Fighting for good public services: Now for midwives and continuous care

by Mar 5, 2015Infants, Mothers0 comments

An important new guideline was released this week by NICE, the National Institute for Clinical Evidence, which suggested that pregnant women in maternity care should have continuous one-to-one care. This is an important recommendation and has been widely backed by health officials across the country.

This will of course cost money, probably as much as £4m, but currently there are not enough midwives to go around, and senior managers have been suggesting that maternity units are at breaking point. Cathy Warwick, chief executive of the Royal College of Midwives said: ‘Our current estimates are that we need 3,200 more midwives, and in 2013 a major survey by the Care Quality Commission found that a quarter of women felt abandoned in labour and some were left to give birth in waiting rooms.

Why is this important? Midwifery and maternity care is but one example of the importance of investing in both very early intervention, and of continuity of care, an investment that will in the long and even medium term save the country huge sums, much more than the implementation of such measures will cost. Savings would, for example, come from reducing re-admission to hospital, from less physical problems, from lessening maternal depression and less need for  future psychological help and much more. Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social care at NICE emphasised the crucial role individual midwives have: ‘From planning to have a baby, to giving birth and the days after, the care provided by midwives has a lasting impact on a woman’s wellbeing, and on the health of her baby.’

A recent Cochrane review [1], a meta-analysis of a huge number of studies, found that continuous care in the birth process has dramatic effects. Women with continuous support were more likely to have shorter labours, less likely to have a C-section, less likely to need analgesics, or have births using implements, more likely to have a spontaneous vaginal birth, their babies were more likely to have a good  apgar score. As importantly, there were no adverse risks with continuous support, no downsides at all.

These are just the sort of interventions and services that are so badly needed and that are being cut now, and are likely to be under even more threat after the next election, as austerity bites even further.

We have known about such research for a long time. Klaus and Kennel as early as 1974 in maternity hospitals in Guatemala piloted schemes in which supportive women stayed with the mother throughout the birth, and the result was quicker births and less complications. In a later study 240 first-time mothers were randomly assigned either to a control group whose births were managed ‘as normal’, and another group who were assigned to a continuous supportive companion called a ‘doula’ (Klaus et al. 1993). The supported mothers had babies with less caesarean sections, less muconium staining or foetal distress, and who were less likely to be hospitalised in their first 6 months.  A similar impact on the length of labour was seen elsewhere when a personal nurse was guaranteed for each mother, and labour times were so reduced that no increase in staff numbers was needed [3].

The quality of the experience of birth can of course have a knock-on effect on mother-child relationships, as research on post-traumatic stress symptoms following birth testifies [4].  Traumatised mothers often feel rejecting of their babies and the mother-infant relationship can struggle to recover (Ayers et al. 2006).  It is certainly clear though that companionship and support for mothers can smooth the birth process, as well as reducing the risk of post-natal depression in mothers, leading them to feel closer to their infants [6]. It makes sense that reducing stress levels through emotional support leads to easier labours, less birth complications and hence better outcomes generally.

Providing continuous support of this kind is just one of many examples of how crucial is early intervention, including prenatal input,  and consistent care. For example, amazing research, based on samples followed now for nearly 3 decades, has come through from a project called the Family Nurse Partnership developed by David Olds  [7] in the US and now also being delivered here in the UK via the Tavistock Clinic. In this program, which targets low income vulnerable mothers, first time mothers are visited regularly throughout pregnancy and then for 2 years after birth. Compared to control groups those in the program had fewer injuries and generally  less problems linked  with child abuse and neglect, and the children’s  emotional and language development was better. Indeed  the maternal life course was improved  so that, for example, there were fewer subsequent pregnancies, greater numbers in work,, and reduced dependence on welfare and food stamps. The  program even produced long-term effects on the number of arrests, convictions, emergent substance use, and promiscuous sexual activity of 15-year-old children whose nurse-visited mothers were low-income and unmarried when they registered in the study during pregnancy. These are extraordinary results. What so much research shows is that putting in consistent, empathic and emotionally sensitive early care goes a long long way. Similar research about the profound impact of pre and post-natal nursing was recently presented to n all-party parliamentary group led by Frank Field, by for example Lynn Kemp, in a huge study in Australia [8] and by Sarah Cowley in the UK [9]

We need continuous and attuned support from the off. Stress in pregnancy is increasingly recognised as a later risk factor for unborn babies, many of whom can be born with highly reactive HPA (stress) systems [10]. Of course violence and abuse in pregnancy has a far worse effect on the baby [11]. Other research is suggesting that prenatal stress is linked to autistic features [12], asthma [13]a, and adhd symptoms in kids of smoking mothers, to name but a few  issues which could  be ameliorated by good early support.

