Female genital mutilation · ISSUE 4 | 2014 Female genital mutilation Can it be eradicated in a...

ISSUE 4 | 2014

Female genital

mutilationCan it be eradicated in

a generation?

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rcm.org.uk/midwives 2014 • ISSUE 4 • MIDWIVES 3

Midwives5 ► JON SKEWES The RCM’s director for policy, employment relations and communication asks if it is time to take a stand over pay.

7 ► NEWSBirth spacing and pregnancy loss.

10 ► ICM NEWSA round-up of news from the ICM in Prague.

12 ► GLOBAL NEWSThe latest news from around the world.

13 ► IN FOCUS World maternity services report fi ndings.

16 ► RCM NEWSPay consultation and scholarships.

18 ► COUNTRY NEWSRCM UK latest news for England and Northern Ireland.

19 ► ON POLITICSStuart Bonar on the need for politicians to understand the UK’s midwifery challenges.

20 ► WORK LIFEAmy Leversidge reports on the RCM’s actions protesting for fair pay for the NHS.

23 ► ONE-TO-ONEJulie Griffi ths speaks to Cathy Atherton, HoM at Europe’s largest maternity hospital.

26 ► FEEDBACKMIDIRS and NCT merger concerns.

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Volume 17 ˙ Issue 4 ˙ 2014

EDITORIAL

HEADLINES

OPINIONS

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MIDWIVES • ISSUE 4 • 2014 rcm.org.uk/midwives4

MidwivesThe offi cial magazine of The Royal College of Midwives15 Mansfi eld Street, London W1G 9NH0300 303 0444

EDITORIALEditor: Emma [email protected] 7324 2751Deputy editor: Rob [email protected] 7324 2752News and features writer: Hollie [email protected] 7880 6210Professional editor: Professor Mary SteenPhD MCGI PGDipHE PGCRM BHSc CIMI RM RGNGeneral enquiries: [email protected]

EDITORIAL BOARDLouise Silverton, Jon Skewes, Val Finigan, Kate Brintworth, Suzanne Truttero, Jane Sandall, Carmel Lloyd

PUBLISHERSRedactive Publishing Ltd17-18 Britton Street, London EC1M 5TP 020 7880 6200Director: Jason Grant

ADVERTISINGGroup sales director: Steve [email protected] 7880 6220Sales manager: Giorgio [email protected] 020 7880 7556 Sales executive: James [email protected] 020 7880 7661

DESIGNCreative director: Mark ParrySenior designer: Carrie Bremner

COVERIllustration: Ana Villalba

PRODUCTIONSenior production executive: Aysha [email protected] 7880 6241

MEMBERSHIP0300 303 0444

MAGAZINE SUBSCRIPTION RATES(For non-members only, per annum) UK: £130 European Union: £175Rest of the world: £185

MAGAZINE SUBSCRIPTION QUERIESAbacus e-Media, Chancery Exchange, 10 Furnival Street, London EC4A 1YH020 8955 [email protected]

Printed by Polestar, Colchester. Mailed by Priority, Salisbury.

All members and associates of the RCM receive the magazine free.

The views expressed do not necessarilyrepresent those of the editor or of The Royal College of Midwives.

All content is reviewed by midwives.

Midwives ISSN: 1479-2915

27 ► MSW VOICEMCAs organise fi rst MCA conference.

28 ► STUDENT NOTICEBOARDWhat’s new in the student world?

29 ► ON COURSEThe importance of student study days.

30 ► UP FRONTA mother’s thoughts on antenatal screening for Down’s syndrome.

33 ► CUTTING EDGEEmma Godfrey-Edwards reviews the latest midwifery-related research.

34 ► HOW TO…Treat a primary postpartum haemorrhage.

36 ► EBMA summary of the papers in the latest issue of EBM.

41 ► FGMCan the practice can be eradicated?

45 ► PARENTAL RIGHTSAn update on the latest changes to parents’ rights that midwives can off er.

46 ► COMMISSIONINGHow can midwives in England get more involved with commissioning services?

48 ► POSTNATAL CAREDebra Bick presents the annual Zepherina Veitch lecture.

50 ► SCOTLAND REFERENDUMTo vote yes or no? You decide.

52 ► PEER REVIEWA record-keeping initiative.

54 ► RCM AWARDSupporting deaf women and couples through pregnancy and childbirth.

56 ► EVENTS

57 ► COMPETITIONS

58 ► CROSSWORD

ON FOCUS

FEATURES

FOOTNOTES

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Editorialrcm.org.uk/midwives 2014 • ISSUE 4 • MIDWIVES 5

RCM director for policy, employment relations and communications Jon Skewes

T he RCM has been consulting all members working in the NHS in England on their willingness to take industrial action to defend the pay system. This is hugely

signifi cant – if RCM members do take action, then it would be for the fi rst time. The elected RCM Board will need to consider if there is suffi cient support to ballot members on either action short of strike or strike action.

This follows the announcement by the secretary of state to ignore the Pay Review Body (PRB) recommendations to uprate pay by 1%. Even this would represent a further pay cut, compared to rises in the cost of living. Instead, Jeremy Hunt imposed an unconsolidated 1% for those at the top of their pay band. This will last for two years, but will be removed in 2015-16. If members are still receiving increments, that is all you’ll get. Unsocial hours and London weighting are frozen.

Scottish members have received the PRB-recommended award, so it can be aff orded. The PRB specifi cally said it was aff ordable and that failure to pay would hit morale. We await decisions in Wales and Northern Ireland.

What is the coalition government doing in England? Our estimate is that they are saving £155m on an NHS spend of

around £110bn by ignoring the PRB award. They say it is to save jobs. Yet they wasted £3bn on a senseless top-down reorganisation, paid top executive-level directors increases of more than 6% in the last two years and have hardly matched

the increase in the birth rate with enough midwives. We know their aim is to cut the top level of pay

to roughly the middle of each pay band. Anything else would be earned on a rationed basis for performance each year. Most midwives could lose thousands. It also makes the NHS a cheaper proposition for commercialisation of services.

So the time to oppose this act of political will, less than a year before an election, is now. The RCM has already supported demonstrations in London and Liverpool and a lobby of MPs was held in early July. The NHS and how its staff are valued will need to be at the forefront of political and public attention.

Finally, the government has a decision to make. Does it engage with the RCM and other health unions to ensure fair pay through negotiation or does it pick a dispute within the NHS? The RCM will always seek to achieve the best solutions for women and their families, as well as our profession. It may be that the time is coming for all midwives, MSWs and other NHS staff to stand strong.�

Time to say enough is enough

rcm.org.uk/midwives 47MIDWIVES • ISSUE 4 • 201446 COMMISSIONING

The new NHS structures in England came into being in April 2013. Midwives who have an interest in influencing how services are

commissioned need to understand who does what and how they can get involved. Most midwives will be aware that the new clinical commissioning groups (CCGs) now have the responsibility for commissioning on behalf of their local population, but other organisations also have a role.

Regardless of where they are, commissioners require a certain level of knowledge and expertise to commission effectively. Midwives can help them access this experience to enable them to commission high quality services and, at the same time, get a greater voice for the midwifery profession.

A changing horizonBefore April 2013, primary care trusts (PCTs) held the budget for both primary and secondary care, community and acute services. This included private hospitals, as well as those in the NHS and ex-NHS

InfluenceTo be as influential as possible, understand the design of your local CCG. Find out which clinical director is maternity lead and who has the role of nurse director. Also, it may be useful to find out if there is a quality lead, because in some CCGs they are separate posts. It is important to understand the wider commissioning landscape in the health and social care setup and look into how your organisation engages with the CCG and local authority.

As midwifery leaders, you need to influence what commissioner’s commission by being the voice for maternity services. Challenge the current commissioned services, and be prepared to make difficult decisions in order to make that difference for women and babies.

Commissioners value clinical input, so get involved. It is a great opportunity for learning and, who knows, it could be your next career move?�

Diane Jones Registered midwife, SoM and deputy nurse director, Barking and Dagenham, Havering and Redbridge CCGs

commissioning for quality and innovation (CQUIN). Some KPIs will have a financial penalty attached, so that if it has not been achieved, money can be withheld from the provider. A CQUIN offers a financial incentive when a target has been achieved. Both KPIs and CQUINs should be agreed with the provider and commissioners of services prior to the contract being signed off. Examples of commonly used KPIs include the rates for normal vaginal birth, CS and breastfeeding initiation.

It is also useful to agree clinical indicators. These have no financial penalty or reward but, instead, are about best practice. For example, they might include pain relief usage, postpartum haemorrhage rate, intensive treatment unit and neonatal intensive care unit unplanned admission, staff training and appraisal.

As a provider of maternity services, you will have a contractual responsibility to assure the CCG that women and babies are receiving the best possible care. If there are weaknesses or deficiencies then it is your job to explain to the CCG about how this will be managed and improved upon.

The way that services are commissioned in England has changed and there is an opportunity for midwives to get more

involved, as Diane Jones explains.

ideas must clearly demonstrate a service improvement for women and, therefore, they are likely to fall under one or more of the four strands in the quality spectrum – organisational integrity, patient experience, clinical effectiveness and patient safety.

It should also fit with the corporate objectives of your organisation, otherwise it could be blocked without ever being discussed with commissioners.

The role of the commissioners is to be assured that services are of excellent quality for the local population. Quality will present differently, depending on the strand. For example, organisational integrity may show quality via staff questionnaires and the NHS Litigation Authority. Meanwhile, the strand on patient experience would demonstrate good care by how it handles complaints and the friends and family score. Commissioners would look for NICE compliance and audit reports in the strand on clinical effectiveness and patient safety would cover issues, such as safeguarding and serious incidents.

Quality in each strand can be measured by key performance indicators (KPIs) and

Making the midwifery

voice heard

community care, alongside private or third-sector community care. Now PCTs have been abolished and CCGs are in charge. Their commissioning landscape covers all the same elements that the PCTs did, including maternity services.

But not all maternity services come through CCGs and it is important to know where other aspects of maternity are commissioned. The

aim is to find out who the key people are in CCGs and elsewhere with whom to engage, so that the midwifery voice is heard and reflected in service specifications.

The three bodies involved in commissioning maternity services are: the local authority, NHS England and CCGs. The local authority is responsible for public health, which includes antenatal screening, the child death overview panel and the deprivation of liberty safeguards. In addition, since April 2014, health visiting comes under the auspices of local authority having previously been covered by NHS England.

NHS England covers general practice and other primary care functions, such as dentistry, ophthalmology and pharmacy. And CCGs cover mental health and other maternity services in acute care and community care, with the exception of screening.

A CCG is generally made up of a collection of GPs. They are appointed as clinical directors and, from their number, they elect a chair and vice chair. Each clinical director will have a special interest or particular experience of a clinical area for which they will take the lead at the CCG. At least one of them will be the lead for maternity. In addition, a CCG will have a nurse executive, as well as an accountable officer, chief finance officer and a chief operating officer, as a minimum requirement.

Making the commissioning caseObviously, it is important to make a compelling case to commissioners. Any

GPs GPs GPs

GPs GPs GPs

GPs GPs GPs GPs GPs GPs

PRIMARY CARE TRUST

CLINICAL COMMISSIONING GROUP

NHS hospital

NHS hospital

Private hospital

Private hospital

Ex-NHS community

care

Ex-NHS community

care

Private/Charity

community care

Private/Charity

community care

BEFORE

Figure 2 – NHS commissioning landscape before and then after April 2013

Abolished NewAFTER

Figure 1 – An overview of the four quality strands

QUALITY ASSURANCE

Organisational integrity

Staff questionnaire

NHSLA submission

NICE compliance

Audit reports

Serious incidents (SIs)

Safeguarding

Complaints

Friends & family score

Patient experience

Clinical effectiveness

Patient safety

rcm.org.uk/midwives 51MIDWIVES • ISSUE 4 • 201450 SCOTLAND REFERENDUM

We want to see investment continue to tackle health inequalities in Scotland.

We certainly don’t want to see problems worsened by budget cuts to

fund separation.The NHS

epitomises Scottish and British values in one institution. We care for our vulnerable and sick with no questions asked and no charges levied.

These values would persist in a separate Scotland, but our means to realise them might not. Under devolution we can steer Scotland’s NHS in the direction we want it to go,

while being backed up by the larger UK economy.

As part of the UK, Scottish clients and patients can get the best of both worlds: excellent treatment in this country’s hospitals, while also having access to specialist treatment our families need across the UK. The Nationalists are asking us to take a huge gamble in September. We know that it is a risk we don’t have to take and that is why Scotland should say ‘No Thanks’ to separation.�

the border, market midwifery and privatised cleaning means the costs are cut where the risk of disaster is least obvious and where there is a profit to be creamed off from the most insecure and marginalised workforce.

In Scotland, we’re still paying through the nose for private finance initiative projects that started years ago and the public purse has borne the burden. But in England, some trusts have gone bust. Where care ends up being provided is a lottery depending on the

We understand the health issues that affect families across Scotland and we also understand that the higher level of public spending in Scotland gives us an advantage in tackling these issues.

After all, that spending allows us to tackle the specific needs of Scotland with the allocation of that spending being decided by the Scottish Parliament.

Like everyone in Scotland, we’re incredibly proud of our NHS. Since 1999, the NHS has been under the control of the Scottish Parliament. The decisions about how the public spending on Scottish hospitals is made in Scotland by people who understand the specific health concerns affecting us. The Scottish Parliament enjoys devolved powers over the NHS in Scotland – so it will be future Scottish Parliaments that decide the shape of our service.

Since devolution meant that all decisions over the health system in Scotland were made here in Scotland, we have made huge strides in improving the health of families.

As part of the UK, Scotland’s yearly health spending is over £200 per person higher than it is in England. Yet under separation, impartial experts suggest that Scotland would face between £3bn and £10bn worth of cuts or tax rises. Even the NHS could not escape the inevitable cuts that would come from such an upheaval in our public finances.

not going to pretend that Scotland is some Nirvana of maternity care. When services are compared, there are many similarities.

But there are differences too – especially when women are asked about cleanliness and postnatal care. This is because of the huge divergence in policy north and south of the border.

There are much higher levels of dissatisfaction in England. It doesn’t take a rocket scientist to work out why. South of

It might not feel like it, but being a midwife in Scotland puts you, and the service, in a better position than in England. This is a direct result of

Scotland moving away from the market model of trusts competing with each other and instead approaching health and midwifery care as a public service, not an opportunity for profit.

When I worked as a midwife and a trade union activist, issues around workload and staffing were perennial sources of stress and controversy. This is still the case; I’m

With Scotland set to take to the polling stations on 18 September, what will

independence mean for the country’s midwives? We hear both sides of the

argument for Scotland leaving the UK.

How will you vote?

operation of the market whereas, in Scotland, maternity care is planned as a public service. We might not always agree with the plan, but at least there’s recognition that babies don’t come along according to where they’ll ping the most cash registers.

Scotland is protected like a neonate in an incubator, but the real power is outside and concentrated in Westminster. We have a chance to change that.

The devolved NHS in Scotland has protected us against privatisation and commercialisation, so far. However, Osborne has promised us there is at least as much austerity to come and even Labour in Westminster has confirmed they will uphold his plans. In Scotland, all the financial slack is out of the system now and further cuts are bound to affect our NHS, which takes up 40% of our block grant.

Midwives’ pay and regulation are all controlled by London bodies. Are the needs of Scotland’s more geographically spread, diverse communities reflected and catered for by the UK structures and processes that wield ultimate power on your day-to-day terms and conditions and regulatory regime? I’ve not worked as a midwife for some time, so you’ll know better than me.

This is a time where midwives in Scotland have the chance to seize all the power that is needed to make maternity services that are really fit for the nation and value midwives north of the border, according to the needs of women and families. How would you want it to look? What would be the point of pursuing your vision without the power to do so? Seize it.

CAROLYN LECKIE YES SCOTLAND

SPOKESPERSON BETTER TOGETHER

Illustration: Jacob Stead

We don’t want to see

problems worsened by budget

cuts to fund separation

rcm.org.uk/midwives 43MIDWIVES • ISSUE 4 • 201442 FGM

In May, a woman was arrested at Heathrow airport on suspicion of conspiracy to commit FGM and a 13-year-old girl travelling with her was taken into care. This came about after a week-long anti-FGM initiative held across six other airports. Comfort, who worked with police years ago at Heathrow on a similar campaign, believes it is a very good form of action. ‘It is raising awareness and also giving information directly to the families travelling to different parts of the world, but particularly targetting the FGM-practising communities,’ she says.

But Comfort opposes the idea of medical examinations at airports – such as those carried out in France on girls thought to be at risk of FGM. Instead, she suggests that medical assessments – similar to those that used to be carried out by health visitors on all children of a certain age – should be brought back to safeguard those at risk.

‘Prevention is better in the sense that we all need to collaborate and work with the grass-roots community in order to change attitudes and mindset,’ she adds.

