In 2006 an exciting opportunity arose which enabled some innovative thinking to become a reality and the award winning Hackney Maternity Helpline was born.
The success of the helpline has exceeded all expectations and in its first 18 months helped over 13,000 callers. Callers who were randomly surveyed at the end of its first year of operation called it ‘absolutely wonderful’ and ‘very reassuring’, recommending it highly to friends and family. It has become one of those ‘why ever haven’t we done this before’ conversations among staff.
The mission statement of the Hackney Maternity Helpline is to improve access to maternity care in Hackney by providing a ‘one stop’ phone service where clients have one-to-one time with an experienced midwife for as long as they need it, when they need it.
In 2005 Team Hackney (the London Borough of Hackney’s Local Strategic Partnership), carried out a comprehensive review of performance against floor targets and noted that infant mortality in Hackney (2002-2004) was high at 6.5 per 1,000 births. In London as a whole it was 5.4 and in England and Wales 5.2 per 1,000 births.
There is a significant ethnic dimension to infant mortality rates in Hackney – infant mortality rates for African and Afro-Caribbean women are over three times higher than for white mothers.
Pre-term birth and low birth weight are also significant factors, a high proportion of infant deaths are associated with births before 37 weeks.
Caribbean women, followed by African women, have significantly higher rates of pre-term births than do white women and Caribbean women have the highest rates of stillbirths among pre-term births.
Gestational age at booking is significant in infant mortality. The later the booking, the higher the risk. Those who do not book at all and receive no antenatal care have significantly higher rates of stillbirth and infant mortality.
Reasons for late or non-booking include lack of experience or understanding of antenatal care, cultural attitudes, language difficulties, fears concerning immigration status, fear of HIV status identification, institutional barriers to access and communication.
Other identified risk factors are maternal age (very young), smoking, not breastfeeding, poor nutrition (CEMACH, 2007). There is also an association between deprivation and low birth weight. These known indices of poor outcome are prevalent in Hackney’s population.
In response to this data, Team Hackney established a priority action team to target infant mortality. The team produced a floor target action plan on infant mortality (see www.teamhackney.org)
The team identified the following target groups
- (West) African and Caribbean women
- Those not accessing antenatal care at all.
- Very young mothers.
A range of interventions was designed to address the problem, including the Maternity Helpline. These interventions were initially funded by Team Hackney but in April 2009 were successfully negotiated into the commissioning process and are now part of mainstream services.
The rationale for a telephone helpline was that improved access to maternity services would benefit the targeted vulnerable groups identified above. In addition a telephone helpline addresses the recommendation that “women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies” Department of Health (DoH) (2004) and DoH (2007).
In addition, Jiwa and Mathers (2003) reported that telephone consultations can reduce the demand for direct consultations by up to 39%, substantially reducing workload while improving access and retaining client satisfaction. Work began on this project on 4 June 2007.
1. Preliminary research
Opinions and ideas were sought from maternity service users in the community by visiting children’s centres, maternity peer group training sessions, young parents group at the Family Welfare Association (FWA), stakeholders meetings arranged by the primary care trust (PCT), the Nia Project – the local domestic abuse agency - and the Sanctuary Clinic (a GP practice for asylum seekers and refugees in the north of the borough), and also by the simple expedient of engaging mothers in conversation on buses, in shops and in the street.
The overwhelming response of women consulted was that a single telephone number for maternity care information and expert advice would be a definite improvement on the current service.
Consultation with voluntary agencies also indicated that the opening times 10:00 to 18:00 would be the most useful for women and their families and analysis of hospital ad hoc ‘out of hours’ non labour calls/admissions suggested that the cost of a 24 hour helpline could not be justified, therefore the decision was made to cover eight hours per day, 365 days a year.
Fact finding visits were made to NHS Direct, the Terrence Higgins Trust (THT), and the Samaritans. All the above were helpful in different ways, in particular Adam Duncan from NHS Direct.
THT delivered phone skills training to our specially selected helpline staff in September 2007, and the Women’s Trust delivered an excellent training day on domestic abuse in January 2008.
Extensive consultation also took place with HUHFT midwifery managers, and the managers and/or practitioners of related departments such as ultrasound scanning, A&E, physiotherapy, psychiatry, the Starlight children’s ward, and diabetes unit as well as the hospital specialist midwives, to ensure referral pathways are effectively mapped.
A great deal of information gathering took place about our local maternity and related services, including times and places of antenatal classes, community clinics, children’s centres, post natal clinics and drop-ins and the breastfeeding support infrastructure.