This blog  is not just about the need for midwives or nursing support. This is only one example of the kind of emotionally attuned  early intervention that is so crucial but also so sadly under threat. So many research studies have shown how loving touch and kindly compassionate presence of someone who cares enhances our wellbeing, reduces physical and mental distress, and leads to the release of hormones like oxytocin that indeed lower pain and increase feel-good factors. The presence of a known and trusted other who cares for our welfare is vital to the provision of good care. We need more of this, maybe now more than ever, more continuity of care by experienced and well supported practitioners. We also need these professionals to be well trained. All this is under threat in a public sector rife with cost-cutting and short-termism and with too little belief in or commitment to emotional wellbeing, whether to mothers, babies, children, to the staff who work in these services, and indeed to the future generations who will suffer if we do not fight for this.

 

[1]        E. D. Hodnett, S. Gates, G. J. Hofmeyr, and C. Sakala, ‘Continuous support for women during childbirth’, Birth, vol. 32, no. 1, pp. 72–72, 2005.

[2]        M. H. Klaus, J. H. Kennell, and P. H. Klaus, Mothering the mother: how a doula can help you have a shorter, easier, and healthier birth. Reading MA: Perseus, 1993.

[3]        K. O’Driscoll, M. Foley, and D. MacDonald, ‘Active management of labor as an alternative to cesarean section for dystocia.’, Obstetrics and gynecology, vol. 63, no. 4, pp. 485–90, 1984.

[4]        E. Olde, O. van der Hart, R. Kleber, and M. van Son, ‘Posttraumatic stress following childbirth: A review’, Clinical Psychology Review, vol. 26, no. 1, pp. 1–16, 2006.

[5]        S. Ayers, A. Eagle, and H. Waring, ‘The effects of childbirth-related post-traumatic stress disorder on women and their relationships: A qualitative study’, Psychology, Health & Medicine, vol. 11, no. 4, p. 389, 2006.

[6]        W. L. Wolman, B. Chalmers, G. Justus Hofmeyr, and V. C. Nikodem, ‘Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study’, American Journal of Obstetrics and Gynecology, vol. 168, pp. 1388–1388, 1993.

[7]        D. L. Olds, ‘Improving the Life Chances of Vulnerable Children and Families with Prenatal and Infancy Support of Parents: The Nurse-Family Partnership*’, Psychosocial Intervention, vol. 21, no. 2, pp. 129–143, 2012.

[8]        L. Kemp, E. Harris, C. McMahon, S. Matthey, G. Vimpani, T. Anderson, V. Schmied, and H. Aslam, ‘Benefits of psychosocial intervention and continuity of care by child and family health nurses in the pre- and postnatal period: process evaluation’, J Adv Nurs, vol. 69, no. 8, pp. 1850–1861, Aug. 2013.

[9]        S. Cowley, K. Whittaker, M. Malone, S. Donetto, A. Grigulis, and J. Maben, ‘Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: A narrative review of the literature’, International Journal of Nursing Studies, vol. 52, no. 1, pp. 465–480, Jan. 2015.

[10]      V. Glover, ‘Annual Research Review: Prenatal stress and the origins of psychopathology: an evolutionary perspective’, Journal of Child Psychology and Psychiatry, vol. 52, no. 4, pp. 356–367, 2011.

[11]      A. A. Levendosky, B. Lannert, and M. Yalch, ‘The effects of intimate partner violence on women and child survivors: An attachment perspective’, Psychodynamic psychiatry, vol. 40, no. 3, pp. 397–433, 2012.

[12]      D. J. Walder, D. P. Laplante, A. Sousa-Pires, F. Veru, A. Brunet, and S. King, ‘Prenatal maternal stress predicts autism traits in 6½ year-old children: Project Ice Storm’, Psychiatry Research, 2014.

[13]      A. S. Khashan, S. Wicks, C. Dalman, T. B. Henriksen, J. Li, P. B. Mortensen, and L. C. Kenny, ‘Prenatal stress and risk of asthma hospitalization in the offspring: a Swedish population-based study’, Psychosomatic medicine, vol. 74, no. 6, pp. 635–641, 2012.

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