The first ever prosecution for FGM is currently working its way through the judicial system. The question is: will this be the first of many or a one off?

Leyla Hussein, FGM survivor and campaigner, hopes the action is not an isolated instance, but the start of a drive to eradicate the practice.

Over the past 18 months Leyla, and many others campaigners, have battled to keep FGM in the headlines. Her online petition ‘Stop FGM in the UK now’ has over 110,000 signatures and has already been addressed by the government, with Leyla invited to give evidence at the Home Affairs Committee inquiry in March.

Also famous for her Bafta-nominated documentary The cruel cut, which aired last year, Leyla believes that it is thanks to survivors like herself who have been speaking out recently, that the anti-FGM campaign has reached such a level.

‘You can talk about any social issue all day, every day, but you need to actually have the person who has experienced it speaking out,’ she says.

‘Then people connect to it because they can hear it and see it first hand and they can’t walk away from it. I think that the British public was ready for a British girl like me, with a London

EYEV

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NEW

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TERN

ATIO

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/CO

RBIS

Over

66,000 women in the UK have

already undergone FGM

More than

24,000 girls are at risk in the UK

FGM has been a criminal offence in the UK since

the Prohibition of Female Circumcision Act

1985 This was later replaced by the FGM Act (2003) in England, Wales and

Northern Ireland and the prohibition of FGM Act

(2005) in Scotland

Both the 2003 and 2005 acts carry a maximum

prison sentence of

14 years

‘We recommend in the intercollegiate report that there is a clear pathway for referral for all health professionals, but it has to be a national pathway, so whether a midwife works in deepest Cornwall or in Brixton, she knows the pathway and what to do if a woman in her care has undergone FGM,’ Janet says.

But just how prevalent is FGM in the UK?New figures reveal that nearly 4000 women and girls have been treated for FGM in London’s hospitals since 2009 (FOI, 2014) and at least 66,000 in the UK are believed to be victims (Dorkenoo et al, 2007).

‘We average about two reversals per week,’ says Comfort Momoh, midwife and FGM consultant/public health specialist at Guy’s and St Thomas’ Hospital in London. Comfort established and runs the African Well Woman’s Clinic at Guy’s, offering support, information and surgical reversal of FGM. She has also helped to set up similar clinics across the UK and has run a course to train others in FGM reversals.

accent, who has gone through FGM and is willing to speak out about it.’

Leyla’s documentary has not been the only TV show to beam FGM into homes across the UK, as popular primetime TV dramas, such as Casualty and Law and Order: UK have been covering the subject, which for so long has been surrounded by cultural sensitivities and social taboo. The Evening Standard has also been a particularly vocal news source, running regular stories, features and interviews as part of its own anti-FGM campaign.

The latest bid to raise awareness comes in the form of a music video by youth charity Integrate Bristol, which features politicians, celebrities and local members of the public. Trustee of the charity, Fahma Mohamed, also launched her own online petition to Michael Gove, asking him to write to all schools in England reminding them of their duty to safeguard girls from FGM.

The petition was a success with over 250,000 signatures and resulted in a meeting with Michael Gove and even backing from UN secretary-general Ban Ki-moon, who met with

Fahma and backed her call to use education as the tool for change.

But it’s not just survivors and charities making the push for change. ‘There’s so much going on – we can hardly keep up with ourselves,’ says RCM policy advisor Janet Fyle, who helped to head up a royal college and union collaboration, which has resulted in the report Tackling FGM in the UK: intercollegiate recommendations for identifying, recording and reporting.

The intercollegiate report was launched at the House of Commons in November and makes nine recommendations, with the first being to treat FGM as child abuse. The report states that implementing a comprehensive multi-agency action plan is urgently required to ensure that the UK laws already in place protect young girls at risk of undergoing FGM.

As Midwives went to press, the Home Affairs Committee was preparing to publish its report Female genital mutilation: the case for a national action plan, after considering the intercollegiate report, which Janet and other RCM policy staff were invited to discuss.

WHO (2014) CLASSIFICATION OF FGM

► Type I: Clitoridectomy: partial or total removal of the clitoris.

► Type II: Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

► Type III: Infibulation: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitoris.

► Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterisation.

Almost 30 years after FGM was made illegal in the UK, the Crown

Prosecution Service announced the first UK prosecutions over FGM.

Hollie Ewers looks at the latest efforts being made in the

anti-FGM campaign.

Closing in on FGM

at cal be

years

Clockwise: Fahma Mohamed (second

from right) with fellow anti-FGM campaigners

before their meeting with education

secretary Michael Gove in London;

Comfort Momoh; items used in FGM

››

Top picks Looking at the latest FGM developments, the changes to commissioning in England and the upcoming Scottish referendum.

Closing in on FGM (p41) Making the midwifery voice heard (p46) How will you vote? (p50)

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rcm.org.uk/midwives/news 2014 • ISSUE 4 • MIDWIVES 7

HeadlinesThe latest professional news

Hot off the press / News

A charity fi lm has been created to help reduce the risk of parents harming crying babies.

Over the last two years, the NSPCC has been piloting a programme called ‘Coping with crying’.

It involves showing parents a powerful new fi lm to help them care for, and reduce the risk of harming, a crying baby.

Over 30,000 parents have now seen the fi lm and an evaluation of the programme suggests that it is helping to keep babies safe.

A telephone survey, which compared parents who had seen the fi lm and a matched comparison group, revealed 99% remembered the fi lm at least six months after watching it. While 82% said they used advice from the fi lm when caring for their baby.

Parents who watched the fi lm were signifi cantly more likely to agree with the message that ‘you shouldn’t handle your baby roughly’ and reported lower rates of injuries among babies with feeding, sleeping or crying diffi culties.► For more information, visit: tinyurl.com/nsbr6qp

FILM HAS IMPACT‘COPING WITH CRYING’ IS RELEASED

IMAG

E SO

URCE

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MIDWIVES • ISSUE 4 • 20148

HeadlinesNews / Hot off the press

WOMEN LINKED WITH MATERNITY SERVICES

A scheme to link pregnant women directly with local maternity services has been launched in Glasgow and Inverclyde.

NHS Greater Glasgow and Clyde has a new central booking line to encourage women to make an appointment with their midwife as soon as they discover they are pregnant.

It comes after four years of controversy, in which doctors warned it could put expectant mothers and babies at risk by circumventing the GP.

Helplines are already set up in other health board areas in Scotland, including NHS Lothian.

All mothers-to-be, even those who already have children, have been urged to book into their local maternity services by the 12th week of their pregnancy.

Michelle McLauchlan, general manager for obstetrics and gynaecology, said that women can make their fi rst midwife appointment as soon as they know they are pregnant.

‘This provides more time for improvement of health behaviours, including reducing smoking rates, substance and alcohol misuse, and increasing breastfeeding rates. All of this will have a positive impact on long-term public health,’ she said.

When women make a call they will be given an appointment with a named midwife, a scan slot, and an SCI Gateway

information request will be sent to the GP, with details of the two appointments asking for medical history to be provided in advance of the booking appointment.

As far as possible, women will be off ered appointments close to the GP, and their local hospital, to ensure improved continuity of care.

If the GP considers that a woman needs to be seen very early or should be seen fi rst by an obstetrician, the usual SCI referral process can be followed.

EARLY PREGNANCY LOSS

NEW CODE TO HELP PARENTS

The RCM has welcomed a code of care put together by Mumsnet that aims to lessen the trauma of early pregnancy loss for parents.

RCM chief executive Cathy Warwick said that midwives could help improve care for women at a diffi cult time.

‘Kind, compassionate and empathetic communication around care and treatment is an essential step to support families,’ she said.

The code was drawn up after extensive consultation with Mumsnet

users, as well as professional and campaigning organisations working in this area of care.

Mumsnet said that, if implemented by NHS care providers, it could help to lessen the trauma of early pregnancy loss for parents.

Mumsnet has issued a list of fi ve elements needed for miscarriage care, which are: supportive staff ; access to scanning; appropriate treatment spaces; good information and eff ective treatment; and joined-up care.

Cathy said: ‘It is particularly important that there is eff ective communication between the hospital, GP and midwife to provide ongoing support or advice, as needed.’

Mumsnet has urged women to ask politicians for a pledge to improve miscarriage care, based on the principles of the code, by 2020 – the end of the next parliament.

Women are asked to email or tweet the three politicians who can make this happen – Jeremy Hunt, Andy Burnham and Norman Lamb – to include a promise in their next manifesto to better miscarriage care.► For more information, visit: tinyurl.com/n6zdtaf

SKULL DEFORMITYHELMETS HAVE ‘NO BENEFIT’ STUDY CLAIMS

Babies whose skulls become deformed from lying in the same position for long periods do not benefi t from wearing a corrective helmet, a study has found.

A randomised controlled trial investigated the treatment of plagiocephaly, which aff ects around a fi fth of babies under the age of six months.

Dutch researchers identifi ed 84 healthy babies born at full term who had a moderate or severe positional skull deformation.

Half the babies were randomly allocated to wear a rigid, custom-made, closely fi tting helmet for 23 hours a day for six months from the age of six months. The other half had no treatment.

The results showed that, at two years old, no signifi cant diff erences were seen in detailed measurements of the

babies’ heads.However, all the parents

whose babies wore a helmet reported side eff ects, including skin irritation in 96% of babies.

More than three-quarters of parents reported feeling hindered from cuddling their baby and the same number experienced an unpleasant smell, while a third of parents reported pain.

In the UK, helmet therapy is unavailable on the NHS, but some parents pay over £2000 to have their babies treated privately.

It is commonly used in some countries, such as the Netherlands, where it is used on 1% to 2% of all babies.

The study has been published in the BMJ.► For more information, visit: tinyurl.com/qzqsx4s

CENTRAL BOOKING LINE

WOMEN CAN NOW MAKE THEIR

FIRST MIDWIFE APPOINTMENT

AS SOON AS THEY KNOW THEY ARE

PREGNANT

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rcm.org.uk/midwives/news 9

56% of women surveyed felt too

embarrassed about postnatal incontinence to tell anyone

17 July the date on which the Indemnity Order

is set to come into force, after being approved in the Lords and Commons

90% of headaches in pregnancy

are migraine or tension-type headaches

// /FAST»FACTS

→ Babies do not benefit from wearing a

corrective helmet

The NMC is asking the public and midwives to help shape the future of regulation through a consultation.

It is currently revising the Code, and is seeking the views of the public, midwives, nurses and others who may be aff ected by changes to it.

Jackie Smith, NMC chief executive and registrar, said: ‘The NMC exists to protect the public, and the Code is central in all that we do.

‘It explains exactly what is expected of all midwives and nurses, no matter how and where they practise or what stage of their careers they are at.

‘The Code states that midwives and nurses must treat the people in their care with kindness, consideration and respect.

‘The overwhelming majority of midwives and nurses do this, often under diffi cult circumstances.

‘This is a chance to tell us what is important to you, and explain exactly what you expect from the people who care for you.’

The revision of the Code has been informed by the recommendations of recent major healthcare reviews, including the Francis Report.

The revised Code will also align to revalidation, a process which will require all midwives and nurses to regularly confi rm to the NMC that they are fi t to practise.

Jane Cummings, chief nursing offi cer for England, said: ‘I am pleased that the NMC is seeking a wide range of views for the revised Code, importantly including the patients and public we are here to serve.’

The consultation is the second part of the wider revalidation consultation and will run until 11 August. ► For more information, visit: nmc-uk.org/code-survey

NMC CONSULTATION

SHAPING FUTURE REGULATION

BIRTH SPACING

STUDY LOOKS AT INFLUENCE

New research on birth spacing has been released, which reinforces advice currently given out by midwives. A study concludes that short intervals between pregnancies – less than 18 months – result in a decreased length of subsequent pregnancies.

The US study, published in BJOG, covered 454,716 live births from women with two or more pregnancies over a six-year period. The researchers looked at the infl uence of inadequate birth spacing on the duration of the subsequent pregnancy.

The study defi ned short interpregnancy interval as time from the immediate preceding

birth to subsequent conception of the next pregnancy. Researchers categorised the women with short intervals into two groups – less than 12 months, and 12 to 18 months – and compared them to women who were considered to have an optimal interval of 18 months or more.

Following a short interval of less than 12 months, 53% of women had delivered before 39 weeks compared to 38% of women with an optimal interval.

RCM director for midwifery Louise Silverton said: ‘This study supports advice that midwives give to women about birth spacing.

‘If women are to breastfeed for the recommended six months before introducing solid foods, they may delay ovulation and assist in birth spacing.’► For more information, visit: tinyurl.com/pb48lzrSC

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HeadlinesNews / ICM special report

Reading and implementing evidence is vital for the future wellbeing of women, said a top midwifery researcher.

Cecily Begley, chair of nursing and midwifery at Trinity College Dublin, encouraged all midwives to follow and act on research.

Cecily, who has published more than 100 peer-reviewed research papers, was a keynote speaker at the ICM.

She told a packed conference hall: ‘We need to read research and use research to educate ourselves – that’s my take-home message today.

‘What we want to do is to strengthen and safeguard women and their families, this is my challenge to you.

‘We need to read research, to act on research and give women the best possible care.’

She talked the audience through her research on episiotomies in Ireland in 1984.

When looking at the procedure rates of individual midwives, she found that they varied from 6% to 84%.

She stressed that the majority of reasons as to why episiotomies were once recommended are now defunct, having been ruled out by research.

‘Most of the reasons we were taught in the 1970s are false,’ she said. ‘So we should not be carrying them out without a reason. Without a valid reason, an episiotomy is an unjustifi able assault on a woman.’

Cecily looked at other practices where the evidence-base has changed, such as the use of enemas and shaving.

She urged midwives to keep up to date with research, so that when there are changes to evidence, they will immediately know and can act accordingly.

She said: ‘In the future, I hope women will say we used the research we had.’

ENJOYING A RECORD-BREAKING YEAR THOUSANDS FLOCK TO PRAGUE

The ICM 30th Triennial Congress broke records to become the most well attended in the event’s history.

More than 3800 midwives from around the globe attended the event in Prague, the theme of which was ‘Midwives: improving women’s health globally’.

Over fi ve days, there were hundreds of sessions including keynote speeches, seminars, debates and workshops.

Alongside the sessions, were a range of presentations and awards.

The ICM named Toyin Saraki, founding director of the Wellbeing Foundation Africa, as its fi rst global goodwill ambassador.

She said that she was ‘honoured and humbled’ to be the fi rst person to take up

the prestigious role and added that ‘midwives are life-givers, care-givers, protectors and advocates’.

In the opening speech, ICM president Frances Day-Stirk said that there were midwives from a total of 126 counties present at the congress.

Among the countries that had the strongest presence were the UK, which had almost 360 midwives at the congress, Australia and Canada – which is due to host ICM in Toronto in 2017.

Frances refl ected on the three years in the run-up to the conference.

‘It has been about building relationships and expanding collaborations, because we recognise that we can’t do it all ourselves and we have reaped the rewards,’ she said.

‘Together, we have completed a lot of work and set the strategic direction and we’ve increased our profi le on the global health arena.’

In her speech that closed the congress, she said to the audience: ‘The global family is with you and working towards the health of the women, babies and families of this world.’

3800»THE NUMBER OF MIDWIVES FROM AROUND THE GLOBE

WHO ATTENDED THE EVENT

IMPLEMENTINGEVIDENCE

‘RESEARCH IS VITAL FOR THE FUTURE’



/NEWS»BRIEFS

Location of servicesThe centralisation of maternity services can often be detrimental to women, claimed Lisa Kane Low,

director of midwifery education at the University of Michigan. Speech for professorA speech was made to honour Mary Renfrew,

professor of mother and infant health at the University of Dundee, for becoming the fi rst midwife ever elected as a fellow of

the Royal Society of Edinburgh.Profi le of US midwivesOnly 26% of people in the US are aware

that midwives off er family planning advice said Tina Johnson, a director at the American College of Nurse-Midwives.

Crowds packed into a hall for a session to launch a new research series on the future of the Millennium Development Goals. The presentation and Q&A explained the methodology and drive behind the four papers, which are being published in The Lancet.

In the Q&A, before any of the papers were released, the lead authors remained tight-lipped on the fi ndings from the landmark series. However, author Mary Renfrew did state: ‘One recommendation is that women should be at the heart of planning maternity services.’

The fi rst in the series, Midwives and quality care, has now been published, as has an executive summary of the whole series. Drawing on sub-Saharan Africa as a case study, the summary looks at the shortage of midwives.

It says they only attend 27% of births at present and to achieve 75% coverage by 2035 would require 299,661 more midwives – a workforce increase of nearly 6% every year. The summary concludes: ‘Midwifery is a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants, in all countries.’

The series of four papers are closely interlinked and hopes are high that their publication will have a tangible impact on maternity services around the globe.

