Florence Smith: Delivering women centred care in maternity services

florence_smithDo maternity services put women at the centre of care? Are medical professionals providing women with the necessary resources, choices, and information to have a positive birthing experience? A conference held at City University London last month looked at how the NHS can make maternity services more women centred.

Cathy Warwick, general secretary of the Royal College of Midwives, considered whether women-centred care was a practice or more of a mantra in NHS maternity services. She asked whether midwives and doctors are basing their care on what benefits the woman or the institution. Enabling partners to stay with women overnight postnatally would be a woman-centred move—most women express the desire for their partners to stay overnight—but often this doesn’t happen for institutional reasons. Warwick and others used examples like this to argue that women-centred care could be just a mantra.

Christine McCourt, professor of Maternal and Child Health at City University London, said that staffing was a big barrier to providing women-centred care; there can be a “them vs. us” mentality in trusts with both obstetric units and midwifery-led units. When midwives lead care of low-risk women they promote natural childbirth with alternative pain relief therapies, such as massage and aromatherapy. In contrast, obstetric units often take a more medicalised approach, specialising in epidurals, assisted deliveries, and caesarean sections. Working separately and following different ideologies can alienate staff from their colleagues in other areas. Autonomous working should not, however, undermine teamwork with all professional colleagues—as Warwick suggested it could.

Ideology should not, said Warwick, drive care. What is right for a population is not always right for an individual. Over promoting best practices on breastfeeding or natural birth can leave patients feeling inadequate. This highlights the importance of keeping the patient always central to the thought process behind care provision.

A further barrier to providing safe women-centred care is an increase in complex maternity cases. Rising obesity rates, maternal age, comorbidities, and multiple births all contribute to increasing complexity. An Office for National Statistics report shows the standardised mean age of mothers in England and Wales has been rising since 1975, when it was found to be 26.4 years, and was at an all-time high at 30 in 2013. Cultural and social factors are at play, with suggestions ranging from increased participation in higher education to instability of partnerships. Obesity rates are also rising—between 1993 and 2013, the obesity rate for all women rose from 16.4% to 23.8% in England. Increased complexity of cases means that despite more midwives being trained the demands on the service are changing and making women-centred care harder to deliver.

In an attempt to reduce the “them vs. us” mentality, training should be given in all areas of the maternity unit. Working across departments is a good way to reduce animosity; staff are able to understand how other units work and appreciate different ways of working. New midwives should be supported to work more effectively as part of the team. This training should always be supported by good leadership.

We should be finding out not what women would like, but what they would prefer. Cathy Warwick used an excellent analogy: she enjoys chocolate cake, and given some she would be happy, but if someone offered her lemon drizzle cake she would prefer that and be even happier. Without actively asking women the right questions we might not truly understand what women want. We must not be blinded by our patients’ enjoyment of chocolate cake when really it is their love of lemon drizzle we need to discover.

By giving patients all the information on their options we allow them to make their own decisions, putting women in the driving seat of their own care. We need to make women-centred care the practice and the norm.

Florence Smith is a maternity support worker at a London NHS hospital.