NHS: Maternity Care

Earl Howe Excerpts

Thursday 5th February 2015 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, first, I join other noble Lords in thanking the noble Lord, Lord Harrison, for securing this debate. In doing so, I thank all noble Lords who have spoken for their excellent contributions. We cannot overstate the importance of good health and well-being for women before, during and after pregnancy. It is an absolutely critical factor in giving children the best possible start in life and in building the foundations for good health and well-being as they get older. That is why providing high-quality maternity care is a key priority for the Government. In their mandate to NHS England, the Government set out an expectation to see significant progress, by March 2015, in improving the standards of care and experience for women and families during pregnancy, and in the early years for their children.

The noble Lord, Lord Hunt, emphasised the importance of choice for women and we agree. Women should have as much choice and control as possible over decisions about their care while they are pregnant. The mandate is clear that women should be offered the greatest possible choice of providers and that they should have a named midwife who is responsible for ensuring she has personalised, one-to-one care throughout pregnancy and childbirth, and during the postnatal period, including additional support for those who have a maternal health concern. I quite agree with the noble Lord, Lord Harrison, about the importance of continuity. NHS England is working to deliver these commitments through the Maternity & Children Programme Board.

Part of that delivery must lie in increasing the number of midwives. The Government have taken steps to improve the size and capacity of the maternity workforce. There are now more than 22,000 qualified midwives, which is an increase of nearly 2,000 midwives since 2010. Another 5,000 midwives are currently in training, which is a record number, and we expect that this level of midwifery training commissions will be maintained in 2015-16. The number of midwifery-led units has increased from 87 units in 2007 to 152 units in 2013, giving most women a choice of place of birth, and 79 per cent of women of childbearing age in England now live within a 30 minute drive of both a midwifery-led unit and an obstetric unit, which is up from 59 per cent in 2007. We have also taken steps to improve the quality of the environments in which women give birth and are cared for. In 2013 and 2014, we provided a total of £35 million capital funding for the NHS to improve birthing environments.

The Government’s investment represents the single biggest capital investment in maternity care for decades, with more than 100 maternity services benefitting. Across the country, many local maternity services have been transformed. Improvements delivered by our maternity investment fund include almost 40 new birthing pools, which can help to make labour less stressful and painful; nine new midwife-led units, which are less clinical and can be more relaxing places to give birth; more en-suite bathroom facilities in more than 40 maternity units, providing more dignity and privacy for women; more equipment, such as beds and family rooms, in almost 50 birthing units that allow dads and families to stay overnight and support women while in labour or if their baby needs neonatal care; complex needs suites for women who need a more constant care environment due to maternal mental health or substance abuse problems; and better bereavement rooms and quiet area spaces at nearly 20 hospitals to support bereaved families after late pregnancy loss, a stillbirth or an early neonatal death.

The noble Lord, Lord Harrison, spoke of the bumpy road faced by women and the wide variation in quality of service. I recognise that there is variation but we are making progress. According to December’s friends and families test, 96% of women said that they would recommend their maternity service for antenatal care; 97% for their labour and birth care; and 98% for their postnatal community care. However, we are keenly aware that we must not be complacent. Although the birth rate in England fell by 3.6% in 2013-14, we know that complexity of maternity care is increasing with increases in average maternal age, obesity rates and awareness of other physical and mental health concerns.

To meet those challenges, it is important that the maternity workforce continues to develop. This Government established Health Education England, which is responsible for promoting high-quality education and training that is responsive to the changing needs of patients and local communities. For maternity services, this means ensuring that the NHS has access to the right numbers and mix of staff with the right skills, and the right values and behaviours to provide every woman with personalised one-to-one care throughout pregnancy and childbirth, and during the postnatal period

As set out in its mandate, HEE is working with NHS England to establish a vision of personalised maternity care by 2022 across geographical and service settings; to describe the workforce needed to deliver it; and to work with key stakeholders, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health and the Royal College of Midwives to deliver it.