The fi nal paper of the series will draw on the fi ndings of the previous three. Petra ten Hoope-Bender, one of the authors of the fourth paper, said: ‘This paper gives us the opportunity to look at what really works and, as well as looking at what is necessary, it also looks at quality of care. It’s almost an international policy brief with all of the information pulled together.’

The papers, when published, are free to access on The Lancet’s website. ► For a summary of the series, see page 33.

Midwifery practice is not driven by women’s choice, the audience decided at an ICM debate session.

About two-thirds of the hundreds in attendance agreed that this was the case.

The debate chair, Margaret McGuire, said: ‘The room agrees that midwife care is not woman centred, but this isn’t the end of something – it’s the start.

‘The debate that we’ve had here isn’t about the pros and cons, it’s about challenging ourselves and getting ourselves to question our practice and continue to grow.’

Jemima Dennis-Antwi, an ICM Anglophone Africa advisor, was on the side arguing that midwifery is not centred around women’s needs.

‘The structures of our health services are generally paternalistic and not women friendly,’ she said.

‘If a woman seeks a particular service and it is not available to her, then how can

we say midwives provide a service based on women’s choice?’

She added: ‘Within the circumstances that midwives fi nd themselves, it can be diffi cult to provide women-centred choice.’

The counter argument was that, despite some countries having little or no resources, ‘midwives across the globe are faithful to supporting women in their choices, even if it goes against protocol and is at great personal cost’.

Employing a midwife could save more than 60 times the amount it costs, it was claimed at the congress.

Jim Campbell, director of the research institute ICS Integrare, and one of the authors of the State of the world’s midwifery 2014 report, made the statement.

The hefty report reveals that, over a 30-year career, a midwife could save 16 times the amount spent on their training and employment.

However, speaking to

Midwives after the launch, Jim said ‘you could probably double, triple, or even quadruple the cost benefi t’.

The 16-fold fi gure contained within the report is based on a study conducted in Bangladesh.

Jim said: ‘The model that was used for the study looked at CS that were averted, which obviously has a savings implication.’

But he added that the saving forecast is ‘a very conservative estimate, at the

low range of the scale’ and once other cost-savings were factored in, it would lead to far greater savings.

The report, by UNFPA, ICM, the WHO and partners, looks at 73 countries where midwifery services are most desperately needed.

It reveals major defi cits in the midwifery workforce in these countries and recommends new strategies to address these defi cits.► To read more about the report, turn to page 13.

GLOBAL REPORT

RESEARCH FINDS ‘MIDWIVES MEAN SAVINGS’

WOMAN–CENTRED?

MIDWIFERY DEBATE SESSION

RESEARCHLAUNCH

LANDMARK SERIES FOR LANCET



HeadlinesGlobal news / Headlines around the world

Global News stories

making headlines around the world

news

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DENMARK1 BREASTMILK HELPS GUT BACTERIA GROWBreastfeeding helps children grow friendly gut bacteria, a study by the National Food Institute at the Technical University of Denmark has found.

The researchers tracked 330 children in their fi rst three years of life and found that the longer they were breastfed, the longer the lactic acid bacteria fl ourished in their guts.

The results showed signifi cant diff erences in bacteria composition between infants either breastfed or no longer breastfed at nine months.

Previous studies have shown that breastfed babies tend to be slimmer, grow more slowly than formula-fed infants and have a lower risk of obesity, diabetes, infl ammatory bowel disease and allergies later in life. The development of friendly bacteria, as a result of breastfeeding, may be the reason, the study suggests.▶ tinyurl.com/ojkow5m

ARGENTINA2 POSITION DOESN’T EFFECT DCCA study published in The Lancet found that how a mother holds her baby after birth makes no diff erence for delayed cord clamping (DCC).

At three hospitals in Argentina, researchers from the Foundation for Maternal and Child Health in Buenos Aires tested whether the transfer of blood in DCC was aff ected by the position in which the baby is held immediately after birth.

In the study, 197 babies were held in the introitus position while undergoing DCC, as per the usual practice, while 194 babies were immediately placed on the mother’s stomach or chest.

The volume of blood that transferred from the placenta to the child was measured by taking the babies’ weights at the point of birth and immediately after DCC.

No signifi cant diff erence in the volume of blood transferred was found between the two groups, indicating that the introitus position is no more eff ective than on the stomach or chest.▶ tinyurl.com/ptwvwwd

GERMANY3 MUSIC IN PREGNANCYThe eff ects of music are stronger in pregnant women, according to a study.

Researchers from the Max Planck Institute for Human Cognitive and Brain Sciences in Leipzig said that music can aff ect blood pressure, heartbeat, respiration and even body

temperature under normal conditions.But its infl uence on pregnant women is much stronger, suggesting a prenatal conditioning of the fetus to music.

Musical sequences up to 30 seconds long were played to female participants. The passages were then modifi ed, making them less pleasant to hear, and then played again.

Pregnant women rated the pleasant music as more pleasant and the unpleasant music as more unpleasant. Additionally, the blood pressure response was much stronger in the pregnant women than in their non-expectant peers.▶ tinyurl.com/qaqafay

CANADA4 CAR CRASH RISK IN PREGNANCYWomen in their second trimester are more likely to be involved in a serious car crash, according to research published in the Canadian Medical Association Journal.

A study of 507,262 pregnant women looked at whether common features of pregnancy, such as nausea, fatigue, insomnia and distraction could increase the risk of a crash that required emergency medical care.

During the three years before pregnancy, as drivers, the women had 177 crashes per month. During the second trimester, they had 252.

The elevated risk during the middle of pregnancy equalled a 42% increase in serious traffi c crashes from baseline.▶ tinyurl.com/ny6gld2

ITALY5 NEWBORN DIALYSIS The fi rst newborn kidney dialysis machine has been created by researchers at San Bortolo Hospital in Vicenza, Italy.

Acute kidney injury (kidney failure) aff ects around 18% of low-birthweight infants and approximately 20% of children admitted to intensive care.

For newborns with kidney failure, the fi rst port of call for treatment is peritoneal dialysis, which involves using a continuous renal replacement therapy (CRRT) machine to remove waste products from the blood through a catheter inserted into the abdomen. But in some cases the procedure is ineff ective and unfeasible for such small infants, so the team developed the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) – a miniaturised CRRT device that can provide kidney support for newborns and infants weighing between 2kg and 10kg.▶ tinyurl.com/k9lteyk

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State of the world’s midwifery 2014 / In focus

The poorest countries around the world are suff ering due to a lack of trained midwives, says a new

report. Here we look at the fi ndings and recommendations.

THERE ARE MAJOR midwifery workforce defi cits in 73 countries where the services are most desperately needed, according to a global report.

The State of the world’s midwifery 2014 report recommends new strategies to address these defi cits and save the lives of millions of women and newborns.

The report, by the UNFPA and a range of global partners, was released at the ICM in Prague.

It states that the 73 African, Asian and Latin American countries that it covers suff er 96% of the global maternal deaths, 91% of stillbirths and 93% of newborn deaths.

However, between them, they only have 42% of the world’s midwives, nurses and doctors.

The report urges countries to invest in midwifery education and training to contribute to closing the glaring gaps that exist.

It says that investments in midwifery at agreed international standards can yield big savings for countries, in terms of lives saved and medical procedures avoided.

The report was launched to a conference hall packed with more than 1000 midwifery and health professionals from around the globe.

UNFPA executive director

Babatunde Osotimehin recorded a video message that was played to mark the launch.

He said: ‘Midwives make enormous contributions to the health of mothers and newborns and the wellbeing of entire communities. Access to quality health care is a basic human right.

Progress has been made in the 73 countries covered, with a 3% drop in maternal deaths and a 1.9% drop in newborn deaths, but faster action is needed.

Frances Day-Stirk, ICM president, said: ‘More than three-quarters of the countries in this report have serious shortages of midwives that will result in deaths.

‘Midwives could save the lives of millions of mothers and newborns each year.’

The report includes recommendations to close the gaps and ensure all women have access to sexual, reproductive, maternal and newborn services.

Issues, such as preventive and supportive care from a collaborative midwifery team, immediate access to emergency services when needed, and completing post-secondary education are included.

Flavia Bustreo, WHO assistant director-general for family, women’s and children’s health, believes the report ‘sets a clear way forward’.

‘It aims to encourage governments to allocate adequate resources for maternal and newborn health services within national health sector plans,’ he said.

‘This should include funds for the education and retention of midwives.

‘We will continue to support countries to develop and strengthen their midwifery services as a critical intervention to save the lives of women and newborns.’�

For more information, and to access the full report, visit: unfpa.org/public/home/publications

Greater investment in midwifery is key to making this right a reality for women everywhere.’

He added that ‘midwifery is the best buy in primary health care’.

The report highlights that midwives have a crucial role to play in the achievement of the Millennium Development Goals to decrease child death and increase maternal health.

It states that, when educated to international standards and within a fully functional health system, they can provide an estimated 90% of the essential care to women and newborns and can potentially reduce maternal and newborn deaths by two-thirds.

GLOBAL MIDWIFERY SHORTAGE

→ Midwives could save the lives of millions

of mothers and newborns each year

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HeadlinesRCM news / The latest stories

For the fi rst time, the RCM took part in the London Pride Parade.

It was held on Saturday 28 June and thousands took to the streets.

Amy Leversidge, RCM employment

relations advisor, said: ‘It was a fantastic day – thank you to all the members that came along.’

She added: ‘We are already all looking forward to Pride 2015.’

BEREAVEMENT

SCHOLARSHIP NOW OPEN

Applications for the bereavement care scholarship have been invited by National Maternity Support Foundation Jake’s Charity and the RCM.

The award provides funding – Jake’s Scholarship – to enable a midwife or a group of midwives with at least fi ve years’ experience to develop or improve a bereavement service. Their aim should be to provide high-quality care to women and families during bereavement. The deadline is 22 September. ► For more information, visit: rcmawards.com/categories/#5

IDM EVENTA lively event to celebrate International Day of the Midwife (IDM) was held in London on 5 May.

The event was hosted by the RCM and speakers included Frances Day-Stirk, the ICM president.

LONDON PRIDE PARADE

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PRESSURE POINTSThe latest Pressure Points report into areas of concern in postnatal care was launched to coincide with Breastfeeding Awareness Week and focuses on infant-feeding.► To download the report, visit: rcm.org.uk/pressurepointsWEBSITE UPDATEMembers may have encountered a number of glitches on the RCM website recently.

The RCM is currently revamping the site to give members better usability and functionality. It’s hoped that the work will be completed by the end of summer. Our apologies for any inconvenience caused in the interim.WIN RECOGNITION Entries have been invited to the RCM Annual Midwifery Awards. The RCM is looking for the very best in innovation, evidence-based projects

and outstanding achievements from midwifery teams across the UK. The deadline for entries is 22 September. ► For a guide to enter, visit: rcmawards.com BREASTFEEDINGAnother successful Breastfeeding Awareness Week was lead by the RCM, in partnership with Mothercare, on 19 to 25 May. Many members hosted events at local Mothercare stores and

midwives were also on hand to answer questions and host discussions about the importance of breastfeeding. DILEMMA DEBATCThe RCM’s Dilemma Debate: Trade unions – vested interest or force for good? is due to take place in London on 22 July. The event is free to attend, but members must register in advance.► To register, email: [email protected]

ICM CONGRESS The RCM delegation attended the 30th Triennial ICM Congress in Prague in June. ANNUAL REPORTSThe RCM Annual Reports and Accounts are available to view online. Those who have requested hard copies will receive them with their September issue of Midwives.► Visit: rcm.org.uk/content/reports

RCM NEWS AND DATES

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11 Sept Uncertainty and Loss in Maternity

and Neonatal Care Conference

22 July RCM Dilemma

Debate

22 Sept Deadline to enter the

RCM Annual Midwifery Awards// /QUICK

LOOK DATES»

JOIN OURUNCERTAINTYAND LOSSCONFERENCE

SIGN UP NOW

PAY CONSULTATION

MIDWIVES AND MSWS VOTE ‘YES’ IN PAY CONSULTATION

Midwives and MSWs working in the NHS in England have overwhelmingly voted that they are prepared to take industrial action in the RCM’s consultation about pay.

In total, 46.5% of members voted, of which 94.3% said they were prepared to take industrial action. The RCM will now be taking the results to its board to consider the next steps, which could include balloting members for the fi rst time in its history. It is also urging the government to enter into talks and reconsider its position.

Cathy Warwick, RCM chief executive, said: ‘The sense of anger and frustration among midwives is palpable. We knew midwives were angry about the derisory off er from the government but this response highlights how unfairly they have been treated.

‘Such an unprecedented response with such a large number willing to consider action should ring alarm bells with the government.

‘Midwives and other health workers are seeing their pay falling in real terms as their pay stagnates, pension contributions increase and the cost of living rises.

‘The RCM is calling on this government to recognise, respect and implement the recommendations of the independent NHS Pay Review Body.’

Cathy added that any industrial action taken by members ‘will not aff ect the safety of women and their babies’.

IN THE NEWSCOVERAGE OF THE RCM

Junk food before falling pregnant raises premature birth risk: studyThe Telegraph

RCM chief executive Cathy Warwick was quoted in a story saying a junk food diet before conception is linked with an increased risk of premature birth. ‘If we can invest in these preventive measures and prevent preterm labour, then there will be huge cost-savings later on,’ she said.

Saved by baby: How breastfeeding mum found tumourEdinburgh Evening News

A woman recovered from a fast-growing lump on her breast, which she initially thought was a blocked milk duct. Gillian Smith, RCM Scotland director, said it shows how important it is for health professionals not to be complacent with changes to women’s breasts when lactating.

NHS midwives consider strike after Jeremy Hunt’s U-turn on 1% pay riseThe Guardian

Jon Skewes, RCM director of policy and employment relations, explained that it is ‘time for midwives to take a stand’ against Jeremy Hunt’s U-turn on pay ‘because the government is intent on assaulting their pay and conditions’.

‘Fantastic improvements’ unveiled at revamped midwifery unitWolverhampton Express & Star

RCM chief executive Cathy Warwick offi cially opened a new midwifery unit at Russells Hall Hospital in Dudley, following a £41,000 government grant awarded to create a more homely setting for mothers-to-be to give birth.

The annual Uncertainty and Loss in Maternity and Neonatal Care Conference is set to take place on 11 September.

The conference, now in its fi fth year, is held in London and is a partnership event between the RCM, Sands and Bliss.

The event builds on the foundations of the fi rst conference, held in 2009, which recognised the need for additional support for professionals, both in and out of the workplace.

As a result, an eNetwork was launched to facilitate information exchange and peer-to-peer support, which now reaches almost 1000 healthcare professionals.

The conference presents discussion from a range of practitioners on essential topics and includes parents talking about their experiences.

The one-day conference will be held at the Brunei Gallery, SOAS, London.► For more information, or to book, email: info@profi leproductions.co.uk

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HeadlinesCountry news / Northern Ireland and England

PAYROLL ISSUESThe biggest issue facing midwives in Northern Ireland (NI) this year has been the ongoing debacle of the new pay system.

Hundreds of midwives have been wrongly paid since the beginning of the year, with the situation becoming more acute with each passing month. I would like to pay tribute to our hardworking RCM stewards who have been supporting our members at grass-roots level, dealing with enquiries ranging from midwives who have received no pay to those who have been overpaid by thousands of pounds.

Midwives are facing uncertainty at the end of every month; some are borrowing money from relatives to keep them going and many are incurring bank charges for overdraft facilities. Holidays are unable to be booked and the sense of frustration is growing. The new system appears to be unable to cope with staff that work fl exibly outside of a Monday to Friday, nine to fi ve pattern. Someone has forgotten that healthcare staff provide a 24-hour service every day of the year.

The RCM has met with the health minister to discuss the situation and we are awaiting the outcome of his discussions with the Business Services Organisation. In the meantime, can I ask that if you have any problems with your pay, please speak to your local steward, who will help you to resolve your specifi c issue.

MIDWIFE-LED CAREThere is some good news as midwifery-led care remains high on the agenda. Work is proceeding apace at developing the role of community maternity care, with a special emphasis on promoting the midwife as the fi rst point of contact for pregnant women. NI’s third free-standing midwifery unit at the Mater Hospital in Belfast was offi cially opened in April and is being well used by the women of North Belfast and indeed further afi eld.

NORMAL BIRTHWe held a very successful multi-disciplinary conference in March, which focused on normalising the birth experience for as many women as possible (even those deemed to be high risk). We also looked at the recent NI Audit Report, which highlighted the wide variation in CS rates across NI, and has resulted in a renewed emphasis on the need to keep childbirth normal for all women.

QUEEN'S IDM EVENTFinally, congratulations to Queen’s University midwifery society, which held a wonderful event to celebrate IDM. It was a pleasure and a privilege to be there to celebrate midwifery both in NI and around the world.

