The Care Quality Commission published the National Maternity Survey in December. We tweeted about it at the time and various press stories highlighted the main findings (see here for the Guardian, BBC, Independent), but we thought it was worth taking a more considered look at the results and comparing them to what we found in our own Dignity Survey, undertaken in October.
The National Maternity Survey obtained responses from over 23,000 women who had given birth in English NHS Trusts in February 2013. It is the only large-scale maternity survey of its kind in England. The Scottish government also conducted a similar survey last year and results are expected on 28 January. The survey matters because it informs both consumer perspectives on maternity care – the CQC ‘scores’ for individual NHS Trusts are intended to help inform women about where they might choose to have their baby – and because it sets an agenda for improvements in maternity care over the next three years.
The media focused on the fact that 25% of women reported being left alone during labour (an increase from 22% in 2010). This depressing finding reveals the impact of persistent NHS staffing shortages and adds yet more support, if it were needed, to the call for an increase in the number of midwives. What was not picked up in the media reports was the potential impact of being left alone on the outcome of women’s births. The survey found that significantly more women who reported being worried about being left alone went on to have an assisted birth or a c-section. We can conclude that being left alone contributes to poor birth outcomes, with associated mental and physical trauma for the woman. Any savings achieved by cutting the numbers of midwives are very likely to be lost in the financial consequences of bad births for the NHS.
Birthrights is particularly interested in the survey findings that related to respectful care. In common with the finding in our Dignity Survey, overall a substantial majority of women surveyed by the CQC said that they felt treated with respect and dignity (85% in the CQC survey, 82% in the Birthrights survey). However, 19% of women surveyed felt that staff did not listen to them when they raised a concern during labour. This accords with our finding that 18% of women felt that staff did not listen to them. When asked whether staff introduced themselves, 16% of women surveyed by the CQC reported that only some did and 2% that few or no staff did. Similarly, we found that 20% of women did not know the names of all the staff caring for them. These results suggest worrying failures in communication that can lead to women feeling degraded and disrespected. No doubt good communication is harder when staff are overstretched, but it ought to be possible to maintain basic standards of kindness and politeness whatever the staffing situation.
The CQC has not provided a breakdown of its results by type of birth (other than those relating to being left alone in labour). We found that women who experienced an assisted birth reported significantly poorer care than those who had a spontaneous vaginal delivery or a c-section. In particular, our findings showed that a quarter of women who had an assisted birth believed that their consent had not been sought for procedures during labour. It would be useful if the CQC were to provide results by type of birth in the future, so that maternity providers are made aware of serious issues that can arise during assisted deliveries.
When it came to choices in childbirth, the survey painted a depressing picture. As the CQC concluded, ‘Information needed to make choices was not consistently provided and the choices themselves were not universally offered to women.’ 18% of women said they were not offered any choice about where they gave birth, only 38% were offered the choice of home birth, 35% were offered the choice of a birth centre and 60% a choice between hospitals. The respondents to our Dignity Survey reported similar lack of choice – 26% said they did not have a choice about where to give birth and 21% said they were not given adequate information to make choices about their birth.
The government’s maternity policy, enshrined in ‘Maternity Matters‘, expects NHS commissioners to implement a ‘national choice guarantee’ of the full-range of places of birth – home, birth centre and hospital. The NHS Choice Framework, written for patients, entitles women to ‘self-refer’ into a midwifery service of their choice. The difference between the choices that are promised and the choices that are being delivered is stark. It is all the more depressing in light of what we know about the outcomes for women who are given choices about where they give birth. Our Dignity Survey repeatedly highlighted that women who give birth in birth centres and at home have dramatically more positive experiences that those who birth in hospital. Just one example – 45% of women who gave birth in hospital felt it had a negative effect on their self-esteem, compared with only 11% of those who gave birth in a birth centre.
The survey underscores a systemic failure to introduce real choice into maternity services that must be addressed by the Department of Health, NHS England and Monitor. If NHS Trusts are not going to provide services to meet women’s needs, private maternity providers that take advantage of the new NHS commissioning arrangements will grow to fill the gap.