Perinatal mental health has not previously been given the attention that it deserves. I was grateful to my noble friend Lady Manzoor for emphasising that. That is why we have made creating a maternity service that meets the individual needs of women and supports the prevention, diagnosis and treatment of maternal mental health issues a priority. HEE is continuing to work with the Nursing and Midwifery Council and the Royal College of Midwives to ensure that midwives in training have a core training module focusing on perinatal mental health, which should be in place for those entering midwifery training in 2015. It is also developing a continuing professional education framework for the existing maternity and early years workforce, which will include identifying the care and treatment required by women with perinatal mental illness. It is also continuing to work with the medical royal colleges to support specific perinatal mental health training being incorporated into the syllabus for doctors in postgraduate training.

The noble Lord, Lord Harrison, referred to the midwife to birth ratio, which is an interesting subject. The ratio set by the Birthrate Plus tool of 29.5 births per midwife is not a mandatory ratio. The Department of Health does not recommend a midwife to birth ratio. The midwife to birth ratio is an indication of throughput only and does not indicate the safety, quality or outcome of the service provided. Nevertheless, the National Institute for Health and Care Excellence published draft guidance on safe staffing in maternity settings in October 2014. That guidance proposes that the number and skill mix of midwives needs to be determined by the midwife in charge at the start of every shift or service and sets out the process that midwives should use to determine whether there is sufficient staff to provide for the needs of women and babies. NICE is planning to publish the final guidance this month.

The noble Lord also referred to the importance of maternity networks. I entirely agree with him. NHS England has set up 10 women and children maternity strategic clinical networks which are working with NHS England area teams to support clinical commissioning groups to commission maternity services. These networks can develop action plans and collaborative working to drive improvements in access, quality of care and inter-service communication to enhance the experience of women and families generally and, more specifically, of the large numbers of women who are at risk of poor mental health during pregnancy and following childbirth.

As I have mentioned, my noble friend Lady Manzoor referred to the costs of perinatal mental health problems. She is right to do so. Two fundamental principles articulated in our mandate to NHS England are relevant. The first is equal access for equal need; the second is parity of esteem for mental health. There is no doubt that offering better support to new mothers to minimise the risks and impacts of postnatal depression is a priority. Indeed, NHS England has announced that perinatal mental health will be a priority for it in 2015-16.

To support CCGs, NHS England has just updated its maternity services commissioning guidance, which will be published soon, and include information on commissioning for parity of care for a woman’s mental health as well as her physical health, and there will be more detailed guidance on the development and delivery of perinatal mental health services across a range of geographies and demographics for all commissioners and service providers.

My noble friend bemoaned the lack of maternal mental health outcome data. The Department of Health has commissioned the National Perinatal Epidemiology Unit at Oxford University to develop a maternal mental health outcome indicator to monitor mental health outcomes for women across the maternity pathway. We expect to include this in future NHS and public health outcome frameworks.

My noble friend also referred to the incidence of suicide, about which we are extremely concerned. However, again, this is a focus for both NICE and midwives in training.

My noble friend Lord Farmer referred, rightly, to the importance of fathers in perinatal care. There is no doubt that involving new fathers and partners in a child’s life is extremely important for maximising the lifelong well-being of a child. It is absolutely central to that and our policies are quite clear that pregnancy and birth are the first major opportunities to engage fathers in the appropriate care and upbringing of their children. This is explicitly mentioned in the healthy child programme, which every health visitor has to implement. I referred earlier today to the Start 4 Life information service, the material on NHS Choices, the baby guide and on the online birth-to-five guide. All these signpost parents to wider information about parenting and relationship support. The NICE guidance for health professionals on antenatal and postnatal mental health explicitly mentions the role of the partner, family or carer in providing support.

My noble friend Lady Cumberlege referred to the Five Year Forward View and the need to reconfigure maternity services. NHS England, in that forward view, said that it would look at new models of maternity care. It has set up a programme board, co-chaired by NHS England and Cathy Warwick, the external secretary of the Royal College of Midwives, and the first meeting for this is tomorrow.

Time prevents me, unfortunately, from addressing all the other questions that noble Lords have put to me. I undertake to write as soon as possible to every noble Lord who has spoken. In the mean time, this debate has drawn out some extremely important threads and themes that both the Government and NHS England would do well to follow up and implement.