Breedagh HughesDirectorRCM Northern Ireland

EVENT SUCCESSESCongratulations to midwives Annabel Nicholas and Jo Camac of Royal Bolton Hospital’s birth suite for hosting an inspirational and well-organised conference ‘Born to Safe Hands’. It left many of us feeling inspired and proud at such a great event.

The two very busy practising midwives organised the amazing event, which was trending on Twitter, with high-profi le speakers, such as Soo Downe, Cathy Warwick, Mary Stewart, Sheena Byrom and Denis Walsh.

Well done to East Lancashire HoM Anita Fleming for hosting a brilliant maternity awards event for her team. This was a result of winning a joint RCM maternity team of the year award in January.

GLOBAL MIDWIFERYI had the privilege of opening the MAMA conference in Glasgow with RCM director for Scotland Gillian Smith, where we presented the RCM’s Global Midwifery Twinning Project and international midwifery work. My favourite part was the awards ceremony and congratulations go to student midwife Jude Jones, from the

University of Salford, for winning the MAMA Student Midwife of the Year Award.

Thank you to the RCM Brighton branch and Lisa Jeff rey for inviting me to talk about the GMTP. It was great to meet you all and share this brilliant work.

The RCM’s IDM event was hosted in SOAS in London and was attended by 140 delegates. Opened by ICM president Frances Day-Stirk, it was another fabulous event, which showcased the international work the RCM is doing in partnership with other agencies and charities. One of the highlights was the big ‘selfi e’ taken by Save The Children to emphasise ‘midwives changing the world one family at a time’.

PELVIC HEALTHIn partnership with the Chartered Society of Physiotherapists, the RCM has launched a pelvic health initiative to get pelvic fl oor muscle exercise back on the midwifery agenda, following the 2013 joint position statement publication. It was well received at the recent Primary Care conference in Birmingham, with the information leafl ets on training for pelvic fl oor fl ying off the stand.� Jacque GerrardDirectorRCM England

ENGLAND

NORTHERN IRELAND

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Stuart Bonar / On politics

I s the baby boom ending? In 2013, there were just over 56,000 births in Scotland – down by more than 2000 from

the previous year – which is the lowest number since 2006. The same trend is evident in Northern Ireland. In the same year, there were almost 24,300 births, a fi gure that is down by 1000 and, again, it is the lowest number since 2006 (Offi ce for National Statistics (ONS), 2014).

So does that mean that the pressure on maternity care staff has also fallen? If we used birth numbers as a crude measure of workload, then it should be the case. But, of course, it is not as simple as that. The complexity of pregnancy and labour is on the rise and this loads more pressure on midwives, MSWs and others.

The age of mothers is one

example of growing complexity. In each part of the UK, the average age at which women give birth is at a record high. In 2012, the average age was just short of 30 years old in England and Scotland. In Wales, it was just over 29, but in Northern Ireland it was already over 30 – the highest average age in the UK (ONS, 2014).

We are using these latest fi gures as we continue making our case to the politicians. We will not let anyone get away with arguing that a small drop in the

→ The age of mothers is one example of growing complexity. In 2012, the

average age was just short of 30 years old

Stuart Bonar explains why it is important that politicians understand the challenges that face midwifery.

number of births gives them an excuse to take their eye off the ball when it comes to improving maternity care and making sure that there are enough midwives and MSWs in post.

Outside England, we need to fl ag up the issue of an ageing midwifery workforce, making sure we train and recruit enough new midwives into the NHS. The timing is important. If action is not taken before midwives begin to retire, then it will be too late to do much about the situation. New midwives need to enter the workforce now.

While that problem exists in England too, the bigger problem is driving down the longstanding shortage of midwives. At the last count, the NHS in England was short of the equivalent of 4800 full-time midwives. All parties have tried to increase midwife numbers. We have seen the numbers climb under Labour and now under the Conservative/Liberal Democrat coalition, but neither administration has

managed to increase numbers quickly enough.

As we go into a general election next year, it must be a central demand from the RCM to all political parties – end the midwife shortage.

Those of you in Scotland will have the chance to vote in the independence referendum on 18 September and there is an article on page 50 and 51 about this. One piece is from the Better Together campaign, which wants to see Scotland stay in the UK, and the other is from Yes Scotland, which is keen to see Scotland become an independent country.

The RCM is neutral in this debate, but we encourage you to read what the campaigns have to say, fi nd out more, ask questions, and, above all, be sure to vote on Scotland’s future.�

Stuart BonarRCM public aff airs advisor

For references, visit the RCM website.

THE POLITICS OF BIRTH

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Work life / Amy Leversidge

Headlines

Amy Leversidge describes what the RCM has been doing to get maternity staff ’s voices heard across England.

PROTESTING FOR PAY

RCM MEMBERS AND other NHS workers across England have sent a clear message to the government – enough is enough: fair pay for the NHS.

The RCM joined other NHS trade unions at the Department of Health in London on 5 June to protest against the government’s pay off er and to present a giant cheque for £1.5bn, which is the estimated amount of unpaid overtime that staff in England carry out annually. Francis O’Grady, the general secretary of the TUC was also present at the protest.

Meanwhile, in Liverpool, the RCM and other NHS trade unions protested outside the NHS Confederation conference, and also presented the giant cheque to make the point that the NHS relies so much on goodwill. The health secretary Jeremy Hunt was speaking at the conference in the afternoon, as was shadow health secretary Andy Burnham. While Andy Burnham met with NHS staff , Jeremy Hunt refused.

In addition to the two main events in London and Liverpool, there were events up and down the country in local NHS organisations. The RCM produced stickers, badges, posters, fl yers and postcards to MPs in order to get the message out there.

There was also a lot of activity on social media. Our campaign logo, photos and infographics on Facebook have been ‘liked’ over 800 times and shared nearly 900 times.

It was a fantastic day – thank you to all RCM members who got involved up and down England.

We are facing an unprecedented attack on NHS pay. Not only has the government

rejected the NHS Pay Review Body’s (PRB) recommendation, but they have backtracked on their previous promise of a 1% pay uplift for all staff .

Instead of a permanent 1% pay uplift, the government has given a 1% ‘non-consolidated’ uplift to just the staff at the top of their pay band.

They have also said that they will take the same approach for 2015-16 and staff who are at the top of their pay band will receive a 2% uplift, which will also be ‘non-consolidated’ and, again, staff who are not at the top of their band will mis out. They have said that because the announcement is for two years they will not ask the NHS PRB to report in 2015.

The term ‘non-consolidated’ means that the increase is only a temporary payment and it will get taken away, like a bonus. The ‘non-consolidated’ award only applies to basic pay, so will not apply to high cost area supplements, unsocial hours payments, overtime or on-call payments. In addition, the 1% is not pensionable. This means that in 2016 the pay rates in England will return to the pay rates they were in 2013.

This is part of the government’s

→ Our campaign logo, photos and infographics on

Facebook have been ‘liked’ over 800 times

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attempt to fundamentally change the pay structure by ending incremental progression in the NHS, bringing in bonus style pay awards and removing the independent PRB.

At the time of going to press, the RCM has begun a consultation with members working in the NHS in England to ask if they are prepared to take industrial action. We are recommending to members that they vote ‘yes’ and are prepared to take such action, as we need every midwife and MSW to stand together with the RCM to fi ght this appalling treatment of NHS staff .�

Amy LeversidgeRCM employment relations advisor

Clockwise from left: RCM stall with leafl ets, badges and petition; the RCM’s Jon Skewes, Gill Adgie and Lynne Galvin holding the giant cheque outside the NHS Confederation conference in Liverpool; the RCM’s Sean O’Sullivan, Angela Hulbert, Ralph Mirams, Mandie George and Simon Popay protesting with RCM fl ags; midwife and MSW actual salary comparisons.

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OpinionThoughts, views and your feedback

Cathy Atherton / One-to-one

Cathy Atherton describes the skills needed as

the HoM at Liverpool Women’s Hospital »

A juggling

act

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OpinionOne-to-one / Cathy Atherton

B eing the HoM at the largest single site maternity hospital in Europe requires juggling abilities that would be the envy of any street performer.

Likewise, the skills in planning and strategy would be as well suited to a career in the military as one in health care.

Cathy Atherton, who has been the HoM at Liverpool Women’s NHS Foundation Trust for more than three years, is skilful on all these fronts, but she is also very much in touch with her roots and midwifery colleagues. She describes herself as ‘a midwife’s midwife’. Proof, if it were needed, is in the fact that she helped to deliver a baby on a particularly busy shift, when she was on-call.

Although that was an unusual incident, Cathy says it showed midwives that she is willing to muck-in when necessary.

‘I understand the pressures that midwives face better, as a result.’

Those pressures are considerable given that the service sees 8000 births each year – about 20 a day. There are 300 midwives working for Cathy and, while that number is not full-time equivalent, the part-time status makes it tougher to juggle. She admits that it is challenging to have a workforce of such size.

Another challenge is the diversity of women who attend the hospital. As well as those who come from the city, the tertiary unit attracts women from across the country for specialist care. Although the maternity unit receives a tariff for each woman who gives birth there, this does not account for need and complexity.

‘The tariff is just a number and women don’t fi t into a number. So we use our professional judgement around how we plan for staffi ng numbers. We do it every day, several times. We look at the activity on the unit and how many staff we have on,’ says Cathy.

The number of births and the diversity of women mean that it can be a juggling act on a huge scale. A midwife might start looking after eight women on a ward, but then it becomes apparent that she needs to focus on one particular person. The need to provide women with one-to-one care when they are in active labour is sometimes to the detriment of other aspects of care, such as discussions about feeding or parenting.

While planning and organisation are essential, Cathy says it is important to remember that each woman is an individual going through a life-changing experience. Her aim is to make every woman feel as though she has been treated with kindness and support.

‘My vision is around each woman who is pregnant and having a baby is treated well. It’s such a big event in people’s lives and we mustn’t forget that, especially as we recognise how important midwives are at that time,’ she says.

‘It’s easy to get caught up on a busy ward but treating people with a smile and respect is important. We are dealing with people – either colleagues or women.’

CareerPart of Cathy’s job has been to build a team that shares her ethos and values. It is one reason that she is so passionate about mentoring and supervision. Cathy was shortlisted for the Midwives Magazine Mentor of the Year Award at the RCM awards 2013.

“There has been a real shift in postnatal

care becoming the

bridesmaid of the

service, even though

it’s important”


rcm.org.uk/midwives 25

experience of good mentors and managers throughout her career has resulted in Cathy’s belief that it can make a huge diff erence. Equally, she says that she has learned from managers who have been fl awed.

‘I’ve been able to pick out areas where I hope that I don’t behave in the same way,’ she says.

Her career, up until her move to Liverpool, had almost exclusively been spent in Bolton. She moved to the Royal Bolton Hospital as a newly qualifi ed midwife in 1982 and stayed there for 28 years.

She became the hospital’s fi rst consultant midwife in 2005 and HoM in 2009. She was instrumental in developing the new birth suite in Bolton and was involved in the creation of

All about Cathy► Cathy started her career in Wigan, training as a nurse, before starting her midwifery training in 1981

► When she became a midwife, the CS rate was 12%. Now it is 25%, which shows how midwifery and the complexities of the women have changed

► Cathy manages the midwifery-led unit that runs alongside the maternity unit. It sees 2500 babies born there each year, a number that Cathy would like to increase

► In her spare time, she likes keeping up to date with the latest midwifery issues

► She relaxes by walking her dog, spending time with her grown-up children and her friends.

FACT FILE

and midwives becoming more autonomous.’But, on the other hand, she points out

that the rate of home births was higher then and the rate of CS has doubled in that time. In part, that is because of the increasingly complex cases. Some of the women seen now would never have been pregnant when Cathy started out.

And, when Cathy was a new midwife, women stayed in hospital for fi ve days and then they were seen every day at home until 10 days, with visits continuing frequently after that.

‘Now women are with us for 24 hours and postnatal care is much more scanty,’ says Cathy. ‘There has been a real shift in postnatal care becoming the bridesmaid of the service even though it’s important.’

She cites midwifery numbers that have failed to keep apace with a rising birth rate along with fi nancial constraints as the reasons for this. The service does the best it can with the workforce and resources available.

‘It’s a balancing act,’ she says, thereby adding the skills of a tightrope walker to the list of abilities needed for her job. Juggler, military strategist and tightrope walker – or, in other words, the HoM in Liverpool Women’s Hospital.�

a regional supercentre for the care of women, babies and children.

She also gave birth to her own three children at the Royal Bolton.

‘It was a really hard decision to leave Bolton. I made it because I wanted to get into

a position where I could infl uence maternity services on a national scale. A unit

of this size meant I could do that,’ says Cathy.

And so it has been. On the day that Cathy speaks to Midwives, the

morning had been spent speaking to BBC Radio 4’s Woman’s Hour,

alongside Cathy Warwick. The programme was broadcast live

from the women’s hospital in a midwife special.

ChangesIn a career spanning more than three decades, Cathy has seen many changes in midwifery.

‘I entered midwifery in the early 80s and, at

that point, childbirth was medicalised. Now we see

women having more choice

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OpinionFeedback / Have your say

midwifery Lorna Davies, senior lecturer midwifery Sarah Davies, community midwife Jude Davis, independent midwife Jane Evans, AIMS vice chair Nadine Edwards, independent midwife Elsie Gayle, retired midwife Ishbel Kargar, professor of midwifery Mavis Kirkham, independent midwife Brenda van der Kooy, emeritus professor of midwifery Rosemary Mander, lecturer in midwifery Nessa McHugh, community midwife Emma Mills, sociologist Jo Murphy-Lawless, midwife Becky Reed, and midwife Linda Wylie

RCM response: The RCM had no legal authority to intervene in discussions between the boards of other charities nor was the RCM ever in a position that allowed us to act for any individual member. MIDIRS has always been entirely independent of the RCM.

The RCM was never offi cially approached to express an opinion on the wisdom of the agreement. As far as we could ascertain the agreement was legal and we were reassured by the NCT of their intention to maintain MIDIRS’ independence after the ‘takeover’.

MERGER CONCERNSWe are writing to express our concern regarding the recent merger between the independent educational charity MIDIRS and the NCT. We feel there are implications for our highly valued and formerly independent educational resource.

In May 2011, a pre-merger agreement was signed between MIDIRS and the NCT, which proposed the two charities merge in May 2013 if both parties were still in agreement. By April 2013, the MIDIRS board of trustees had concluded that the aims and values of the two organisations were too diff erent for them to work as a merged entity, and wished to vote to opt out of the merger. At this point, the trustees felt they had no other option but to resign. The board, whose trustees had mostly been midwives, was then replaced with NCT-affi liated trustees, only one of whom had midwifery experience.

As the takeover became inevitable, the editors of MIDIRS midwifery digest and members of its editorial board, as well as the editor and the editorial advisory group of its sister journal Essentially MIDIRS, resigned between June and

August 2013. Their concern about the loss of editorial independence once MIDIRS came under the NCT umbrella prompted the resignation of 13 people.

It is of serious concern that the new NCT chair of trustees was employed until January 2013 as the head of the large charities division at the Charity Commission (CC) and was commissioned by NCT to undertake consultancy work during the period of the pre-merger agreement. Several midwives and academics formally raised their concerns with the CC and were told that it could fi nd no issues worthy of investigation.

We are dismayed that the RCM has not been more proactive in trying to protect MIDIRS from being taken over by the NCT. Midwives are now left without a truly independent educational resource to support their practice.

Chair of the Association for Improvements in the Maternity Services (AIMS) Beverley Beech, AIMS committee member Gill Boden, senior lecturer midwifery Ethel Burns, retired midwife Mary Cronk, principal lecturer

From NCT CEO Belinda Phipps:We’d like to clarify some of the issues arising from the merger. After working together for several years, MIDIRS approached us in 2009 with a proposal to unite. It was not in a position to continue to operate without our fi nancial support. As this letter agrees, the CC considered the merger process and was satisfi ed it met their requirements.

Now that it has taken place, we recognise there are still some worries about how MIDIRS might be aff ected. We have therefore set up a MIDIRS Advisory Committee (made up of senior midwives) to ensure editorial independence of its publications. With our support, MIDIRS is now in a stronger position to reach more midwives with the evidence-based information they need.

Finally, we’d like to correct a few of the letter’s factual inaccuracies. Beryl Hobson left the CC in January 2012, not 2013 as it states. She did not undertake any paid work for the NCT after November 2012 and was appointed as a trustee in July 2013, following a rigorous selection process by Russam GMS, an independent recruitment fi rm.

We’ve got

mailMidwives thrives on your correspondence. Here is a selection of the ones that caught our eye this issue.

WRITE»TO US

Send your comments to: [email protected] (the editor reserves the right to edit letters)

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Cher, Jenny and Vivian / MSW voice

Three MSWs answered the RCM’s call for volunteers to help organise the fi rst maternity care assistants conference in Scotland. Here

they describe what it has been like.

