In deciding how the care of pregnant women is delivered in future, the assumptions that underpin the current polarised debate must be challenged, say Belinda Phipps and Anna Dixon
There is a fight going on over the location of care for pregnant women. One side wants maternity services built around the needs of high risk mothers and babies, with big units and medical expertise focused on one site for optimum presence of a consultant obstetrician. The aim is to assure the safest possible care.
‘We identified the assumptions that appear to be at the root of the stalemate and challenged them’
The other side calls for maternity services to be designed around the majority of women, whose pregnancies are low risk, with community-based care provided by a known midwife. The aim is to ensure the physical, psychological and social needs of pregnant women and their babies are met.
To some extent both sides have valuable arguments, but at the same time neither of them offers a workable solution for the future of maternity services. Let’s face the real challenge: how to deliver safe and personalised care for all women in every pregnancy.
A group of healthcare leaders came together at the King’s Fund last year to think differently about the future of maternity services. We identified the assumptions that appear to be at the root of the stalemate and challenged them.
These assumptions were that locating services in or next to obstetric units is essential to ensure safety. Safety is only assured by obstetrician presence on the labour ward. Adequate staffing levels of both midwives and obstetricians can only be resourced in larger units. Personalised care and the full range of choices can only be offered in community or home settings.
First, the location of care does not necessarily determine whether care is safe. Risk, particularly during labour, is dynamic and can escalate quickly. It is important that all women have high quality expert care continuously available with access to timely intervention if needed, but larger units may not be the best way to provide this.
Emergency surgery takes time to arrange even in a big unit − usually at least 30 minutes from identification of the need. By concentrating these services in fewer locations they become less accessible for women who go into labour in an out of hospital setting but eventually need more assistance.
We considered how this could be achieved for women in all settings. First, it requires joint protocols to be developed and implemented to ensure timely access to urgent support.
‘New social media applications have potential to revolutionise the way that clinicians access expert advice’
Ambulance and obstetric services responses to calls should be immediate, so the necessary care can be provided as fast as if the woman were in an obstetric unit.
There is mixed evidence on this: some suggests there may be a slightly higher risk of poor outcomes from treat and transfer approaches, but for women who have had a straightforward first pregnancy outcomes are as good if they plan to give birth at home or in a community setting.
More radical ideas voiced included more standardised equipment being available in ambulances or mobile obstetric theatres “bringing the hospital to the home”.
The second assumption is that safety can only be assured by obstetrician presence, with the gold standard being 24/7. Even in large units access to a senior doctor can take time. The group discussed whether “presence” should be redefined as “access to the expertise” of a consultant, contacted remotely for example, and not necessarily being physically present for every labouring woman.
If the woman is under the care of an experienced professional who can take the actions advised then the same purpose could be served by the consultant being available virtually.
Access to expertise when required could be online via midwifery, obstetric or paediatric consultants, who provide an immediate response to an unusual circumstance to midwives wherever they are.
Similar support could be available within obstetric units, for example to support a junior obstetrician. Crowd sourcing, Twitter, video conferencing and new social media applications all have potential to revolutionise the way that clinicians seek and access expert advice.
Finding a balance
The third assumption is that requisite staffing levels can only be achieved in a larger unit. Staffing norms are defined according to particular professional roles. Should the outcome be redefined as having a team of people with the right skills available at the right time? This opens up the possibility of different roles, skill mix and deployment.
Regardless of their size, obstetric units face the operational challenge that there is unpredictable variation in demand for labour care. It is a normal occurrence and difficult to manage.
‘Currently the place of birth is a proxy for a set of choices about a personalised approach to care’
Even if fully staffed, units may have too many women in established labour, resulting in an unsafe service, and the unit may close to admissions. Or women may be left without a midwife for long periods during their labour, and continuity of both care and carer can be lost as shifts change. This situation can also trigger earlier intervention because lack of continuity prevents watchful waiting.
One idea is to change the model from staffing a unit to staffing the women, kown as “case loading”. It requires flexibility but could allow midwives to balance their home and work lives and fit the care around the women. This would end fixed clinic times for much of antenatal care and enable home visits to take place where convenient for midwives and women.
There could be other ways to free up obstetric expertise on the labour ward, for example by recruiting dedicated obstetric consultants, who don’t offer gynaecology care. This would increase the number of sessions they were able to dedicate to labour ward cover and so fewer doctors overall are needed.
Also, the decision to intervene need not be made by the same person who carries out the procedure. Could a highly skilled surgical assistant become competent to carry out caesarean sections at high volumes?
The final assumption is that personalised care can only be delivered in a home or community setting. The group felt there should be a range of choices available for all women, offering safe and fulfilling experiences, which are about much more than place of birth. The range of such choices offered to high risk and low risk women may be different and this needs to be clearly explained and understood.
Currently the place of birth is a proxy for a set of choices about a personalised approach to care. There is no reason why many of these could not be available to women in any setting.
Obstetric units do not need to look like clinical hospital wards nor have the same restrictions imposed. Maternity service staff can create “home like” environments within obstetric units so that women do not have to make a choice between safe but depersonalised care, and higher risk, high touch care.
The debate is likely to rage on; these are difficult issues to resolve. In determining how the care of pregnant women and their babies is delivered in future, the assumptions that underpin the current polarised debate must be challenged and redefined.
By thinking differently it may be possible to deliver the outcomes that are important to women in ways we have not yet imagined.
Time to Think Differently is a new programme of work from the King’s Fund aimed at stimulating debate about the changes needed for the NHS and social care to meet the challenges of the future. By engaging others and promoting discussion, it hopes to generate new thinking about innovative ways of delivering high quality care and support health and social care leaders in their decision making. Join the debate.
Belinda Phipps is chief executive of the National Childbirth Trust. Anna Dixon is director of policy at the King’s Fund.