In addition, information was collected about statutory and voluntary organisations dealing with benefits, legal obligations of employers, housing and other social matters, including the law relating to immigrants of various categories. All of this information has been brought together as a central resource.
We opted to keep the telephone system simple in terms of hardware. We have two helpline handsets with optional headsets, and two internal phone lines, one with a fax machine. Each of the two desks has a computer with full access to HUHFT electronic patient records and the internet.
We consulted on the use of a free phone number (our original plan) and were advised by voluntary groups that work with the homeless and asylum seekers, that this would be disadvantageous to our target groups, as these numbers are not free to mobile phones and a mobile is an essential part of maintaining contact with a group of people who may have to change address frequently or have no permanent home at all.
3. Reporting and monitoring calls
A database for reporting and monitoring calls was commissioned from a non-NHS IT consultant, who continues to work with us to modify and adapt the original model as required.
All calls are documented and the record retained on the database. A hard copy can be produced, if required, for a client’s notes. An anonymised daily list of calls and the advice given are printed and retained in the helpline office for immediate reference.
The bespoke database also enables various reports to be extracted from data collected while maintaining client confidentiality.
Posters and folded business cards in English, Turkish, French, Spanish, Vietnamese and Portuguese were widely distributed throughout the borough shortly before we opened and intermittently since.
Posters and business cards were sent out to every GP surgery, health centre and children’s centre and local pharmacies agreed to include a business card with every pregnancy testing kit sold. In addition, stickers with the helpline phone number are routinely put on the front of the women’s handheld notes, and business cards are included in the postnatal discharge packs from the wards.
We appear on the hospital’s website and there has been some publicity in the free local press. Word of mouth is also an effective publicity agent.
It is essential that experienced midwives do this work, therefore staffing was initially funded at 2.0 Band 7 WTE. We were conscious that the success of this project would largely depend on our credibility with the public, specifically, if we advertise a seven day a week service, then that is what we must deliver.
With this in mind, funding was adjusted to enable us to fill 3 band 7 WTE posts, comprising 1 full time and 7 part time midwives, selected by a rigorous interview that focused specifically on communication skills and midwifery knowledge. The staff are mostly seconded from existing HUHFT posts.
The rationale for this is:
- The involvement of a greater number of midwives will raise the profile of the maternity helpline in the department as a whole, leading to better integration with existing services.
- As existing employees, they are already familiar with Hackney’s maternity services so less orientation is needed, thus saving valuable time.
- The more trained helpline midwives who are available, the better able we will be to cover sickness, annual leave and study leave.
The aim is to have two staff on the helpline on weekdays and one on Saturday and Sunday.
6. Clinical governance
Guidelines have been compiled to ensure that all clinical advice given by helpline midwives is evidence based and consistent. This is, of course, a permanent ‘work in progress’, and is based on the HUHFT existing protocols, National Institute for Health and Clinical Excellence (NICE) guidelines and other accredited research sources. A more concise version of this, or ‘cue cards’ for helpline staff, is available for quick reference.
As the helpline is staffed by carefully selected experienced midwives, it was felt that the detailed algorithms used by NHS Direct, for example, were not required. Midwives are expected to use their knowledge, clinical judgment and the ‘cue cards’ to ensure the integrity of their advice. We noted with interest that Stirling Royal Infirmary research supported similar conclusions when establishing the knowledge base for their telephone triage system (Kennedy, 2007).
How has the work progressed?
1. Activity to date
We opened the helpline for business on Saturday September 8 2007. Initially we operated from 10am to 6pm, seven days a week, 365 days a year, and a target of 1,000 calls in the first year was set by Team Hackney – the initial funding body. By May 25 2009, the helpline had received 12,962 calls and due to this high demand we have extended the hours to 7pm on weekdays.
Of these calls, 4,317 were first contacts with the helpline, a figure approaching 60% of our total clientèle (5,000 deliveries per year). 1,692 of these were classified as BME, 546 as non-BME, and 627 as ethnicity not specified. This indicates that the helpline is being used by approximately 60% BME clients, a fairly accurate reflection of the Hackney population (62% BME 2001 census data). 25 callers were under 18 years old, 603 were aged 18-25.
17 callers were women booking over 12 weeks gestation and 23 were booking late over 20 weeks gestation.
At the planning stage, we did wonder whether a telephone helpline would be chiefly used by the articulate middle classes rather than the population as a whole. The above figures indicate that the helpline is being used by a fairly representative cross section of Hackney’s population.
Our other fear was that women for whom English was not their first language would not call, but experience has shown that many do, often using a friend or relative to help. If communication proves difficult, or we are concerned about confidentiality, we can arrange to call the client back with the assistance of a bi-lingual maternity support worker or a hospital advocate.