I n August 2013, the MSW newsletter contained an article asking for maternity care assistant (MCA) volunteers to join a focus group that would organise the fi rst offi cial MCA

conference in Scotland.After reading it, we each had the same

thought: ‘They will have plenty of people stepping forward to be part of this great opportunity.’ However, we got in touch anyway and, as the only three to show interest, we became the working group for this project with the RCM.

Planning began at the beginning of November with a phone call with Angela MacMorran from the RCM. We discussed dates and brainstormed the content of what we thought would be good on the day. This was

for us all – it was also an exciting prospect now plans were in place. It was great to hear a good response from the RCM on the numbers due to attend.

The day arrived and, on 1 May, we were at the Hilton early in order to set up and greet those attending. The numbers were great. MCAs from all over Scotland, and some from England, came along. The place was buzzing with good vibes. We introduced the speakers, and helped to see the day run smoothly.

At the end of the afternoon, it was time for us to take questions from our fellow support workers. The response was fantastic. Everyone was positive and our plans had knitted together perfectly. Delegates left feeling enthusiastic, upbeat and driven about their roles as MCAs and we felt great.

Since the conference, we have received a copy of the evaluation feedback, which showed just how successful the day had been. It made the whole process worthwhile.

But, aside from the success of the day, simply being part of the working group has been a great experience. We have helped fellow MCAs see their roles in a new light. It has helped them to feel assertive and able to drive their role forward.

We are already looking forward to remaining on the working group and, of course, participating in future events.�

Cher Dougan and Jenny WalkerNHS Dumfries and Galloway Health BoardVivi an ForbesNHS Grampian Health Board

tricky – there were so many areas we could have included, but only a certain number of speakers could be invited for the day.

Our next meeting, via teleconference in February, covered the programme draft. We discussed who could present the sessions on our programme and Angela agreed to contact them. Angela also suggested holding the event in the Hilton Grosvenor in Edinburgh and we organised a date to meet and view the venue, which turned out to be perfect. We looked at the rooms available, discussed the seating and the general running of the day. The speakers and programme were also fi nalised.

The day was approaching fast. Although it was slightly daunting to be involved in chairing the event – it was a new experience

→ Delegates left feeling

enthusiastic, upbeat and driven about

their roles

CONFERENCE CALL

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OpinionStudent noticeboard / Tell us your news

Inspirational teacherStudent midwives at Teesside University nominated lecturer Debbie Bunford for the Outstanding Teacher Award at their student union awards, and were delighted when she won.

Primary Care Live

Over 80 student midwives visited the

RCM stand at Primary Care Live at

Birmingham’s NEC in May.

Pictured (left) are Emma Sprawson,

Rebecca Ellis and Kelly Wilson from

Liverpool John Moores University with

the RCM’s Denise Linay, who works with

the Student Midwives Forum (SMF).

WRITE»TO US

If there’s an event you’re organising, or something interesting you’d like to tell your fellow students, please let us know and we can publish it here. Email your news to: [email protected]

Student soundbites

What’s new in the student world? Your chance to tell us where you’ve been and what you’ve been up to...

InStUlethAwawwh

Study day celebrations

The midwifery society at Queen’s

University Belfast (QUB) held a study

day to celebrate IDM.

The event, held in May, consisted

of concurrent workshops that

covered stress management,

refl exology and traffi cking.

A lunchtime session brought new

and experienced student midwives

together to discuss fl exible

placements on a national and

international scale.

Student midwives, university

staff and midwives also

attended an evening reception

to celebrate IDM, as well as the

10th anniversary of direct-entry

midwifery at QUB.

tioniioioio

re LL

AwardStudent midwife Jude Jones (above)

was awarded Student Midwife of the

Year at the MaMa conference in April.

Jude Jones, who studies at Salford

University, is the founding member of

the Salford Midwifery Society and a

member of the RCM SMF.

Deaf awareness conferenceRCM award winner Paulina Ewa Sporek gave a presentation at the fi rst deaf awareness conference for midwives and other professionals in Salford.Paulina’s project, Deaf Nest, has been recognised and awarded the Certifi cate of Commendation by the Cavell Nurses’ Trust. It has also been shortlisted in the British Journal of Midwifery Awards. The event, hosted by the University of Salford, where Paulina studies, welcomed 200 delegates.During preparations for the conference, Paulina gave birth to her son Luis.

nessessss

th

World Café in PragueThe fi rst International World Café of Student Midwives was held at the ICM congress in Prague in June.

Some 370 students travelled from around the world to share their experiences and learn about midwifery education on a global platform.

Themes emerged from across the nations: theory/practice gap, shortage of midwives and job prospect concerns.

Many participants in the World Café had never met student midwives outside their own country. RCM SMF member Hana Ruth Abel said it was a valuable cultural experience: ‘I learned so much about foreign birth cultures.’

n Prnnn PrPrPrn Pr

PO

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29

Sara Sardarizadeh / On course

rcm.org.uk/midwives

Sara Sardarizadeh shares her experience of an insightful study day

and why it’s important for students of all levels to make time for them.

I f I had the opportunity to rewind time to the fi rst day of my midwifery degree, I would off er myself some advice.

I would tell myself to prepare for what will be a very challenging and eventful three years, but not to lose hope, as everything will fall into place during the fi nal year when you least expect it.

After fi nishing a complicated childbearing module in a very busy maternity unit, I found myself feeling weighed down by the constant focus on high-risk situations. I began to doubt my decision in wanting to become a midwife, as my aspirations of focusing on childbirth as a natural life event prior to entering the degree seemed completely opposite to what was my current reality.

While having a comprehensive understanding of complicated childbearing is vital when caring for high-risk women, midwives are the lead healthcare professionals in normal pregnancy, labour and birth (NMC, 2012), and balancing the two perspectives was becoming overwhelming.

While studying towards my dissertation in the library one

afternoon, I found myself reading Rhythms in the third stage of labour by Denis Walsh (2012). Walsh talks about defi ning the benchmark of PPH and maternal physiology when coping with blood loss in the third stage

of labour. As I read further, I began to refl ect on the last few months of clinical placement; are maternity units over-treating women if the threshold for blood loss has been reached? Are we being mindful of the extra circulating blood volume in healthy women with normal labours and the ability to tolerate blood loss of over 500ml without decompensating?

While I continued to refl ect, I began to feel inspired yet slightly dissatisfi ed with my limited experience of the physiological management of the third stage, so I decided to investigate

opportunities for attending a study day.

I was very fortunate to be invited to attend a study day with Denis Walsh, where I could listen to his discussions about Evidence and skills for normal labour and birth (Walsh, 2012). I had no idea the impact this experience would have on me as a future midwife, most importantly that it would reinvigorate my passion for midwifery-led care after such a lengthy focus on high-risk and obstetric-led care. It was also great to have the opportunity to listen to other midwives and student midwives share their experiences and refl ect on their practice. This wonderful study day was an unexpected revelation, which came at the most perfect moment in my fi nal year.

As student midwives, we are encouraged to attend external study days outside of clinical placement and educational studies, but it often seems too challenging as we have such limited spare time. However, I would highly recommend students at any level in their training to make time to attend study days; even when you are tired, even when you are busy, even when you have a looming deadline, you might just fi nd inspiration strikes you when you least expect it to.

Sara SardarizadehThird-year student, Kingston University


→ I had no idea the impact this experience would have on me as

a future midwife

WHEN INSPIRATION

STRIKES

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MIDWIVES • ISSUE 4 • 2014 rcm.org.uk/midwives/news30

OpinionUpfront / Hayley Goleniowska

Hayley Goleniowska’s daughter Natalia has Down’s syndrome, which

was diagnosed at birth. Here, she shares her cautionary thoughts on

antenatal screening for the condition.

B efore Natalia was born, I unquestioningly believed, as do most prospective

parents, that the recommended antenatal tests were for our peace of mind. I naively spouted that we didn’t mind what the sex of the baby was, as long as it was healthy. I refused amniocentesis after an inconclusive nuchal fold scan, because of the risk of miscarriage to a healthy baby.

Looking back at that previous version of myself fi lls me with shame because of my deep-rooted belief that a baby with a disability is somehow worth less than a healthy one. But I also see that my prejudice and fear of Down’s syndrome was a product of the way society, and some within the medical profession, view the condition.

Many argue that an antenatal diagnosis enables parents to have time to adjust and prepare for a child with additional needs. They can research and fi nd the support they will need post-birth. New, more sensitive, early blood tests are hailed as safer for mother and baby. But what are we testing for and why?

Abortion is routinely off ered as the only route, an assumed decision of the prospective parents of any baby with Down’s syndrome. Instead of counselling and the provision of balanced facts to enable informed decisions, frightened parents are simply statistics in the NHS Fetal Anomaly Screening

Programme’s strategy. Down’s syndrome is eff ectively

being screened out like substandard fruit on a

conveyor belt. The tests serve no purpose

other than to identify babies with the condition and eradicate them, since there is no cure.

It may be that, had I been told that termination after

24 weeks could be arranged for babies with ‘severe handicaps’, I would have believed that Down’s syndrome was a severe disability rather than a mild to moderate developmental delay.

If my trusted medical team advised it, would I have chosen the route of the 91% (Morris and Springett, 2014) who terminate when they fi nd out that their unborn baby has Down’s syndrome? Had I been off ered a next-day appointment for termination, would I have

taken it, in spite of there being no chance to get over our shock, discuss it, or read about or meet a family who had a child with Down’s syndrome?

In truth, I don’t know. The person I was then knew little about Down’s syndrome and had no idea of the independence and achievements possible, once the veil of fear and ignorance is lifted. I had no clue that perfection comes in many forms.

When I refl ect on the £30m that is spent on screening versus a mere £1.8m on Down’s syndrome research (Hansard, 2013), I fear that women who think they are making a free choice to abort are actually being denied the option to keep their baby.

And I wonder how I will one day explain to my grown-up daughter why there are so few others with Down’s syndrome. For the subtext of the current screening programme is that her life is worth a little bit less than those around her.�

Hayley GoleniowskaBlogger, speaker and writer for Downs Side Up. Visit the website at: downssideup.com


Hayley’s eldest daughter Mia, 10, has written Down Side Up’s fi rst publication,

I love you Natty, which aims to help other children who become siblings to a child with Down’s syndrome.

SCREEN TEST

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ng

being subs

conse

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030_MID_OPINION_upfront.indd 30030_MID_OPINION_upfront.indd 30 02/07/2014 11:1102/07/2014 11:11

On focusCurrent and completed midwifery research

Emma Godfrey-Edwards / Cutting edge


Meeting the needs of childbearing women

THE LANCET SERIES ON MIDWIFERY

Renfrew MJ, McFadden A, Bastos MH, et al. (2014) Midwifery and quality care: fi ndings from a new evidence-informed framework for maternal and newborn care. See: http://dx.doi.org/10.1016/S0140-6736(14)60789-3.

Homer CSE, Friberg IK, Bastos Dias MA, et al. (2014) The projected eff ect of scaling up midwifery. See: http://dx.doi.org/10.1016/S0140-6736(14)60790-X.

van Lerberghe W, Matthews Z, Achadi E, et al. (2014) Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. See: http://dx.doi.org/10.1016/S0140-6736(14)60919-3.

ten Hoope-Bender P, de Bernis L, Campbell J, et al. (2014) Improvement of maternal and newborn health through midwifery. See: http://dx.doi.org/10.1016/S0140-6736(14)60930-2.

T he needs of the world’s childbearing women and their families are not being met and new solutions are required. This is the focus of The

Lancet’s landmark series on midwifery, which sees it described as ‘the most critical, wide-reaching examination of midwifery to date’.

The four-paper series provides an evidence-based framework for quality maternal and newborn care (QMNC), describing the care characteristics that are needed throughout the childbirth timeline. The exploration of care quality is expanded from the practicalities of what is being done to incorporate the concepts of how, by who and where care is provided.

The series provides a clear defi nition of midwifery and emphasises that educated, regulated, trained and licensed midwives who are fully integrated into the health system and working in multidisciplinary teams can provide the full scope of midwifery care.

In using the Lives Saved Tool to look at the impact a midwife can have, the scaling up of midwifery found that mortality and stillbirth rates could drop by between 27% and 82%

over 15 years in low-resource settings. For high-income countries, the impact would be greater on morbidity rates.

The series presents case studies from four countries – Burkina Faso, Cambodia, Indonesia and Morocco – which have opted to rapidly upscale their midwifery workforce. It fi nds that health improvements depend on how the service delivery network is designed and the investment that is made. It also confi rms that investing in midwives is ‘realistic and eff ective’ in reducing maternal mortality. While low-income countries are short of resources, there is a trend towards over-medicalisation in high-income countries, say the authors.

The evidence reveals that policies to improve maternal and newborn health require both the increase of service coverage and the improvement of care quality at the same time.

The authors state that practical testing of the QMNC framework could identify the clinical, psycho-social and economic outcomes in low-, middle- and high-income countries.

Emma Godfrey-EdwardsEditor, Midwives

→ Mortality and stillbirth rates coulddrop by between 27% and 82%

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On focusHow to... / manage primary postpartum haemorrhage in hospital

—HOW TO...

—

A primary postpartum haemorrhage (PPH) is defi ned as bleeding of 500ml or more, or any amount that has a detrimental eff ect on

a woman’s wellbeing, from the genital tract within the fi rst 24 hours after giving birth (WHO, 2012; Jangsten et al, 2011; Mousa and Alfi revic, 2007; NICE, 2006). A PPH may be accompanied by one or more clinical signs and/or symptoms depending on the amount of blood loss. Clinical signs of a PPH include palpitations, dizziness, tachycardia, weakness, sweating, restlessness and pallor, and ultimately collapse (Schuurmans et al, 2000).

If the blood loss is 500ml to 1000ml with no clinical signs of shock, then it is regarded as a minor PPH. When there is a loss of over 1000ml, or the woman has signs or symptoms of shock, then it is a major PPH (RCOG, 2011).

Once a PPH is identifi ed, four components of management should be instigated simultaneously: communication and resuscitation, monitoring and investigation, as well as measurements to control the bleeding (RCOG, 2011).

This article will primarily look at care within a hospital setting – management of such an emergency at home isn’t addressed here.

CommunicationThe midwife should communicate to the woman and her birth partner the need to summon help quickly and press the emergency buzzer.

If it is a minor PPH, the midwife in charge and fi rst-line obstetric and anaesthetic staff should be contacted in the fi rst instance (RCOG, 2011). For a major PPH, summon the obstetric, anaesthetic and haematology consultants, as well as the blood transfusion laboratory and porters (RCOG, 2011). At a home birth or a standalone birth centre,

...manage primary postpartum haemorrhage

Primary postpartum haemorrhage in the third stage is described as the most dangerous part of childbirth. Karen Baker explains how to act fast and treat it in a hospital setting.

contact the emergency services.Once the PPH emergency equipment is in

situ, coordinate the assistance. Helper one should assess, maintain and monitor the woman’s airway if needed, while helpers two and three should gain intravenous (IV) access, start IV fl uids and take blood if needed. A designated person should note the time of relevant events.

Next comes resuscitation – the woman should be laid fl at, her breathing assessed and she should be kept warm. If required, she should be given a high fl ow oxygen mask at 10l to 15l per minute.

In the event of a minor PPH, with no clinical signs of shock, insert one large bore cannula and start rapid fl uid resuscitation with two litres of crystalloid (RCOG, 2011).

For a major PPH, or if the woman is displaying signs and symptoms of clinical shock, insert two large bore cannulae and transfuse blood as soon as possible. Until blood is available, start a rapid warmed infusion of up to 3.5l of crystalloid (Hartmann’s solution two litres) and/or one to two litres of colloid (RCOG, 2011).

IDENTIFYING POSSIBLE CAUSES OF PPH

The four T’s to look for:

► ToneFailure of the myometrium to contract adequately (atonic uterus) after the birth is the most common cause of PPH (Lewis, 2011; Mousa and Alfi revic, 2007)

► Tissue (retained products of conception)The placenta and membranes should be checked to ensure they are complete

► TraumaA vaginal examination should be carried out to check for any bleeding from the genital tract. If this is the cause, the woman should be stabilised and the tear repaired

► Thrombin (abnormalities of coagulation) The woman’s blood loss should be observed to assess whether it is clotting.

034-035_MID_FOCUS_How_to.indd 034034-035_MID_FOCUS_How_to.indd 034 01/07/2014 12:2001/07/2014 12:20


hypertension. However, ergometrine is not advised if the placenta is still inside the uterus (WHO, 2012; RCOG, 2011).

If the uterus contracts after these measures, a syntocinon IV infusion should be administered (Winter et al 2012; RCOG, 2011), unless there is fl uid restriction (Winter et al, 2012; RCOG, 2011).

If a uterus is still not well contracted after the second dose of an oxytocic drug (Winter et al, 2012; RCOG, 2011), carboprost 0.25mg by IM injection repeated at intervals of no less than 15 minutes to a maximum of eight doses (contraindicated in women with asthma) or misoprostol 1000μg rectally should be used.

