Evidence from NCT New Parent Support / Tystiolaeth gan Ymddiriedolaeth Genedlaethol Geni Plant – SB (F) 04

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For the attention of:

Llinos Madeley

Committee Clerk

Health and Social Care Committee

National Assembly for Wales

Cardiff Bay

CF99 1NA

December 4, 2014

NCT’s response to the progress report from the National Assembly for Wales’s Health and Social Care Committee one-day inquiry into stillbirths in Wales

Thank you for the opportunity to contribute to this follow-up on the original inquiry and subsequent action.

Growth assessment by midwives

We are aware of the introduction of use of the GAP (Growth Assessment Protocol) Toolkit across all the Health Boards and commend this move. Women appear to be experiencing more detailed monitoring and are being sent for growth scans more often. This is generally encouraging, if extra scans are targeted at those needing or choosing them, and we look forward to seeing improved outcomes from the enhanced monitoring.

We should also like to urge that midwifery staffing is organised for maximum continuity of carer among those carrying out the measurements. Apart from the well-recognised benefits of the woman and her midwife developing a personalised and trusting relationship, the effectiveness of fundal height measurement is improved by such continuity. Martin and Gardosi (2007), for example, advocated continuity of practitioner to improve detection rates of growth-restricted fetuses, recommending at least 75% of antenatal contacts with the same midwife.

As highlighted in our earlier evidence we believe that continuity of carer and 1:1 care in labour both help reduce the risk of stillbirth (and other adverse outcomes) as women will respond better to public health messages (e.g. smoking cessation) from a trusted carer and, in labour, will be able to convey any doubts about deviation from normal progress with confidence that the midwife will respond helpfully.

Though it is acknowledged that direct evidence of continuity of carer reducing stillbirth is sparse, it has been demonstrated that ‘women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth and fetal loss before 24 weeks’ gestation’ (Sandall J. The contribution of continuity of midwifery care to high quality maternity care. RCM 2014).

Public awareness of stillbirth and its risk factors

This issue is of high importance as parents who sadly experience the stillbirth of their baby often say they had no idea of the risks. However, it is also reported that during pregnancy women are resistant to hearing or reading information about stillbirth, so that spreading awareness among the most relevant group is not always a straightforward process.

NCT has a representative on the DH/SANDS-led Task & Finish Group, working with the Welsh member and others, and we are contributing actively to this work. There appear to be at least three distinct categories of ‘messages’ to women that are potentially helpful, and we feel it is important to target the information to women in a timely fashion during (or if possible before) their pregnancy:

· Lifestyle choices that would be universally positive, i.e. stopping smoking, reducing alcohol intake, having a healthy diet and taking adequate exercise

· Day-to-day actions particularly appropriate during pregnancy such as avoidance of infections (through vaccinations when advised, hygiene precautions and less contact with sick friends/family) and avoidance of foods that can have toxic effects on the fetus

· Important responses to signs and symptoms in late pregnancy of e.g. swollen face/hands, vaginal bleeding, change in fetal movements, which merit rapid professional attention.

NCT is working to maintain and improve its information on all the above via its website and in antenatal groups and classes. We are aware of the establishment of the Welsh Initiative for Stillbirth Reduction and happy to contribute to this. We urge all health professionals and any other groups or organisations in touch with pregnant women to be aware of the safer lifestyle messages above and aim to provide information and reminders as appropriate.

Non-modifiable risk factors

In addition to the risks cited above, there is a considerable amount of knowledge that health professionals should bear in mind where non-modifiable risks are present, for example maternal age, ethnicity, twin/multiple pregnancy, AB blood group and the woman living in an area of social deprivation.

A very recent study (Matthews F et al. Elevated risk of stillbirth in males: systematic review and meta-analysis of more than 30 million births. BMC Medicine 2014) has shown that ‘the risk of stillbirth is about ten percent higher in boys … and the percentage of increased risk of mortality in males was consistent across both high- and low-income countries’.

While no one of these factors may have serious influence on risks, health professionals should be aware of the accumulating impact of more than one of these being present in any woman and ensure intensified surveillance accordingly.

Action after stillbirth has occurred

We have learned that at least one new bereavement midwife post has been created in S Wales and we strongly support this move, trusting that others will be put in place too. Feedback from bereaved parents, such as that cited in the significant recent report ‘Listening to Parents’ (Redshaw et al, NPEU 2014), shows that the reactions of staff and both immediate and ongoing support can make a major difference to their emotional wellbeing.

In any future pregnancy, sensitive care is crucial and ‘evidence suggests that specialist pregnancy support might lessen anxiety, improve experiences and positively impact on future motherhood’ (Mills T. Improving support in the next pregnancy after stillbirth (current study)).

NCT attended the launch at the Royal College of Obstetricians & Gynaecologists (RCOG) of the College’s ‘Each Baby Counts’ initiative, their national quality improvement programme aimed to reduce the number of babies who die as a result of incidents occurring during term labour. The principal activity will be collecting and analysing data from all UK units to identify lessons learned to improve future care. This programme, too, is to be commended, although we note that only a minority of stillbirths will be affected in this restricted category of babies who have reached term, but die during labour.

Summary

NCT notes a number of positive moves, both across Wales and in specific locations, which it is hoped will improve the experience of parents who are at risk of the stillbirth of their baby. More needs to be done but the direction of travel is the right one.

We believe that overall adequate staffing and appropriate deployment of midwives to optimise continuity will benefit all women in maternity care, whatever their level of risk of stillbirth, but will contribute to safer and more satisfactory outcomes.

Awareness-raising, especially among young or vulnerable expectant parents, is crucial but needs to be carried out with sensitivity and without being perceived as ‘scare-mongering’, since this can deter women from attending antenatal care, which in turn increases the risk. Messages from a known and trusted midwife are more likely to be well-received and followed.

Elizabeth Duff, Senior Policy Adviser, NCT

Marilyn Wills, NCT Antenatal Teacher, Cardiff