Maternity and neonatal services

3.8. Having a baby is now safer than 10 years ago. Since 2010, despite increases in some risk factors such as age and comorbidities of mothers, there has been an 18.8% reduction in stillbirths [69], a 5.8% reduction in neonatal mortality [70] and an 8% reduction in maternal mortality [71]. Maternal mortality occurs in fewer than 1 in 10,000 pregnancies. But we can do even better. Significant regional variation in extended perinatal mortality still exists [72]. Of the term babies who died in 2016, different care might have led to a different outcome for 71% [73]. Women from the poorest backgrounds and mothers from Black, Asian and Minority Ethnic (BAME) groups are at higher risk of their baby dying in the womb or soon after birth [74]. Approximately 700-900 pregnancies a year are affected by neural tube defects – in early 2019, the government will consult on the mandatory fortification of flour with folic acid to prevent foetal abnormalities [75]. As foetal and neonatal care has developed, pre-term birth is more common and the survival rate of sick newborn babies is continuing to improve. Neonatal critical care capacity needs to keep pace with these advances to improve short and long-term outcomes for these children.

3.9. Through the Long Term Plan, the NHS will accelerate action to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025. In order to do so:

3.10. An independent evaluation of the Saving Babies Lives Care Bundle (SBLCB), which supports the ambitions set out in Better Births, has shown a 20% reduction in the stillbirth rate at maternity units where it was implemented. We aim to roll out the care bundle across every maternity unit in England in 2019. We will also support the establishment of Maternal Medicine Networks, which will further ensure women with acute and chronic medical problems have timely access to specialist advice and care at all stages of pregnancy. And the Maternity Incentive Scheme will, for the second year running, reward the delivery of 10 key maternity safety actions through a Clinical Negligence Scheme for Trusts (CNST) rebate.

3.11. However, the prevalence of pre-term birth is increasing [76], and more focus on pre-term mortality is needed to achieve substantial reductions in overall perinatal mortality rates and meet our national ambition [77]. An expansion to the SBLCB will be published in 2019. This will include a focus on preventing pre-term birth, which will minimise unnecessary intervention and define a more holistic approach to risk assessment during labour, alongside further improvements to cardiotocography monitoring, and reductions in smoking during pregnancy. To care for women with heightened risk of pre-term birth, including younger mothers and those from deprived backgrounds, we will encourage development of specialist pre-term birth clinics across England. The SBLCB will also encourage clinically appropriate use of magnesium sulphate – estimated to help reduce the number of pre-term babies born with cerebral palsy by up to 700 per year. We will support maternity services to fully implement the expanded SBLCB in 2020.

3.12. Recommendations from the National Maternity Review: Better Births are being implemented through Local Maternity Systems. These systems bring together the NHS, local authorities and other local partners with the aim of ensuring women and their families receive seamless care, including when moving between maternity or neonatal services or to other services such as primary care or health visiting. By spring 2019, every trust in England with a maternity and neonatal service will be part of the National Maternal and Neonatal Health Safety Collaborative. Every national, regional and local NHS organisation involved in providing safe maternity and neonatal care has a named Maternity Safety Champion. Through the Collaborative and Maternity Safety Champions, the NHS is supporting a culture of multidisciplinary team working and learning, vital for safe, high-quality maternity care. Twenty Community Hubs have been established, focusing on areas with greatest need, and acting as ‘one stop shops’ for women and their families. These hubs work closely with local authorities, bringing together antenatal care, birth facilities, postnatal care, mental health services, specialist services and health visiting services.

3.13. Continuity of carer teams are being developed and launched across the country – with the aim that in 2019, 20% of pregnant women will be offered the opportunity to have the same midwife caring for them throughout their pregnancy, during birth and postnatally. These teams will deliver more personalised care plans for pregnancy. We will continue to work with midwives, mothers and their families to implement continuity of carer so that, by March 2021, most women receive continuity of the person caring for them during pregnancy, during birth and postnatally. Women who receive continuity of carer are 16% less likely to lose their baby, 19% less likely to lose their baby before 24 weeks and 24% less likely to experience pre-term birth [78]. This will be targeted towards women from BAME groups and those living in deprived areas, for whom midwifery-led continuity of carer is linked to significant improvements in clinical outcomes [79].