Should these physical and pharmacological methods fail to control excessive blood loss, then balloon tamponade, haemostatic brace suturing, bilateral ligation of the uterine arteries or the internal iliac arteries, selective arterial embolisation or a hysterectomy may be needed (RCOG, 2011).

Most causes of PPH will be successfully controlled via a second dose of oxytocic drug, bladder catheterisation and repair of vaginal tears. However, if not, subsequent management is most eff ectively performed in the operating theatre (Winter et al, 2012).

The possibility of a primary PPH means that the third stage of labour has been described as potentially the most risky part of childbirth (Jangsten et al, 2011; Rogers et al, 1998). So it is essential that the midwife is familiar with its immediate management, so she can detect excessive blood loss and instigate the necessary treatment with the rest of the multidisciplinary team to reduce maternal morbidity and mortality.

Karen BakerMidwife, Calderdale Birth Centre, West Yorks


Monitoring and investigationIn order to monitor the woman’s condition, her respiratory rate, pulse and blood pressure should be assessed and a modifi ed obstetric early warning system chart should be completed.

For a minor PPH, bloods for group and screen, full blood count and coagulation screen should be taken and identifi ed. The woman’s pulse, respiration rate, temperature and blood pressure should also be recorded every 15 minutes. A foley catheter should be inserted and the woman’s urine output should be monitored.

For a major PPH, in addition to the management above, these measures should be considered: the woman’s blood being taken for crossmatch (four units minimum), a full blood count and renal and liver function for baseline. Also, the pulse oximetry, blood pressure and respiratory rate should be continuously recorded (RCOG, 2011).

It is important to try to identify the possible cause or causes of the PPH (see box, left). Then measures should be taken to stop the bleeding.

Stopping a bleedIf the cause is uterine atony, the midwife should massage the uterus to expel any clots (see above), and administer drugs to promote contractions. The drug treatment used will depend on local guidelines.

If management of the third stage was physiological, then either 10mg of oxytocin or one ampule of syntometrine should be administered intramuscularly (IM), depending on clinical circumstances and availability (Winter et al, 2012). If the woman has already received an oxytocic drug, a second dose should be given (Winter et al, 2012). The RCOG (2011) and WHO (2012) recommend fi ve units of oxytocin by slow IV infusion, which may be repeated if required.

The WHO (2012) recommends that if IV oxytocin cannot be administered, or if the bleeding does not respond to it, then IV ergometrine, syntometrine, or a prostaglandin drug should be given.

The RCOG (2011) recommends that if the bleeding is unresponsive to oxytocin then a slow IV injection of 5mg of ergometrine be given, unless there is a history of

BIMANUAL COMPRESSION OF UTERUS

ILLU

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BIMANUAL COMPRESSION OF UTERUS

✔ Wearing gloves, place one hand inside the vagina, form a fi st and push up in the direction of the anterior vaginal fornix ✔ Place the other hand on the abdominal wall and push down behind the uterus, pulling it forwards and towards the symphysis✔ Press the hands together to compress the uterus✔ Maintain the pressure until the uterus contracts and remains retracted.(Lindsay, 2004)

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MIDWIVES • ISSUE 4 • 2014 rcm.org.uk/ebm36

On focusEBM / June 2014

Midwives united: technology as the conduitMarlene Sinclair

This editorial looks at how technology can work for midwives across the world to personalise care for mothers and babies. It argues that technology remains underused by the profession at a time when it off ers creative opportunities, as marketing companies and corporates have demonstrated. Access to social media, crowd sourcing and other emerging technologies provide unprecedented opportunities for unifi cation at a global level, it states.

An overview of evidence on diet and physical activity based interventions for gestational weight management Sarah J Martin, Alexandra MS Duxbury and Hora Soltani

This paper aims to identify the key components of eff ective interventions on diet or exercise to improve pregnancy and birth outcomes. The authors fi nd that although obesity is on the rise, there is a lack of guidance that quantifi es an ideal gestational weight gain or strategies to help women remain within a limit.

Young mothers’ decision to initiate and continue breastfeeding in the UK: tensions inherent in the paradox between being, but not being able to be seen to be, a good motherLouise Hunter and Julia Magill-Cuerden

The aim is to explore the ways that adolescent mothers conceptualise their decisions to breastfeed. It fi nds that the women view breastfeeding, which has strong associations with being a good mother, as a means of counterbalancing the stigma of being a young parent.

Intrapartum support: what do women want? A literature review Mary Ross-Davie and Helen Cheyne

The aim of this review is to identify how much the support during labour aff ects women’s assessment of their birth experience. It fi nds that high-quality continuous support improves women’s perceptions of the birth and reduces the risk of perinatal mental health problems. A defi nition of the behaviours considered to be central to high-quality support during labour is possible, it says.

Safety before comfort: a focused enquiry of Nepal skilled birth attendants’ concepts of respectful maternity care Kerstin Erlandsson, Jamuna Tamrakar Sayami and Sabitri Sapkota

This paper reports how the concept of respectful maternity care is viewed by Nepal’s skilled birth attendants who take on the midwives’ role. The attendants, who may be doctors, nurses or auxiliaries, believe that safety is more important than comfort, it fi nds. While relatives provide support, attendants deal with the medical care.

An exploration of the experiences of mothers as they suppress lactation following late miscarriage, stillbirth or neonatal death Denise McGuinness, Barbara Coughlan and Michelle Butler

This exploration looks at the experiences of bereaved mothers as they suppress lactation following late miscarriage, stillbirth or neonatal death. It fi nds engorgement and leaking milk to be challenging on a physical and emotional level. The study highlights areas where women could be better prepared for this experience.�

The latest research

Evidence Based Midwifery is the RCM’s quarterly journal featuring in-depth research. Here is the summary of contents from the most recent issue – June 2014.

► RCM members have free access to EBM and the full archive online. To subscribe to the hard copy, visit: rcm.org.uk/ebm

FREE ACCESS

036_MID_FOCUS_EBM.indd 36036_MID_FOCUS_EBM.indd 36 01/07/2014 12:2001/07/2014 12:20


FeaturesIn-depth midwifery reportage and articles


In-depth midwifery reportage and articles

ANA

VILL

ALBA

Female genital

mutilationCan it be eradicated

in a generation?

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MIDWIVES • ISSUE 4 • 201442 FGM

The fi rst ever prosecution for FGM is currently working its way through the judicial system. The question is: will this be the fi rst of many or a one off ?

Leyla Hussein, FGM survivor and campaigner, hopes the action is not an isolated instance, but the start of a drive to eradicate the practice.

Over the past 18 months Leyla, and many others campaigners, have battled to keep FGM in the headlines. Her online petition ‘Stop FGM in the UK now’ has over 110,000 signatures and has already been addressed by the government, with Leyla invited to give evidence at the Home Aff airs Committee inquiry in March.

Also famous for her Bafta-nominated documentary The cruel cut, which aired last year, Leyla believes that it is thanks to survivors like herself who have been speaking out recently, that the anti-FGM campaign has reached such a level.

‘You can talk about any social issue all day, every day, but you need to actually have the person who has experienced it speaking out,’ she says.

‘Then people connect to it because they can hear it and see it fi rst hand and they can’t walk away from it. I think that the British public was ready for a British girl like me, with a London

accent, who has gone through FGM and is willing to speak out about it.’

Leyla’s documentary has not been the only TV show to beam FGM into homes across the UK, as popular primetime TV dramas, such as Casualty and Law and Order: UK have been covering the subject, which for so long has been surrounded by cultural sensitivities and social taboo. The Evening Standard has also been a particularly vocal news source, running regular stories, features and interviews as part of its own anti-FGM campaign.

The latest bid to raise awareness comes in the form of a music video by youth charity Integrate Bristol, which features politicians, celebrities and local members of the public. Trustee of the charity, Fahma Mohamed, also launched her own online petition to Michael Gove, asking him to write to all schools in England reminding them of their duty to safeguard girls from FGM.

The petition was a success with over 250,000 signatures and resulted in a meeting with Michael Gove and even backing from UN secretary-general Ban Ki-moon, who met with

Fahma and backed her call to use education as the tool for change.

But it’s not just survivors and charities making the push for change. ‘There’s so much going on – we can hardly keep up with ourselves,’ says RCM policy advisor Janet Fyle, who helped to head up a royal college and union collaboration, which has resulted in the report Tackling FGM in the UK: intercollegiate recommendations for identifying, recording and reporting.

The intercollegiate report was launched at the House of Commons in November and makes nine recommendations, with the fi rst being to treat FGM as child abuse. The report states that implementing a comprehensive multi-agency action plan is urgently required to ensure that the UK laws already in place protect young girls at risk of undergoing FGM.

As Midwives went to press, the Home Aff airs Committee was preparing to publish its report Female genital mutilation: the case for a national action plan, after considering the intercollegiate report, which Janet and other RCM policy staff were invited to discuss.

WHO (2014) CLASSIFICATION OF FGM

► Type I: Clitoridectomy: partial or total removal of the clitoris.

► Type II: Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

► Type III: Infi bulation: narrowing of the vaginal orifi ce with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitoris.

► Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterisation.

Almost 30 years after FGM was made illegal in the UK, the Crown

Prosecution Service announced the fi rst UK prosecutions over FGM.

Hollie Ewers looks at the latest eff orts being made in the

anti-FGM campaign.

Closing in on FGM

Clockwise: Fahma Mohamed (second

from right) with fellow anti-FGM campaigners

before their meeting with education

secretary Michael Gove in London;

Comfort Momoh; items used in FGM



In May, a woman was arrested at Heathrow airport on suspicion of conspiracy to commit FGM and a 13-year-old girl travelling with her was taken into care. This came about after a week-long anti-FGM initiative held across six other airports. Comfort, who worked with police years ago at Heathrow on a similar campaign, believes it is a very good form of action. ‘It is raising awareness and also giving information directly to the families travelling to diff erent parts of the world, but particularly targetting the FGM-practising communities,’ she says.

But Comfort opposes the idea of medical examinations at airports – such as those carried out in France on girls thought to be at risk of FGM. Instead, she suggests that medical assessments – similar to those that used to be carried out by health visitors on all children of a certain age – should be brought back to safeguard those at risk.

‘Prevention is better in the sense that we all need to collaborate and work with the grass-roots community in order to change attitudes and mindset,’ she adds.EY

EVIN

E/N

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INTE

RNAT

ION

AL/C

ORB

IS

Over

66,000 women in the UK have

already undergone FGM

More than

24,000 girls are at risk in the UK

FGM has been a criminal off ence in the UK since

1985 and the Prohibition of Female

Circumcision Act

This was later replaced by the FGM Act (2003) in England, Wales and

Northern Ireland and the prohibition of FGM Act

(2005) in Scotland

Both the 2003 and 2005 acts carry a maximum

prison sentence of

14 years

‘We recommend in the intercollegiate report that there is a clear pathway for referral for all health professionals, but it has to be a national pathway, so whether a midwife works in deepest Cornwall or in Brixton, she knows the pathway and what to do if a woman in her care has undergone FGM,’ Janet says.

But just how prevalent is FGM in the UK?New fi gures reveal that nearly 4000 women and girls have been treated for FGM in London’s hospitals since 2009 (FOI, 2014) and at least 66,000 in the UK are believed to be victims (Dorkenoo et al, 2007).

‘We average about two reversals per week,’ says Comfort Momoh, midwife and FGM consultant/public health specialist at Guy’s and St Thomas’ Hospital in London. Comfort established and runs the African Well Woman’s Clinic at Guy’s, off ering support, information and surgical reversal of FGM. She has also helped to set up similar clinics across the UK and has run a course to train others in FGM reversals.

t al e

››


MIDWIVES • ISSUE 4 • 2014 rcm.org.uk/midwives44 FGM

no way back from it,’ she adds.Lindsey Ahmet, a senior midwifery lecturer

at Middlesex University London, agrees that FGM is an area all health professionals need to sharpen up on. ‘At the moment there is no real consistency, but FGM is certainly something people should be aware of and I’d emphasise that it’s every midwife’s responsibility to educate themselves, whether they work in Ulster, Birmingham or the outskirts of Scotland. It would be good to make it part of continuing professional development for both students and practising midwives to take up.’

Comfort agrees: ‘We also need to support the woman and her family with information. It’s about making the links between FGM and the complications she may have had and to help her not to have FGM performed on her daughter in the future. We need to give her information about the law and highlight the safeguarding issues and ongoing support to empower her.’

With regards to midwives, Comfort suggests that a clear plan of action for FGM is needed from pre-labour, delivery to post-delivery, to making a note in the red book. ‘But I do have a problem with reporting a 21-year-old non-pregnant woman, who has summoned the courage to come to my clinic asking to be assessed for FGM, to the police or social services,’ she says. ‘I worry that this will send the practice deeper underground, as youngsters I’ve had conversations with say that to be reported would be like being punished twice, so we are still discussing and having conversations around that.’

But Comfort, like Leyla, and the many other FGM survivors, campaigners and supporters, believe that education and changing opinions, beliefs and attitudes at a grass-roots level in the community is the best form of prevention and action in eradicating the practice in a generation. With the UK’s fi rst FGM charges in 2014, who knows how many more there might be, and how many girls may be saved from FGM.�


What role do midwives play in the fi ght against FGM?Earlier this year, the Department of Health announced that, from April, all NHS hospitals would be required to record if a patient has undergone FGM or if there is a family history of it. By September, all acute hospitals will have to report this data to the department on a monthly basis – this will include midwives. ‘Midwives are key people who can actually prevent FGM from taking place,’ says Leyla. She belives that midwives can play a crucial role in educating women about FGM, but also preventing and safeguarding future girls who might be born into FGM-practising families. ‘A lot of these women will not go to their GP and might never have had smear tests done, but a lot of them still fall pregnant and they will visit a midwife because they have to, so the midwife might be the fi rst or the only health professional they’ve come across.’

If it wasn’t for the community nurse who spoke to Leyla two months after the birth of her daughter about the FGM she had undergone years before, Leyla would still be thinking that there wasn’t anything wrong with the practice. ‘That’s why I’m adamant that health professionals, especially midwives, play an important role in tackling FGM – but, obviously, they can’t do it without having the appropriate training in place for them, and until FGM is on every medical students’ curriculum and compulsory in child

››

protection training, we may still be having this conversation in 10 years’ time.’

Leyla is in agreement with the recommendations for a referral pathway made by the intercollegiate group. She is also in favour of midwives using the red book to keep a record of any women who have been subjected to FGM and for this to be passed onto a child’s health visitor, nursery, primary and even secondary school nurses. ‘That’s not going to off end anyone, that’s going to safeguard her child. It also alerts the parents to what is going on and makes them aware that they know they are being watched.’ It is working according to Leyla: ‘Just recently, with all the FGM profi ling, a lot of people in our communities are saying “oh, so-and-so might not do it now because they’re worried they might get arrested”, so the fact that the information is starting to get out there has really helped because once it happens there’s

ALAM

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A SURVIVOR’S STORY: LEYLA HUSSEIN► Born in Somali and underwent FGM aged seven► Came to the UK aged 12 and didn’t realise the eff ects of

her FGM until aged 22 – just two months after the birth of her daughter

► Has campaigned against FGM ever since and previously worked at the African Well Woman’s Clinic in East London

► Co-founded non-profi t organisation Daughters of Eve in 2010 to protect girls and young women at risk from FGM

► Has run many FGM workshops, training, support groups and campaigns

► In 2013 Leyla fronted a BAFTA-nominated documentary for Channel 4 called The cruel cut, which thrust FGM into the spotlight and her e-petition ‘Stop FGM in the UK now’ has gained over 110,000 signatures and has been addressed by the government

► She is now a qualifi ed psychotherapist and has gained funding from Comic Relief for her latest venture, the Dahlia Project, which is a support group and individual counselling service for women who have undergone FGM.

For more information, visit:► www.forwarduk.org.uk► nhs.uk/Conditions/female-genital-mutilation/Pages/Introduction.aspx► nspcc.org.uk/help-and-advice/worried-about-a-child/online-advice/female-genital-mutilation/fgm-

circumcision-cutting_wda102815.html► To read the intercollegiate recommendations, visit: rcm.org.uk/sites/default/fi les/FGM_Report.pdf

Left: a campaigner for women’s rights. Below: health minister Jane Ellison signs FGM pledge


rcm.org.uk/midwives 45 ISSUE 4 • 2014 • MIDWIVESPARENTAL RIGHTSSH

UTTE

RSTO

CK

Now► Maternity leave is up to 52 weeks. A mother can go back early by giving eight weeks’ notice. She may be entitled to up to 39 weeks of statutory maternity pay or maternity allowance; the rest is unpaid.► Ordinary paternity leave is one or two weeks, to be taken shortly after the baby is born. To be eligible, partners must have worked for the same employer throughout the pregnancy and earn at least £111 a week. New employees and self-employed people do not qualify.► Fathers are entitled to take additional paternity leave in some circumstances. If the mother chooses to cut short her maternity leave and return to work, then the father can take additional paternity leave. A mother can only return once the baby is at least 20 weeks old. A father’s additional paternity pay can only be paid for a maximum of 19 weeks, which is the balance of the mother’s 39 weeks’ maternity pay, if she goes back when the baby is 20 weeks old.► Each parent also has the right to up to 18 weeks of unpaid parental leave per child until the child is fi ve (or 18 if disabled). They must have worked for at least a year for the same employer.

