Monthly Archives: January 2017

Birth Choice and Information

For some time now I’ve notice a promoted tweet from Which appearing on my timeline linking to a ‘Birth-choice Tool’. The tool is supported by the Royal College of Midwives (RCM), with the Chief Executive of the RCM Cathy Warwick saying that it will “…go a long way towards helping them [pregnant women] make an informed choice and to decide what is the best place for them to give birth.”

The tool has also been endorsed by Julie Cumberlege, the Chair of the National Maternity Review who (see tweet below) also makes a link with Personal Maternity Care  Budgets. (This was a pre decided recommendation of the National Maternity Review).

jc

Providing unbiased information to women and their families so that they can make informed choices about birth-place is clearly important and positive. This is something I can’t see anyone objecting to. But the emphasis here must be on accurate and unbiased information. To this end, I got a bit of a shock when I used the tool and entered various scenarios.

I’ll go through a worked example here.

The first question the tool asks is under the heading ‘Your birth experience’ and asks the question ‘Do you think you will want to use a birthing pool during labour?’.

q1

Of note, the tool cites the benefits of a birthing pool as being coping with pain and being less likely to need an epidural. There is no discussion around published studies around potential risk and benefit.

The next question is ‘Do you think you will want an epidural?’.

My only comment here is that I can imagine for some first time mums they won’t know what to expect or how they will experience pain. Would a better question be ‘do you want to keep the option of having an epidural open’?

On to the next question… ‘How do you see birth’?

q3

I have to say this is the point at which I began to feel really concerned. The tool gives two options.

  1. As a natural event that should take place in a relaxed and private setting.
  2. As a clinical event that needs medical equipment and staff on hand.

It seems to me that the language here is very loaded; ‘natural, relaxed and private’ vs ‘clinical, medical and equipment.’

Is it the case for example that birth in an obstetric led unit can not be ‘relaxed, natural and private’?

The tool then asks the question ‘Are you willing to plan for the possibility of transfer during labour’?

q4

The explanation note does point out that if you plan to give birth at home or in a birth centre you may have to be transferred. It highlights that that such a choice  ‘can reduce your chance of needing medical interventions.’ There is however no mention that for first time mums the transfer rate nationally is 36-40% and there is no discussion about the implications for the safety of mother or baby in the case of a complication arising that necessitates obstetric intervention.

The tool then asks for your age, if it’s your first birth and what your post code is.

In some scenarios, before coming up with the recommended options, the tool will ask an additional question:

q5

‘Do you actively want to avoid the need for medical intervention’?

I have to admit to surprise  when I read this. No matter what choice a woman and her family make about place of birth it surely isn’t possible to ‘avoid the need for medical intervention’. It might be possible to make choices that reduce the chance of experiencing an intervention that may not have been necessary. However, this is complex and in reality, many lives are saved by virtue of mothers giving birth in a setting where risks are carefully monitored and midwives and doctors train and work together to respond to obstetric emergencies promptly. For example, the obstetric unit at Southmead is regarded as one of the safest places anywhere in the world to have a baby.

Nowhere in the tool are the risks associated with childbirth quantified. For example, in 1999 the World Health Organisation (WHO) published research that showed that globally around 15% of all births are complicated by a potentially fatal condition that requires emergency care.

Academic research also that shows that your risk of death is greater on the day you are born, than any other day of your life until you reach the age of 92.

The things that can go wrong in childbirth (for example sepsis, amniotic fluid embolism, haemorrhage, placental abruption, pre-eclampsia) are not things that can be controlled by making a choice about birthplace. They are complications that on rare occasions,  women and babies sadly continue to die from unnecessarily because interventions (sometimes as simple as a single of dose of antibiotics) were denied.

What did the Birthchoice tool recommended in my imagined scenario?

I live approximately 2 miles from Furness General Hospital (FGH). This is a unit that has recently been through a period of significant change and improvement. In many ways, the unit at FGH is now a leading one in terms of safety, quality and experience.

I completed the Birthchoice tool as a young first time mum, 19 years of age with my postcode. I answered all the questions  leaving the slider in the middle (in reality I think the language in the questions is so loaded that I can’t see how it wouldn’t influence the responses). These are the recommendations the Birthchoice tool made:

results

In my scenario, the tool recommended a freestanding midwifery unit in Penrith, 62.8 miles from my home as a better choice than the unit at Furness General Hospital (FGH) which is just 2 miles away. This recommendation is made for a 19-year-old first time mother.

I always find it interesting to observe the wider context when I come across things like this.

Last week HSJ covered this story stating that there will be a doubling of ‘midwife-led births share by 2020’.

A week earlier, I noticed the following tweets from a midwifery conference attended by senior NHS and RCM midwifery leaders.

o-v

v-worrying

The tweet says “Obstetric violence, we have all seen it…” and shows what seems to be a video with a male doctor (presumably an obstetrician) and the words ‘No, no, no. Stay there quietly’. Someone comments that the phrase is worrying and the response is,  ‘it’s very worrying… & exists’.

Last week I also took the time to watch a presentation from Bill Kirkup about events at Morecambe Bay where 16 babies and 3 mothers lost their lives. If you have the time, please watch it also. It is hard for me to reconcile the messages in Dr Kirkup’s report with some of the observations I’ve highlighted in this blog.