The evidence shows that the helpline is being called by women newly arrived in Hackney and by women who say how reassuring it is to have a number to call where they know that they will be able to talk to a midwife about all kinds of issues related to pregnancy and new babies.
Being physically based in the hospital means that the midwives have access to the electronic patient record system and can take self-referrals over the phone and arrange urgent scans or appointments where appropriate. If necessary, a woman in advanced pregnancy can be ‘booked’ during a call, not ideal, but better than arriving on delivery suite as a completely unknown quantity.
Through our monitoring and evaluation processes we have noted that the maternity helpline is making a positive contribution to a number of health agendas in addition to reducing infant mortality.
- We facilitate early booking, before 12 weeks, by taking self-referrals over the phone and where necessary booking early pregnancy screening tests as recommended by Maternity Matters 2007.
- We promote the idea of choice by informing callers of all their options.
- We provide much needed support and reassurance for the chronically anxious client, for example one woman called us 48 times antenatally.
- We are a source of information and support for those women suffering the, often lonely, pain and distress of early miscarriage.
- We provide direct access to a midwife as required by the national service framework.
In particular, we provide this access during the latent phase and very early stages of labour, an area highlighted by Healthcare for London’s 2007 Review of Maternity Services, where care was felt to be especially poor. Clients can call the helpline for professional advice and reassurance as many times as they like while at home “awaiting events”.
We facilitate breastfeeding. This hospital is pursuing WHO Baby Friendly status at present and we feel we are making a significant contribution to this.
Many of our postnatal callers are seeking breastfeeding support. For instance a breastfeeding mother may call because she thinks her baby has diarrhoea, the helpline midwife can enlighten her concerning the properties of human milk and all its advantages.
Another example can be mothers’ concerns that the baby seems perpetually hungry and it transpires that the mother’s nipples are sore. We can talk through positioning and latching on and encourage mothers to call back for support at feed times if they want to. We also signpost clients to community breastfeeding support groups.
As a result of the many calls for breastfeeding advice the helpline is about to adopt a more pro-active approach to infant nutrition. Instead of waiting for clients to develop problems and call us for help, we will call all mothers the day after discharge and ask them how breastfeeding is going. Perhaps we may be able to prevent problems as well as trying to fix them.
Another area where room for service improvement has been highlighted, as a result of calls to the helpline, is the matter of tongue-tie in newborns, and its adverse affect on breastfeeding. Consequently, a helpline midwife has co-operated with infant feeding specialist and public health midwives to formulate a business plan for a midwife-led tongue-tie clinic at the Homerton.
A less anticipated feature of the helpline is that by the collation and auditing of calls, problem areas and/or instances of sub-optimal care are highlighted. For example, a missed postnatal visit will be tracked back to the point at which the system failed and, if necessary, the appropriate manager informed.
Likewise, in the early months of the service we took a lot of calls from community midwives seeking blood test results for clients in their antenatal clinics. This illuminated some systemic problems with finding results which have now been addressed by the community manager, resulting in an improved service for clients and a little less stress for community midwives.
In May 2008 an external evaluation of all reducing infant mortality project interventions was undertaken by NLH Partnership an independent social research agency.
The key findings from the evaluation of the helpline showed that:
- The majority of calls (61%) were from pregnant or postnatal women, with 32% of calls from health professionals (predominantly community midwives), and 5% from pregnant or postnatal women’s friends or family.
- In the majority of cases, helpline midwives were able to offer advice to the caller that was sufficient to deal with and ‘close’ their query and no further immediate action was required.
- Just over half of calls dealt with resulted in callers being referred or signposted on to other services or professionals, suggesting that, as well as appropriately dealing with callers’ queries and resolving callers’ issues, Maternity Helpline staff also identified clients’ needs and signposted and referred on accordingly. The midwives can arrange for children’s centre based midwives to engage with women who are considered in need of more purposeful and ongoing support. If women present for care who don’t have a GP, the midwives can signpost them to the City & Hackney PCT ‘Find-a-Doc’ service
- A significant number of calls resulted in blood results being provided for health professionals (mostly community midwives)suggesting that the helpline may be an important resource for midwives and other professionals, enabling them to gain easy access to information about their clients.
Women like the helpline
Another feature of the evaluation was a telephone questionnaire administered to a random selection of callers over the month of June 2008. Callers were re-contacted and asked to complete a short (validated) telephone questionnaire regarding the helpline service. The response was overwhelmingly positive with spontaneous comments like ‘the midwives were wonderful, kind and knowledgeable – I have recommended the helpline to all my friends’. They are amazed that when someone says they will call them back, they actually do! Given people’s general experience of using telephone information services one of the questions on the survey was ‘what did you expect when you called the helpline’ a classic response was ‘that no one would answer!’