With the recent changes to parents’ rights, the charity Working Families

explains what is happening and what advice midwives can off er to those

expecting children in the next few months and years.

► The amount of total paid leave will stay the same. So there will be a maximum of 37 weeks of fl exible parental pay that could be taken by the father when the mother, who is receiving statutory maternity pay or maternity allowance, chooses to stop those payments by returning to work. ► Flexible parental leave means that it will be possible for a parent to stop and start their leave. So, a mother could go back to work and then return to her time off looking after her baby.► Mothers and fathers can take leave at the same time under the new system, as long as they don’t exceed the total amount of leave available. This remains the same as now – 52 weeks. ► It will be possible to take unpaid parental leave for any child up to the age of 18, instead of fi ve years old as it is at present. It will continue at 18 weeks per child, per qualifying parent.► Employed fathers or partners will have the right to attend two antenatal appointments. This will be an unpaid right.�

► Need more advice? Contact the Working Families legal helpline on: 0300 012 0312 or email: [email protected]

All change

Mothers and fathers can take leave

at the same time under the new

system

From 2015► A system of shared parental leave will replace current maternity leave and additional paternity leave.► A mother will still be able to take up to 52 weeks of leave and she must take two weeks after the birth for recovery. After that, it is up to her how she wants to share the leave with her partner. ► Fathers will still have the right to one or two weeks of leave around the birth, providing they meet the same conditions as now – new employees and the self-employed miss out.

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MIDWIVES • ISSUE 4 • 201446 COMMISSIONING

The new NHS structures in England came into being in April 2013. Midwives who have an interest in infl uencing how services are

commissioned need to understand who does what and how they can get involved. Most midwives will be aware that the new clinical commissioning groups (CCGs) now have the responsibility for commissioning on behalf of their local population, but other organisations also have a role.

Regardless of where they are, commissioners require a certain level of knowledge and expertise to commission eff ectively. Midwives can help them access this experience to enable them to commission high-quality services and, at the same time, get a greater voice for the midwifery profession.

A changing horizonBefore April 2013, primary care trusts (PCTs) held the budget for both primary and secondary care, community and acute services. This included private hospitals, as well as those in the NHS and ex-NHS

The way that services are commissioned in England has changed and there is an opportunity for midwives to get more

involved, as Diane Jones explains.

Making the midwifery

voice heard

community care, alongside private or third-sector community care. Now PCTs have been abolished and CCGs are in charge. Their commissioning landscape covers all the same elements that the PCTs did, including maternity services.

But not all maternity services come through CCGs and it is important to know where other aspects of maternity are commissioned. The

aim is to fi nd out who the key people are in CCGs and elsewhere with whom to engage, so that the midwifery voice is heard and refl ected in service specifi cations.

The three bodies involved in commissioning maternity services are: the local authority, NHS England and CCGs. The local authority is responsible for public health, which includes antenatal screening, the child death overview panel and the deprivation of liberty safeguards. In addition, since April 2014, health visiting comes under the auspices of the local authority having previously been covered by NHS England.

NHS England covers general practice and other primary care functions, such as dentistry, ophthalmology and pharmacy. And CCGs cover mental health and other maternity services in acute care and community care, with the exception of screening.

A CCG is generally made up of a collection of GPs. They are appointed as clinical directors and, from their number, they elect a chair and vice chair. Each clinical director will have a special interest or particular experience of a clinical area for which they will take the lead at the CCG. At least one of them will be the lead for maternity. In addition, a CCG will have a nurse executive, as well as an accountable offi cer, chief fi nance offi cer and a chief operating offi cer, as a minimum requirement.

Making the commissioning caseObviously, it is important to make a compelling case to commissioners. Any

Figure 1 – An overview of the four quality strands

QUALITY ASSURANCE

Organisational integrity

Staff questionnaire

NHSLA submission

NICE compliance

Audit reports

Serious incidents

Safeguarding

Complaints

Friends and family test

Patient experience

Clinical eff ectiveness

Patient safety

46-47_MID_FEATURES_Commissioning.indd 4646-47_MID_FEATURES_Commissioning.indd 46 01/07/2014 12:2201/07/2014 12:22


Infl uenceTo be as infl uential as possible, understand the design of your local CCG. Find out which clinical director is the maternity lead and who has the role of nurse director. Also, it may be useful to fi nd out if there is a quality lead, because in some CCGs they are separate posts. It is important to understand the wider commissioning landscape in the health and social care setup and look into how your organisation engages with the CCG and local authority.

As midwifery leaders, you need to infl uence what commissioner’s commission by being the voice for maternity services. Challenge the current commissioned services, and be prepared to make diffi cult decisions in order to make that diff erence for women and babies.

Commissioners value clinical input, so get involved. It is a great opportunity for learning and, who knows, it could be your next career move?�

Diane Jones Registered midwife, SoM and deputy nurse director, Barking and Dagenham, Havering and Redbridge CCGs

commissioning for quality and innovation (CQUIN). Some KPIs will have a fi nancial penalty attached, so that if it has not been achieved, money can be withheld from the provider. A CQUIN off ers a fi nancial incentive when a target has been achieved. Both KPIs and CQUINs should be agreed with the provider and commissioners of services prior to the contract being signed off . Examples of commonly used KPIs include the rates for normal vaginal birth, CS and breastfeeding initiation.

It is also useful to agree clinical indicators. These have no fi nancial penalty or reward but, instead, are about best practice. For example, they might include pain relief usage, postpartum haemorrhage rate, intensive treatment unit and neonatal intensive care unit unplanned admission, staff training and appraisal.

As a provider of maternity services, you will have a contractual responsibility to assure the CCG that women and babies are receiving the best possible care. If there are weaknesses or defi ciencies, then it is your job to explain to the CCG about how this will be managed and improved upon.

ideas must clearly demonstrate a service improvement for women and, therefore, they are likely to fall under one or more of the four strands in the quality spectrum – organisational integrity, patient experience, clinical eff ectiveness and patient safety.

It should also fi t with the corporate objectives of your organisation, otherwise it could be blocked without ever being discussed with commissioners.

The role of the commissioners is to be assured that services are of excellent quality for the local population. Quality will present diff erently, depending on the strand. For example, organisational integrity may show quality via staff questionnaires and the NHS Litigation Authority. Meanwhile, the strand on patient experience would demonstrate good care by how it handles complaints and the friends and family test. Commissioners would look for NICE compliance and audit reports in the strand on clinical eff ectiveness and patient safety would cover issues, such as safeguarding and serious incidents.

Quality in each strand can be measured by key performance indicators (KPIs) and

GPs GPs GPs

GPs GPs GPs

GPs GPs GPs GPs GPs GPs

PRIMARY CARE TRUST

CLINICAL COMMISSIONING GROUP

NHS hospital

NHS hospital

Private hospital

Private hospital

Ex-NHS community

care

Ex-NHS community

care

Private/charity

community care

Private/charity

community care

BEFORE

Figure 2 – NHS commissioning landscape before and then after April 2013

Abolished NewAFTER

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MIDWIVES • ISSUE 4 • 201448 POSTNATAL CARE

included transfer of place of birth from home to hospital, increased medicalisation and high inpatient turnover. Policy to inform service revision was often based on assumption rather than evidence until the Winterton report (House of Commons Health Committee, 1992), which recommended that maternity services should be focused on choice, control and continuity with women at the centre of the service.

In 2007, the Department of Health (DH) in England published Maternity matters (DH, 2007), which recommended maternity networks and a national choice ‘guarantee’ that women could choose where they gave birth. In 2006, the NICE guideline for

the fi rst Midwives Act received royal assent in 1902. Maternal deaths had halved by 1917 and continued to decline over the next decades, refl ecting better public health, access to emergency obstetric care and introduction of antibiotics, as well as universal midwifery care.

Such was the fear of puerperal sepsis that midwifery postnatal care in the early 20th century was highly prescriptive. Midwifery texts of the time included recommendations about how often a woman’s perineum should be swabbed postnatally to prevent genital tract infection (Marchant, 2009) and the need for postnatal women of diff erent social classes to be managed appropriately to promote adequate rest, a particular concern for women from lower social classes (Marchant, 2009).

Postnatal care in the NHSIn 1948, the NHS was launched, which formalised the GPs’ role in maternity care and provided universal health care ‘from the cradle to the grave’. In the last revision to the Midwives rules, from the current NMC, a minimum contact of 10 days post-birth is still promoted, although midwives can maintain contact with women ‘for such longer period as the midwife considers necessary’ (NMC, 2012), introducing a much broader scope of practice. It is worth noting, however, that there is no evidence base to support the defi nitions of ‘postnatal’ that we currently use.

From 1948, changes to maternity care

Postnatal care is a subject close to my heart and an area I have researched for over 20 years. My master’s thesis study showed, for the fi rst time, that common postnatal health problems were

severe and impacted on women’s lives. My PhD thesis focused on implementation of a new model of midwifery-led postnatal care that was associated with better mental health outcomes and use of NHS resources.

But long before me was the pioneering Zepherina Veitch who, along with others, campaigned for the statutory training and registration of UK midwives in the early 20th century.

Born in 1836, she was the daughter of a cleric and witnessed fi rst-hand the impact of birth on the health of poorer women in her father’s parish. Her midwifery training was completed at the British Lying-in Hospital in Endell Street, London, at a time when hospital maternal mortality rates were extremely high, mainly as a result of puerperal sepsis.

Several early attempts to introduce a ‘Midwives Act’ had failed and in 1892 Zepherina gave evidence to a Parliamentary Select Committee where she referred to the inability of poor families to pay for doctors, who would not even ‘wash babies as beneath their dignity as educated gentlemen’ (Halliday and Halliday, 2007). Sadly, Zepherina died in 1894 before

Professor Debra Bick gave the RCM’s annual Zepherina Veitch lecture, talking about the importance of postnatal care. Here she explains why it remains one of her passions.

Postnataloptımism

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Improving postnatal careAchieving an eff ective continuum of midwifery care is fraught with diffi culty. Giving birth is the most common reason women are admitted to hospital, yet birth cannot be demand-managed or controlled through referrals. Maternity is a core NHS service, delivered by acute service providers but mainly in primary care settings, with wide unexplained variation in outcomes between NHS trusts (National Audit Offi ce, 2013). We lack eff ective measures of postnatal care, and reductions in service provision have raised concerns about an overall decline in women-centred quality standards (Bhavani and Newburn, 2010). The RCM Pressure Points campaign found that only a quarter of women were off ered information about severe postnatal morbidity in line with NICE guidance (RCM, 2014). Many NHS trusts are in fi nancial defi cit and new maternity pathway tariff s could impede service development due to poor quality data and lack of strategic planning. More midwives are needed (National Audit Offi ce, 2013), although resources could be better utilised through revision to current postnatal systems and processes (Bick et al, 2012).

NHS reforms in England could mean the end of the NHS as we know it, or we could meet challenges by engaging and reforming postnatal services. Evidence has shown that midwives can make a diff erence to the health of women, their infants and families (MacArthur et al, 2003), but current NHS service provision and funding mitigates eff ective universal postnatal care.

Maternity pathways need to refl ect planned, tailored postnatal care based on an individual woman’s needs, with midwifery staffi ng projections refl ecting policy ambition for life-long health, rather than a predicted number of births. We need objective measures that refl ect the priorities of women and their families. Engagement with local clinical commissioning groups is essential to ensure universal postnatal care is promoted to enhance priority health outcomes.

Postnatal care should no longer be viewed as the poor relation of maternity services.�

Debra Bick, Professor of Evidence-Based Midwifery Practice, King’s College London, Florence Nightingale School of Nursing and Midwifery/Division of Women’s Health


during labour and birth are continuing to rise (Health & Social Care Information Centre, 2013). Evidence from the 1990s onwards shows high rates of maternal morbidity including incontinence, perineal pain and depression. Despite evidence of morbidity, the content and duration of postnatal care have not been revised.

Inpatient care generates more complaints than other aspects of maternity services, with evidence that women feel unable to ask for help and are unfamiliar with hospital routines (Beake et al, 2010). The incidence of severe maternal morbidity is increasing, with evidence of the impact of maternal obesity on infant outcomes (Denison et al, 2014) and inequalities in maternal health outcomes (Knight et al, 2009). Genital tract sepsis was the leading direct cause of maternal death during 2006 to 2008 (Lewis, 2011). It begs the question: can 21st century health needs be met within a 20th century postnatal framework?

routine postnatal care for women and their babies was published (NICE, 2006) with recommendations to support maternal and infant health and infant-feeding, based on a systematic review of evidence. For the fi rst time, health professionals and women had evidence-based guidance on the content of care that should be off ered in the fi rst 24 hours post-birth, between two and seven days afterwards and weeks two to six. More recent policy development has acknowledged the importance of interventions to improve the ‘life chances’ of women and their infants (RCOG, 2011; The Marmot Review, 2010).

In 2012-13, just over 670,000 women gave birth in England, and interventions

Postnatal care should no longer be viewed

as the poor relation of

maternity services

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MIDWIVES • ISSUE 4 • 201450 SCOTLAND REFERENDUM

the border, market midwifery and privatised cleaning means the costs are cut where the risk of disaster is least obvious and where there is a profi t to be creamed off from the most insecure and marginalised workforce.

In Scotland, we’re still paying through the nose for private fi nance initiative projects that started years ago and the public purse has borne the burden. But in England, some trusts have gone bust. Where care ends up being provided is a lottery depending on the

not going to pretend that Scotland is some Nirvana of maternity care. When services are compared, there are many similarities.

But there are diff erences too – especially when women are asked about cleanliness and postnatal care. This is because of the huge divergence in policy north and south of the border.

There are much higher levels of dissatisfaction in England. It doesn’t take a rocket scientist to work out why. South of

It might not feel like it, but being a midwife in Scotland puts you, and the service, in a better position than in England. This is a direct result of

Scotland moving away from the market model of trusts competing with each other and instead approaching health and midwifery care as a public service, not an opportunity for profi t.

When I worked as a midwife and a trade union activist, issues around workload and staffi ng were perennial sources of stress and controversy. This is still the case; I’m

With Scotland set to take to the polling stations on 18 September, what will

independence mean for the country’s midwives? We hear both sides of the

argument for Scotland leaving the UK.

How will you vote?

CAROLYN LECKIEYES SCOTLAND

Illustration: Jacob Stead

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We want to see investment continue to tackle health inequalities in Scotland.

We certainly don’t want to see problems worsened by budget cuts to

fund separation.The NHS

epitomises Scottish and British values in one institution. We care for our vulnerable and sick with no questions asked and no charges levied.

These values would persist in a separate Scotland, but our means to realise them might not. Under devolution we can steer Scotland’s NHS in the direction we want it to go,

while being backed up by the larger UK economy.

As part of the UK, Scottish clients and patients can get the best of both worlds: excellent treatment in this country’s hospitals, while also having access to specialist treatment our families need across the UK. The Nationalists are asking us to take a huge gamble in September. We know that it is a risk we don’t have to take and that is why Scotland should say ‘No Thanks’ to separation.�

We understand the health issues that aff ect families across Scotland and we also understand that the higher level of public spending in Scotland gives us an advantage in tackling these issues.

After all, that spending allows us to tackle the specifi c needs of Scotland with the allocation of that spending being decided by the Scottish Parliament.

Like everyone in Scotland, we’re incredibly proud of our NHS. Since 1999, the NHS has been under the control of the Scottish Parliament. The decisions about how the public spending on Scottish hospitals is made in Scotland by people who understand the specifi c health concerns aff ecting us. The Scottish Parliament enjoys devolved powers over the NHS in Scotland – so it will be future Scottish Parliaments that decide the shape of our service.

Since devolution meant that all decisions over the health system in Scotland were made here in Scotland, we have made huge strides in improving the health of families.

As part of the UK, Scotland’s yearly health spending is over £200 per person higher than it is in England. Yet under separation, impartial experts suggest that Scotland would face between £3bn and £10bn worth of cuts or tax rises. Even the NHS could not escape the inevitable cuts that would come from such an upheaval in our public fi nances.

operation of the market whereas, in Scotland, maternity care is planned as a public service. We might not always agree with the plan, but at least there’s recognition that babies don’t come along according to where they’ll ping the most cash registers.

Scotland is protected like a neonate in an incubator, but the real power is outside and concentrated in Westminster. We have a chance to change that.