I know that there are many fantastic people working hard to ensure safer maternity care is a priority, but is it now time that we saw some national leadership in challenging these issues? If so, would a good place to start be by providing a resource for women and families that really did provide unbiased and accurate information to enable informed choice? Instead of conferences that promote ‘normality’ in childbirth and appear to promote negative messages relating to obstetricians that must be very frightening for women to see, shouldn’t we be holding conferences attended by all professionals involved in delivering maternity care, where we celebrate teamwork, discuss and learn from poor outcomes, listen to all voices and agree actions we can take together to make maternity care safer and better for everyone.

James Titcombe – 8th Jan 2017

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A few thanks…..

2016 has been a very busy year personally and for patient safety in England. I wanted to write a quick blog to thank a few people who have made a difference.

In February, a report commissioned by NHS England relating to the tragic loss of baby Kate Stanton-Davies in 2009 was published. The report only came about because of the hard work and determination of Kate’s parents Richard and Rhiannon. The report was shocking for many reasons, including the fact findings  were very different to the initial supervisory investigation carried out following baby Kate’s death and identified failures that had previously not been acknowledged.The report also made the recommendation for there to be a national audit of the quality of similar supervisory investigations following serious incidents/avoidable deaths in maternity services. A big thank you to Richard and Rhiannon for all they have done to push for the truth about Kate’s loss and for there to be national learning. 2017 will be an important year for midwifery and a new model of supervision is being developed, it’s vital that Kate’s story and the results of the national audit feed into the new model.

It’s been approaching 2 years since the Morecambe Bay Investigation report was published. If I’m being frank, I have a growing concern that some of the key messages of the Morecambe Bay report, especially amongst some elements within Midwifery, risk being lost and overlooked. However, since publication, the Chair of the Morecambe Bay Investigation Dr Bill Kirkup has consistently and superbly kept a focus on the issues. This has included articles and talks at high profile events about what happened at Morecambe Bay and what the keys message are.

If you only have 30 mins to spare to learn about Morecambe Bay, please watch this talk from Bill, it’s so important that these messages aren’t lost or forgotten.

I’d like to repeat my thanks to the whole Morecambe Bay Investigation panel, but especially to Bill Kirkup for working so hard to spread the learning from his report.

Another area of significant progress in 2016 has been the establishment of a new Healthcare Safety Investigations Branch (HSIB), which is set to go operational in April next year.  This new body has come about as a consequence of sustained effort from people like Martin Bromiley and the Clinical Human Factors Group (CHFG) and others. A breakthrough moment was when Carl Macrea and Charles Vincent published their paper ‘Learning from failure: the need for independent safety investigation in healthcare’ towards the end of 2014. The paper was read by Bernard Jenkin MP, the Chair of Public Administration Select Committee (PASC) who also became a passionate champion for the creation of the new body and set up a PASC inquiry which made recommendations that the government supported.

Another person who in my mind has made a huge difference in 2016, is the Patient Safety Correspondent at the HSJ, Shaun Lintern. I highly recommend watching this recent talk by Shaun which highlights the mountain that we still have to climb in improving safety and culture in the NHS. I also recommended this piece and hope 2017 will be a year we make real progress in changing this.

Earlier this month, the Care Quality Commission (CQC) published a comprehensive report into the quality of investigations and learning following the deaths of patients in the NHS. This is a report that everyone working in healthcare should read. It wouldn’t have come about without the considerable efforts of the family of Conner Sparrowhawk, whose preventable death whilst in the care of Southern Health (and the appalling way the trust responded), triggered the Mazars report and subsequently the CQC review.

Before 2017 arrives, I’d like to say a big thank you to the Chief Executive of Morecambe Bay, Jackie Daniel and all the staff at the Trust. My relationship with Morecambe Bay has been a turbulent one since Joshua’s death as until recently, I have felt that there has been a lack of ownership for what happen and that questions about what happened to Joshua and why remained unanswered.

I must say that during the past year, Jackie and the team at Morecambe Bay could not have worked any closer with me to resolve this. Jackie has shown huge understanding, thoughtfulness and compassion.

As part of the work the Trust did with me, it was discovered that a senior midwife central to events at the trust and involved in a flawed investigation into Joshua’s death, had received an ‘irregular payoff’ in a deal that avoided an internal trust investigation. Before these facts were made public, Jackie was issued with a legal injunction by the Royal College of Midwives (RCM) to try and ensure the circumstances of what happened were kept secret. I think it shows huge moral courage that Jackie ignored the legal threat and did the morally right thing by releasing the report regardless.

On 4th November 2016, a day before the 8th anniversary of Joshua’s death, the Trust published a summary report of their recent investigation on their website.

The report is honest, thorough and accurate. I now feel that the Morecambe Bay trust genuinely does ‘own’ what happened to Joshua and I  believe that they will ensure the lessons from his death and other tragic events, are never forgotten.

In 2008, it is now abundantly clear that Morecambe Bay was a trust that had much to learn from the wider NHS. As we approach 2017, I honestly believe that it is the wider NHS that has much to learn from Morecambe Bay. Once again, huge thanks to Jackie and the team at Morecambe Bay for all your hard work.

It’s not possible to mention all the other people who continue to make a difference, but thanks to everyone who works to make healthcare safer and wishing you all a very Happy New Year and all the best for 2017.

James Titcombe – 31.12.16