A major area for improvement in maternity services is postnatal support, say Don Redding and colleagues.
Now the government has clarified that it will be consortia which commission local maternity services, it should follow up by charging them with a new improvement priority - raising the standard of information and support to mothers, especially during postnatal care.
Results from the 2010 national survey of women using maternity services, coordinated by the Picker Institute Europe for the Care Quality Commission, show many of the targets for improvement in the early stages of the pathway - antenatal care - which were set by the previous government have delivered significant benefits.
But the back end of the pathway - postnatal care - appears to have been comparatively neglected, and there is clear scope for better and more consistent advice and support to mothers, especially among the weakest local services.
The previous maternity survey was conducted in 2007. Maternity was then under huge scrutiny, both in the NHS next stage review and in special inquiries led by the King’s Fund and the Healthcare Commission.
The main issues that became the focus of the government’s Maternity Matters in 2008 were to get more women onto the pathway at an earlier stage in their pregnancy, and to increase the proportion of women who saw a midwife first when they thought they were pregnant.
Evidence suggested these measures would contribute most strongly to safer and more effective care, particularly for single women and those from more disadvantaged groups.
By the 2010 survey, progress on these targets was very noticeable. In January and February 2010, when more than 25,000 respondents gave birth:
- 24 per cent of women said they had seen a midwife first, compared with 19 per cent in 2007;
- More than half (53 per cent) said they had their booking appointment before nine weeks, as National Institute for Health and Clinical Excellence guidance recommends, - a big rise from 37 per cent in 2007;
- Almost all the women - an impressive 95 per cent - had their dating scan between eight and 14 weeks, in line with another NICE recommendation, and a rise from 89 per cent in 2007.
These are very significant improvements - patient experience results rarely show such leaps. But while trusts and their midwife leaders are to be congratulated for these advances, there is an emerging consensus that it is now time for postnatal care to receive similar attention. The new survey results support that view.
Having a good experience of postnatal care relates largely to the quantity and standard of information, advice, and practical and emotional support with which mothers are provided. An examination of these indicators shows large numbers of women for whom the experience is not satisfactory - and considerable variation in the performance of local services.
For example, just over one tenth of women who gave birth in hospital said they did not get the information and explanations they needed after the birth. In the worst 20 local services on this question, the average was 19 per cent.
Infant feeding is a major issue, and should be discussed with women both while they are pregnant and again, more extensively, after the birth, to explain the options and to promote breastfeeding. Although breastfeeding rates and information provision have slightly improved, there is much further to go.
In the 20 worst local services on this question, nearly a third of women (29 per cent) said midwives failed to discuss feeding options with them during pregnancy. Asked about the same issue in the six weeks after birth, 13 per cent of all women said they did not get help and advice about feeding - rising to an average 22 per cent for the 20 worst local services on this question.
The three worst indicators for postnatal care raise a serious question about the quality of the services - are they woman-centred? Where the information and advice that is needed relates more directly to the mother than to the baby, scores are poor, and the variation appears to be unacceptable. One fifth of all women (21 per cent) said midwives and other carers did not give consistent advice - 28 per cent in the worst services.
Nearly one fifth of all women (18 per cent) said they did not get information about their own recovery - 26 per cent in the worst services.
And one fifth of all women (21 per cent) also said they were not given enough information about any emotional changes they might experience after the birth - rising to one third of women (32 per cent) in the 20 worst services on this question.
In its 2010 report, Postnatal Care: still a Cinderella story? the National Childbirth Trust called for NICE’s guidance to be properly implemented. The guidance specifically advises that every woman should have a documented, individualised postnatal care plan. It says every mother should have a coordinating health professional with lead responsibility for continuity and consistency of care.
These, and a renewed drive to increase breastfeeding rates, should be the new maternity priorities for primary care trusts in their remaining time as commissioners, and for consortia taking up the reins.