3.14. The NHS will continue to improve how it learns lessons when things go wrong and minimise the chances of them happening again. The Healthcare Safety Investigation Branch reviews all term stillbirths, early neonatal deaths and cases of severe brain injury in babies, as well as all maternal deaths. A Perinatal Mortality Review Tool is now used by all maternity providers, supporting high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death.

3.15. Maternity digital care records are being offered to 20,000 eligible women in 20 accelerator sites across England, rising to 100,000 by the end of 2019/20. We will continue to expand the roll-out of maternity digital care records. By 2023/24, all women will be able to access their maternity notes and information through their smart phones or other devices. Maternity Pioneers have commissioned and rolled out apps to help women to make choices about their care and access services and information in a more convenient and efficient way. Women’s experiences of maternity care are also improving, with improvements across almost every question in the latest Care Quality Commission (CQC) survey [80]. Involving service users has been at the heart of these improvements with over 100 Maternity Voice Partnerships in place across England to ensure that maternity services are rooted in, and responding to, what women and their families need and want.

3.16. Around one in four women experience mental health problems in pregnancy and during the 24 months after giving birth [81]. The consequences of not accessing high-quality perinatal mental health care are estimated to cost the NHS and social care £1.2 billion per year [82]. The Long Term Plan will improve access to and the quality of perinatal mental health care for mothers, their partners and children by:

  • Increasing access to evidence-based care for women with moderate to severe perinatal mental health difficulties and a personality disorder diagnosis, to benefit an additional 24,000 women per year by 2023/24, in addition to the extra 30,000 women getting specialist help by 2020/21. Care provided by specialist perinatal mental health services will be available from preconception to 24 months after birth (care is currently provided from preconception to 12 months after birth), in line with the cross-government ambition for women and children focusing on the first 1,001 critical days of a child’s life [83];
  • Expanding access to evidence-based psychological therapies within specialist perinatal mental health services so that they also include parent-infant, couple, co-parenting and family interventions;
  • Offering fathers/partners of women accessing specialist perinatal mental health services and maternity outreach clinics evidence-based assessment for their mental health and signposting to support as required. This will contribute to helping to care for the 5-10% of fathers who experience mental health difficulties during the perinatal period [84];
  • Increasing access to evidence-based psychological support and therapy, including digital options, in a maternity setting. Maternity outreach clinics will integrate maternity, reproductive health and psychological therapy for women experiencing mental health difficulties directly arising from, or related to, the maternity experience.

3.17. We will improve access to postnatal physiotherapy to support women who need it to recover from birth. About one in three women will experience urinary incontinence after childbirth [85], one in ten faecal incontinence [86], and one in twelve pelvic organ proplapse. Physiotherapy is by far the most cost-effective intervention for preventing and treating mild to moderate incontinence and prolapse [87]. We will ensure that women have access to multidisciplinary pelvic health clinics and pathways across England via referral. Clinics can also provide training and support for local clinicians working with women, such as GPs and midwives.

3.18. All maternity services that do not deliver an accredited, evidence-based infant feeding programme, such as the UNICEF Baby Friendly Initiative, will begin the accreditation process in 2019/20. Only 57% of babies in England are currently born in an accredited ‘baby friendly’ environment. Our breastfeeding rates compare unfavourably with other countries in Europe [88]. There is substantial variation between parts of England, with 84% of children breastfed at 6-8 weeks in London compared to 32% in the North East [89].

3.19. We will redesign and expand neonatal critical care services to improve the safety and effectiveness of services and experience of families.  In particular, we will address the shortage of neonatal capacity through the introduction of more Neonatal Intensive Care Cots where the Neonatal Critical Care Review has identified under capacity. We will improve triage within expert maternity and neonatal centres so that the right level of care is available to babies as close to the family home as possible. This will improve survival, safety and the quality of outcomes for babies.

3.20. We will develop our expert neonatal nursing workforce. This will mean extra neonatal nurses and expanded roles for some allied health professionals to support neonatal nurses.

3.21. We will enhance the experience of families during the worrying period of neonatal critical care. From 2021/22, care coordinators will work with families within each of the clinical neonatal networks across England to support families to become more involved in the care of their baby and invest in improved parental accommodation.