Examples of calls taken
1. A particularly distressing call was from a young girl (Miss X) whose heavily pregnant friend was suicidal. I talked to them at length, obtained all the necessary information and arranged to meet them personally on delivery suite as soon as they could get here. My co-worker was happy to take all calls while I dealt with this emergency situation.
Miss X, a spirited young teenager, had suffered hyperemesis throughout this pregnancy and just wanted the baby ‘cut out’ to end her misery. I ensured she was taken care of on delivery suite and returned to the ‘phone lines leaving my contact details in case she attempted to self-discharge. After 18.00 I returned to delivery suite, contacted her mum and transferred her to the antenatal ward for IV rehydration therapy.
Miss X has recently had her baby girl and they are both home, she looks and feels a lot better physically and mentally. Her suicidal thoughts were an immediate reaction to her desperate situation, feeling so ill, no-one listening. Miss X will have 28 day care from the community midwifery team, a very satisfying outcome. I am thoroughly enjoying working the Maternity Helpline.’ (Midwife TF)
2. A woman at home with her new baby called. It was quickly apparent that she was having serious problems with depressive and self-harming thoughts and feelings. The midwife taking the call kept her talking and after a while asked the woman if she could arrange to get her some professional help. The woman agreed. The midwife indicated this to her colleague. The midwife then continued to engage with the woman over the phone while her colleague arranged for an emergency home visit from the community psychiatric team. When they arrived they took over her care. There is no doubt that the Helpline made a difference to this woman and her baby.
A great number of postnatal calls are related to feeding issues and many hours of breast feeding advice is given over the phone. The midwives will then call the woman back to assess progress and if they feel that the woman would benefit from further ‘hands on’ support they will arrange for an appropriately trained maternity support worker or community midwife to visit, or direct her to her nearest breast feeding support group (usually in her local children’s centre).
The experienced midwives answering calls know the area, the GPs, the midwives, the obstetricians, the services available. In addition to giving advice, helpline staff can liaise with other professionals, providing a single clear point of contact in often complex care provision.
Direct impact on service
Feedback from colleagues throughout the unit has been positive. There is a general perception on delivery suite, the wards and antenatal clinic, that the helpline relieves pressure on busy staff. Prior to its existence, no-one had counted the number of calls dealt with by midwives and others. 3,000 calls per year were taken as a working estimate.
It turns out that the helpline, working only eight hours a day, took that number in the first six months.
“The person on the other end of the phone, they just want to get advice…..and to be passed from one person to another is really irritating.” (delivery suite midwife)
“Sometimes the midwives [on the helpline] will take calls from women who are quite distressed, maybe on the verge of postnatal depression and they’ll spend an hour on the phone to them. Nobody in a clinical environment would [have the time to] do that” (ward midwife)
In response to demand from clients and staff highlighted in the evaluation, we hope to further extend our opening hours to 10:00 to 21:00.
Needless to say, in the current climate of anxiety over swine flu, the helpline is invaluable in providing up to the minute information for clients and easing what would otherwise be a considerable extra burden on hospital staff.
Our plans for the future include a more inclusive ‘multi-media’ helpline, with the addition of texting and e-mail facilities. We are currently working with CHPCT on the development of a maternity website.
In addition HUHFT is currently working towards ‘Baby Friendly’ status. The Helpline will continue to contribute to this work by giving telephone breastfeeding advice and support and following up by referral to other relevant agencies and encouraging women to call back, feed by feed, for as long as they need to.
External funding ended in March 2009, but the helpline, supported by the local NHS commissioners has been mainstreamed.
The Hackney Maternity Helpline has exceeded all expectations and what started as an interesting initiative has quickly become a valuable service. Enquiries have been received from commissioners and providers of maternity services around the country and if clusters of local providers were to initiate similar services there would be the potential for sharing the overnight calls, thus extending to 24 hour cover.
Client response has been overwhelmingly positive, which is gratifying but hardly surprising. What could be better than direct access to a midwife who is glad you’ve called, is happy to listen to you, wants to help you and is able to do so? It is not unreasonable, as our management team have, to conclude that the 16% reduction in self-referred ante-natal admissions to the maternity unit, known as HRG N12s, recorded in early 2008, is partly due to the work of the helpline.
Alison Russell is co-ordinator of the Hackney Maternity Helpline. For more information about the Helpline, or to visit and see the service for yourself email Alison.firstname.lastname@example.org