The devolved NHS in Scotland has protected us against privatisation and commercialisation, so far. However, Osborne has promised us there is at least as much austerity to come and even Labour in Westminster has confi rmed they will uphold his plans. In Scotland, all the fi nancial slack is out of the system now and further cuts are bound to aff ect our NHS, which takes up 40% of our block grant.

Midwives’ pay and regulation are all controlled by London bodies. Are the needs of Scotland’s more geographically spread, diverse communities refl ected and catered for by the UK structures and processes that wield ultimate power on your day-to-day terms and conditions and regulatory regime? I’ve not worked as a midwife for some time, so you’ll know better than me.

This is a time where midwives in Scotland have the chance to seize all the power that is needed to make maternity services that are really fi t for the nation and value midwives north of the border, according to the needs of women and families. How would you want it to look? What would be the point of pursuing your vision without the power to do so? Seize it.

SPOKESPERSONBETTER TOGETHER

We don’t want to see

problems worsened by budget

cuts to fund separation

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MIDWIVES • ISSUE 4 • 201452 PEER REVIEW

Statutory supervision of midwives has been an essential component of professional regulation since the beginning of the 20th century. The NMC has set standards to ensure midwifery care

is safe and meets regulation. One key standard is documentation.

The NMC (2009: 1) states: ‘Good record-keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and eff ective care. It is not an optional extra.’

The objective of record-keeping is to provide a factual account of care provided and off er protection to the mother and midwife. Of course, it can be used as evidence in the event of complaints or claims. Good documentation has been seen to reduce risk and improve quality of care to women. It also reduces litigation claims and fi nancial cost to the employer (Dimond, 2005). Accurate record-keeping is essential from a medico-legal point (Chandraharan and Arulkumaran, 2006).

Although good documentation can protect the midwife, the fear of litigation is a concern for most, with many feeling a constant worry about their standard of documentation (Roberts, 2012). Regular audits of documentation are essential to ensure that a good standard of record-keeping is maintained with necessary action taken to improve practice.

This auditing is performed by SoMs on an annual basis as part of the statutory supervision process (NMC, 2012). It is important that strategies are in place to provide feedback for midwives on their standard of documentation. This includes positive feedback and constructive criticism where documentation needs improving.

Pilot studyIt is also a good idea to get others’ opinions. Professional peer review is a strategy that

focuses on performance evaluation by colleagues of the same level. It is based on the concept that objective colleagues of the same level will usually fi nd more weaknesses and errors in work or performance. Therefore, peers can make a more impartial evaluation of the standard.

Peer review is used extensively in professional fi elds including academia and medicine. According to Haag-Heitman and George (2011), peer review helps to maintain and enhance

Peer review in supervision

Good record-keeping is an important skill in a modern NHS, but it is easy to get it wrong. An award-winning initiative

in NHS Lanarkshire has found a way of improving it.Illustration: Joe Waldron

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to their peers, they were reluctant to give them constructive criticism.

They provided some recommendations as a result of the study. Participants indicated that it would be benefi cial if the standard of documentation was audited against a more consistent criterion of performance. They felt that the fi ndings from the study should be disseminated throughout the maternity services in NHS Lanarkshire. They suggested that peer review of documentation should be continued and extended to include all midwives in the region.

In response, the subgroup developed a graded scoring documentation audit tool, which was approved for use in NHS Lanarkshire by the local SoM and the LSAMO for the South East and West of Scotland. It was implemented in Lanarkshire in May 2013.

Great interest has already been shown for peer review of documentation and the developed audit tool at local and national levels.

This year, there are plans to evaluate the tool to explore if a graded documentation audit tool (see online) improves the confi dence of midwives in providing feedback in peer review. We also want to fi nd out if the introduction of peer review will improve the quality of documentation and therefore impact positively on client care.�

Jean Watson, Madge Russell, Pauline Creaney, Liz Walker and Michelle Walsh, NHS Lanarkshire and the University of the West of Scotland

► The authors received the President’s Award for SoMs at the RCM awards 2014. They wish to thank Dr Jean Rankin for her support.


documentation subgroup. There were 42 from the hospital and 40 from the community.

Results Overall, the audited documentation was good with 80% of the audit boxes meeting the required standard. Good practice statements included ‘thorough and neat and well-documented notes’, ‘good care planning’ and ‘good use of vaginal examination stickers’.

Areas for improvement included the use of unapproved abbreviations. This occurred in a quarter of the community midwives and 21% of those in hospital. Examples include symbols such as @ for at, ↑ meaning increased and ↓ for decreased. There were also examples in which it was unclear what the abbreviation meant such as D/W (discussed with?), O/P (on palpation or occipital posterior?), and O/A (on arrival or on admission or occipital anterior?).

Furthermore, a quarter of the hospital-based midwives had not signed the back page of the Scottish Women’s Handheld Maternity Records. In the same group, 18% failed to time, sign or date some of their entries and a fi fth had not completed prescription charts accurately.

These issues were not replicated in the community sample, possibly due to continuity of carer in the community and the fact that prescription charts are

not used in this setting.Feedback on poor practice included:

‘handwriting diffi cult to read’, ‘no consent recorded for VE’ and ‘no signatures’.

There was an excellent compliance rate by participants, with 80 out of 82 audits completed and they all gave individual feedback to the midwives they had audited. However, while participants felt confi dent in giving positive feedback

quality, both directly and indirectly. The problem of poor documentation

being highlighted in medico-legal cases was replicated at NHS Lanarkshire within several clinical case reviews undertaken by the SoMs. In 2011, a group of SoMs from NHS Lanarkshire was set up to review documentation with the aim of engaging midwives more fully. The annual documentation study day was subsequently updated to include pre-course reading, midwives self-reviewing their documentation, an NMC multiple choice quiz, and an interactive session discussing ‘live case records’.

But, although the sessions were well evaluated by the midwives, there was no signifi cant improvement in the overall standard of documentation within the health board. The SoM group proposed to introduce a peer-review strategy in a pilot study to audit documentation and provide feedback to midwives on their performance. The aim was to fi nd out the eff ectiveness of peer review in improving the standard of midwives’ documentation.

Two clinical areas – one community- and one hospital-based – were chosen to pilot the audit, and the study began in October 2012. A total of 14 midwives took part, seven from each area. Every participating midwife peer-reviewed the documentation of another in the team and the completed audit tools were then collated and reviewed by the

The audited documentation was good with

80% of the audit boxes meeting

the required standard

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MIDWIVES • ISSUE 4 • 201454 RCM AWARD

In spite of hearing loss aff ecting more than 10 million people in the UK (Action on Hearing Loss, 2011), there is little guidance available on the provision of maternity care to deaf women and their families (Bramwell et al, 2000). Deafness and pregnancy

are two concepts rarely considered together.The barriers to deaf pregnant women

include a lack of British sign language interpreters being available for each antenatal, intrapartum and postnatal appointment. The interpretation of fi ndings, communicating a couple’s concerns and ensuring that informed choice is provided becomes a challenge.

A project by University of Salford student

We fi nd out how the fi rst student midwife to win a practice-related RCM award did so with her project to support deaf women and couples through pregnancy and childbirth.

Providing a voice

midwife Paulina Ewa Sporek is about helping deaf couples through the childbirth and pregnancy experience. Deaf Nest aims to improve deaf users’ experience, access, choice and control over maternity care.

It is about implementing clear pathways and guidance, seeking ways to remove barriers and exploring how to make innovative and fl exible adjustments to meet the needs of deaf families.

The RCM’s Slimming World Award for Public Health gave me a boost to develop and test innovative improvement ideas. These include communication aids and quick reference packs for midwives and deaf families.

By the end of 2014, the project aims to have gathered a wide range of learning innovations and resources that can be spread out more

widely to improve the care for deaf people.The project is initially being delivered in

partnership with Manchester Deaf Centre and Deaf Health Champions project, which also recognises that deaf people experience communication barriers and are often excluded from health and social care. Deaf Nest is being piloted across north-west England. The Deaf Nest consultation group has been set up in the Manchester Deaf Centre to make sure deaf families are integral. This involves communicating, listening to deaf people’s experience of childbirth and making them key within the process of bringing about change.

Deaf Nest is also working with audio and video production student Lukas Ziabka at the University of Salford to produce a documentary about the challenges deaf parents face on their journey into parenthood.

Excited at the potential for Deaf Nest to transfer to other units and areas of practice, Paulina says: ‘All materials produced to support this project are accessible for free on the website: deafnest.com. Moreover, the project is producing Deaf Nest support packs, including leafl ets, guidance, visual aids, quick reference diagrams, fl ash cards and videos with up-to-date information, specifi c to each stage of pregnancy presented in British sign language.’

In addition, the project inspired the fi rst deaf awareness conference for midwives, service users and other health professionals at the University of Salford in June.

The project has been designed to ensure dignity and to address the needs of deaf couples in their childbirth journey. The hope is that the implementation of clear guidance, early assessment forms, eff ective referral, deaf awareness study days and Deaf Nest support packs will result in an improved experience. Likewise, better access to information, ongoing assessment of need, improved health and lifestyle choices and greater family involvement will lead to a better quality of care and, of course, outcomes.�

Paulina Ewa Sporek Second-year student midwife, University of Salford


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FootnotesEvents / Dates to remember

Events and courses, competitions and crosswords


If you would like to advertise on this page, please contact sales executive James Condley on: 020 7880 7661 or email: [email protected]

The Association of Hypnobirthing Midwives’ diploma in hypnobirthingCourses run every eight weeksSpecialist training for midwives and student midwives. The course consists of a combination of e-learning and contact days. Learn to run your own hypnobirthing practice (full support and free update days for members).Location: LondonCost: £349W: ahbm.co.uk

RCM Dilemma Debate: Trade unions – vested interest or force for good?22 JulyThe RCM will present the latest in its series of topical dilemma debates. Speakers will explore a number of themes, including the lessons from the Francis report for organisations that seek to combine professional and trade union functions, and the implications of evidence, including the NHS staff survey, that organisations which engage their employees and treat them fairly, achieve good outcomes for service users.Location: Congress House, LondonE: [email protected]

KG Hypnobirthing teacher training diploma course14-17 August, 30 October to 2 November London11-14 September Buxton15-18 September Cardiff 15-18 October York6-9 November BirminghamThe UK course chosen by midwives. Experienced professional specialist hypnobirthing trainers. ‘The home of hypnobirthing.’T: 0845 337 9149E: offi [email protected]: kghypnobirthing.com

One-day RCM leadership workshop10 September Wales Two-day RCM leadership development centre30 September to 1 October Three-day RCM strategic leadership programme9-11 December E: [email protected] (one-day workshop); [email protected] (two- and three-day courses)W: rcm.org.uk/college/your-career/leadership

Uncertainty and loss in maternity and neonatal care conference11 SeptemberA joint annual conference presented by the RCM, Sands and Bliss, this event aims to improve the knowledge base of health professionals in responding to critical illness, loss and bereavement in the delivery of maternity and neonatal care.Location: Brunei Gallery, LondonCost: Managers/health practitioners £150; voluntary sector £100; students £75.W: profi leproductions.eventtrac.co.uk/web/2956

Third- and fourth-degree perineal tears and episiotomy: hands-on workshop13 September, 1 November Pelvic fl oor and anorectal ultrasound masterclass: two-day hands-on workshop2015 tbc Location: Croydon University HospitalCost: Third- and fourth-degree tears and episiotomy workshop – £300 including textbook and DVD; £270 without DVD. Ultrasound masterclass – £290.T: 020 8401 3000 ext 4768E: [email protected]: perineum.net

ARC training day: Supporting parents’ decisions18 OctoberLondon Antenatal Results and Choices (ARC) look at how healthcare professionals can best inform and support parents through diagnosis of fetal anomaly and the decision-making process.Location: LondonCost: £85 T: 020 7713 7356E: [email protected]: arc-uk.org

RCM annual conference11-12 November This is the midwifery professional and trade union conference led by midwives for midwives.Join colleagues from across the country and explore this year’s theme of ‘Better Births: United in Excellence’.Location: The International Centre, TelfordCost: RCM member early bird rate (full conference) (ends 16 July) £250+VAT; RCM member rate (full conference) £350+VAT. E: [email protected]: rcmconference.org.uk

Deborah Robertson’s breastfeeding specialist courseJanuary to December 2015, one Monday per monthSuitable for professional breastfeeding practitioners, lay volunteers, IBCLE lactation consulant exam candidates. The format is 12 study days (70 hours) plus homework (50 hours).Location: Ramada Encore, Birmingham NECCost: £85 each monthW: breastfeedingspecialist.com

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2014 • ISSUE 4 • MIDWIVES 57

UP FOR GRABSHere’s a chance to get your hands on some great giveaways with our free prize draws.

COMPETITIONS

rcm.org.uk/midwives

r free prize draws.

Venepuncture and cannulation: a practical guide off ers an easy-to-read, comprehensive account of the practical procedures of venepuncture and intravenous cannulation. It provides the underlying theory and underpinning knowledge required, as well as a step-by-step approach that will enable healthcare practitioners to carry out these procedures safely, effi ciently and

with confi dence.This book is intended as

a supplementary resource for those involved in practising or teaching these procedures, for healthcare professionals wishing to update their knowledge, and for novice practitioners learning these skills for the fi rst time.

Each chapter contains intended learning outcomes and points for practice. Some chapters also include helpful illustrations and

practical activities, and the book ends with two self-assessment checklists.► Visit: mkupdate.co.uk

WIN ONE OF THREE COPIES OF THE MIDWIFE’S TALEBillie Hunter and Nicky Leap spent several years interviewing dozens of mothers and retired midwives about their experiences of childbirth before the NHS. The result was The midwife’s tale, an oral history of midwifery from the 1910s to the 1950s.

The authors explore the very real poverty of the time; how women coped with rearing large families; and the lack of knowledge of contraception and abortion. Gripping accounts of women’s experiences are set against an informative background of events in the midwifery profession, particularly the transition from unqualifi ed ‘handywoman’ to professional midwife in the 1930s.

The Natural Birthing Company’s (NBC) midwife-developed line of skin treatments lends new mothers a helping hand with its safe and naturally-based skincare systems, created specifi cally to solve the unique skin challenges faced by women during pregnancy, postpartum and breastfeeding.

Based on the latest research and clinical evidence, coupled with the expertise of leaders in holistic midwifery care, these innovative targeted products

deliver both practical solutions and nurturing care at home – helping to restore optimum skin health, while relieving anxieties and keeping women feeling in comfort and empowered.

Products in the collection

include ‘Down below’ perineal massage oil, ‘Cool it Mama’ body spritz, ‘Blissful tincture’, and ‘Bosom buddies’ breastfeeding survival kit with ‘Ooh!’, ‘Aah!’ and ‘Ouch’ oils to use on the organic cotton fl annels.

HOW TO ENTER► To enter these competitions, email your name, address, telephone and membership number, clearly stating which competition you are entering to: [email protected]

► The closing date is 20 August. Winners are drawn at random. Only one entry per household will be accepted. The editor’s decision is fi nal.

WIN A COMPLETE COLLECTION OF NBC PRODUCTS

WIN ONE OF TWO COPIES OF VENEPUNCTURE AND CANNULATION: A PRACTICAL GUIDE

—WORTH £14.99EACH

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£75 —

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057_MID_comps.indd 57057_MID_comps.indd 57 01/07/2014 12:2301/07/2014 12:23


FootnotesCrossword / Puzzle

1. Genetic disorder (13)

8. Umbilicus (5)

9. Highest part of the head (5)

10. Nationality of those born inthe UK (7)

13. None (3)

14. A woman is said to be so when her baby is expected (3)

15. Sanction or ratify (7)

21. Doctor temporarily replacing another (5)

22. Computer images used for navigation (5)

23. Congenital deformity in which foot turns outwards (7,6)

1. Dye used topically to treat skin infections (7,6)

2. Largest organ in the body (5)

3. One of the criteria used in the Apgar score (6)

4. Hidden (6)

5. Formed by tarsal and metatarsal bones in the foot (6)

6. Tumour of muscle tissue (5)

7. Diagnostic test that punctures the amniotic sac (13)

11. Mythological being (3)

12. Indicates equal or identical (3)

16. Commonly used shortened form relating to a woman expecting her fi rst baby (6)

17. A straight muscle of the abdomen (6)

18. Birth canal (6)

19. ----- infection, relates to a specifi c part of the body (5)

20. In the midst of (5)

ACROSS

DOWN

Test your wits on this midwifery-focused puzzle... How many did you get right? Look out for the answers in Issue 5 2014.

Last issue’s answersNotes

1. 2. 3.

18.17.

14.

18.

4. 5. 6. 7.

8. 9.8.

8.

15. 16.

19.

23.

20.19.

10. 11.

15. 16.

21. 22.

19. 20.

11.

13.

12.

Crossword 15: Jan Wallis

058_MID_14_FOOTNOTES_crossword.indd 58058_MID_14_FOOTNOTES_crossword.indd 58 01/07/2014 12:2401/07/2014 12:24

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