References

69. Office for National Statistics (2018) Death registrations summary tables – England and Wales. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathregistrationssummarytablesenglandandwalesreferencetables

70. Office for National Statistics (2018) Child mortality in England and Wales. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/
childmortalitystatisticschildhoodinfantandperinatalchildhoodinfantandperinatalmortalityinenglandandwales

71. MBRRACE-UK (2018) Saving Lives, Improving Mothers’ Care. Available from:
https://www.npeu.ox.ac.uk/mbrrace-uk/reports

72. Healthcare Quality Improvement Partnership (2018) MBRRACE-UK Perinatal Mortality Surveillance Report 2018. Available from: https://www.hqip.org.uk/resource/mbrrace-uk-perinatal-mortality-surveillancereport-2018

73. Royal College of Obstetricians & Gynaecologists (2018) Each Baby Counts: 2018 progress report. Available from: https://www.rcog.org.uk/en/guidelines-research-services/audit-quality-improvement/each-baby-counts/reports-updates/each-baby-counts-2018-progress-report/

74. Draper, E., Gallimore, I., Kurinczuk, J., Smith, P., Boby, T., Smith, L. & Manktelow, B.(2018) MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from January to December 2016. Available from: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202018%20-%20Web%20Version.pdf

75. Department of Health and Social Care (2018) Fortifying flour with folic acid: government to consult. Available from: https://www.gov.uk/government/news/fortifying-flour-with-folic-acid-government-to-consult

76. Langhoff-Roos, J., Kesmodel, U., Jacobsson, B., Rasmussen, S. & Vogel, I. (2006) Spontaneous preterm delivery in primiparous women at low risk in Denmark: population based study. BMJ. 332, 937–939. Available from: https://doi.org/10.1136/bmj.38751.524132.2F

77. MBRRACE-UK (2018) Saving Lives, Improving Mothers’ Care. Available from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports

78. Sandall, J., Soltani, H., Gates, S., Shennan, A. & Devane, D. (2016) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. (4). Available from: https://doi.org/10.1002/14651858.CD004667.pub5

79. Homer, C., Leap, N., Edwards, N. and Sandall, J. (2017). Midwifery continuity of carer in an area of high socio-economic disadvantage in London: A retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997–2009). Midwifery. 48, 1-10. Accessible from: https://doi.org/10.1016/j.midw.2017.02.009

80. Care Quality Commission (2018) Maternity services survey 2017. Available from: https://www.cqc.org.uk/publications/surveys/maternity-services-survey-2017

81. Howard, L., Ryan, E., Trevillion, K., Anderson, F., Bick, D., Bye, A., Byford, S., O’Connor, S., Sands, P., Demilew, J., Milgrom, J. & Pickles, A. (2018) Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. The British Journal of Psychiatry, 212 (1), 50-56. Available from: https://doi.org/10.1192/bjp.2017.9

82. Bauer, A., Parsonage, M., Knapp, M., Iemmi, V. & Adelaja B. (2014) The Costs of Perinatal Mental Health Problems. Centre for Mental Health. Available from: https://www.centreformentalhealth.org.uk/publications/costs-of-perinatal-mental-health-problems

83. The 1001 Critical Days (2016) The 1001 Critical Days The Importance of the Conception to Age Two Period. Available from: https://www.1001criticaldays.co.uk/sites/default/files/1001%20days_oct16_1st.pdf

84. Paulson, J. & Bazemore, S. (2010) Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression: A Meta-analysis. JAMA. 303 (19), 1961–1969. Available from: https://doi.org/10.1001/jama.2010.605

85. Thom, D. & Rortveit, G. (2010) Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstetricia et Gynecologica Scandinavica. 89 (12), 1511-22. Available from:
https://doi.org/10.3109/00016349.2010.526188

86. Johannessen, H.H., Wibe, A., Stordahl, A., Sandvik, L., Backe, B. & Mørkved, S. (2013) Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study. BJOG. 121 (3), 269-280. Available from: https://doi.org/10.1111/1471-0528.12438

87. Barber, M. (2016) Pelvic organ prolapse. BMJ. 354, i3853. Available from: https://doi.org/10.1136/bmj.i3853

88. Victora, C., Bahl, R., Barros, A., França, G., Horton, S., Krasevec, J., Murch, S., Sankar, M., Walker, N. & Rollins, N. (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. Available from: https://doi.org/10.1016/S0140-6736(15)01024-7

89. Public Health England (2018) Breastfeeding at 6 to 8 weeks after birth: 2017 to 2018 quarterly data. Available from: https://www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-2017-to-2018-quarterly-data