Services

• CCG perspective

– Multiple competing demands on time / resource

– Maternity services are “OK”

– No radical innovations and / or new treatments

– No clear direction from DH

Five year forward viewMaternity services• To ensure maternity services develop in a safe, responsive and efficient manner, in

addition to other actions underway – including increasing midwife numbers - we will:

– Commission a review of future models for maternity units, to report by next summer, which will make recommendations on how best to sustain and develop maternity units across the NHS.

– Ensure that tariff-based NHS funding supports the choices women make, rather than constraining them.

– As a result, make it easier for groups of midwives to set up their own NHS-funded midwifery services.

Birthplace studyPrimary outcome (ie perinatal mortality / morbidity)

Planned place of birth

No. of events Incidence / 1000 (95% CI)

Odds ratio (adjusted)

Obstetric unit 48/15676 3.1 (2.2 to 4.2) 1.00

Home 62/15538 4.0 (3.0 to 5.3) 1.59 (1.01 to 2.52)

Freestanding MLU 35/10571 3.2 (2.3 to 4.6) 1.22 (0.76 to 1.96)

Alongside MLU 54/15342 3.4 (2.4 to 4.9) 1.26 (0.80 to 1.99)

Birthplace Collaborative Group BMJ 2011 343 d7400

Birthplace study Primary outcome (ie perinatal mortality / morbidity)

Obstetri

c unit

Home

Freesta

nding MLU

Alongside M

LU0

20

40

60

80

100

Spontaneous Vx birth

Obstetri

c unit

Home

Freesta

nding MLU

Alongside M

LU0

2

4

6

8

10

12

Intrapartum CS

Birthplace Collaborative Group BMJ 2011 343 d7400

Increasing MLU birthsChallenges

• Current actual / planned reductions in freestanding MLUs in the NE

• Actual (rather than stated) choice of pregnant women

• Increasing acuity of pregnant population

• Increasing number of indications for IOL

• Societal changes in attitude to elective CS

Saving Babies’ LivesReducing SBs and early NND

• SB rate in UK one of the highest in Europe

• In UK, about 33% difference between different regions

• Affects 1 in 200 - 300 babies

• About 4000 SBs every year in the UK

• SB reduction mandate from government to NHS England

State of the World’s Mothers 2014

Lifetime risk of maternal death

United Kingdom

Sweden

Switz

erland

Poland

Portugal

Slova

kiaSp

ain

Norway

France

Germany

Ireland

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

0

20,000

40,000

60,000

80,000

100,000

120,000

Lifetime risk of maternal death (1 in n) Gross national income per capita ($)

Save the Children

The Morecambe Bay Report

“Our findings are stark, and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the Trust. The nature of these problems is serious and shocking, and it is important for the lessons of these events to be learnt and acted upon, not only to improve the safety of maternity services, but also to reduce risk elsewhere in NHS systems.”

Dr Bill Kirkup CBE

Morecambe Bay InvestigationA “dysfunctional maternity unit”1. Clinical competence of some staff fell significantly below the standard required

for a safe, effective service

2. The working relationships between different groups of staff were extremely poor

3. Midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care.

4. Advice to mothers that it was appropriate to consider delivery at FGH was significantly compromised by a failure to assess the risks properly.

5. The response from unit clinicians to serious incidents was grossly deficient.

Dr Bill Kirkup CBE

Anoxic neonatal deathTime of birth (Scotland 1985 – 2004)

Weekday 9am - 5pm

Weekday overnight

Weekend All out of hours0

0.5

1

1.5

2

2.5

3

3.5

Anoxic neonatal death (n/10,000)

Pasupathy+ 2010 (n=1,039,560)

State of Maternity Services 2013Age profile of midwives

CfWI O&G stocktake – January 2015Principal projections for O&G CCT holders

CfWI system dynamics model of the O&G CCT holder workforce for England

Five Year Forward ViewMaternity Services• Much to be celebrated about maternity care

• Significant current concerns about quality of care

• Recognition from DH of the need for change

• Major embedded, structural difficulties

• Collaborative working with CCGs essential

Five Year Forward ViewMaternity Services• Birth is the most common reason for hospital admission

• Births up about 25% in last decade, and at highest for 40yrs

• Low risk mothers giving birth in midwife-led units or at home have fewer interventions, with same outcomes

• 80% of women live within an MLU

• Research by WI and NCT suggests over 85% of women give birth in a obstetric unit despite only 25% wanting to do so

National NHS patient survey: 2013Women’s experiences of maternity services

Primips Multips Significant change

Did midwives provide relevant info about feeding your baby - yes, definitely 55% 67% ↑

- yes, to some extent 34% 25% ↓

- no 11% 8% ↓

Did midwives give you consistent advice about feeding your baby - yes, definitely 47% 61% ↑

- yes, to some extent 29% 24% ↓

- no 23% 12% ↓

- I did not receive any advice 2% 2% ↑

Birthplace study Primary outcome (ie perinatal mortality / morbidity)

Planned place of birth

No. of events* Incidence / 1000 (95% CI)

Odds ratio(adjusted)

Obstetric unit 28/8018 3.5 (2.4 to 5.1) 1.00

Home 36/4063 9.5 (6.6 to 13.7) 2.80 (1.59 to 4.92)

Freestanding MLU 22/4785 4.5 (2.8 to 7.4) 1.40 (0.74 to 2.65)

Alongside MLU 35/7518 4.4 (2.7 to 7.0) 1.38 (0.75 to 2.52)

* Women without complicating conditions at start of labour

Birthplace Collaborative Group BMJ 2011 343 d7400