Debate contribution: Maternity and Neonatal Services

Debate contribution by Mr Mike Nesbitt on 22 October 2024.

MLA

Mr Mike Nesbitt

Party at the time

Ulster Unionist Party

Date

22 October 2024

Type

Debate contribution (made as a minister)

Business

Ministerial Statement

Heading

Maternity and Neonatal Services

Assembly identifier

Official Report component 4608025

Read the official Assembly record

Text

Mr Deputy Speaker, given the nature of the subject matter, with your indulgence, I suspect that the statement may exceed the normal duration. I welcome the opportunity to update Members on maternity and neonatal services, including the report by Professor Mary Renfrew entitled 'Enabling Safe Quality Midwifery Services and Care in Northern Ireland'. Pregnancy is, of course, a normal life event. For some, it can be a more challenging experience, but it is mostly a time of joy and new beginnings. The vast majority of women have a safe birth and get to go home with their healthy baby or babies. I acknowledge and thank the staff across our health service in hospitals, GP surgeries and communities who make that possible every day through their dedication to pregnant women and babies, often in challenging circumstances. However, I also recognise that, for some, that is not the case. Whilst, unfortunately, some situations are outside our control, we must do all that we can to make sure that maternity and neonatal services provide the best care. Therefore, improving maternity and neonatal services is an immediate concern for me and for my Department. Maternity and neonatal services are made up of various areas that work together to provide support to women during pregnancy and in the early months after birth. They include community midwives, antenatal clinics, multidisciplinary teams (MDTs) in consultant-led maternity units, midwifery-led units and post-partum support such as health visitors, community midwives and GPs, as well as hospital neonatal units that care for sick babies. I must acknowledge that services have needed to adapt and change over recent years. The impact of COVID-19 meant a downturn and new ways of working for some services. I recognise that that was a difficult time for everybody involved: expectant mothers, their partners and maternity staff. However, having emerged from that difficult period, we now have an opportunity to rebuild and transform service delivery to adapt to current demands, with a new focus to improve maternity and neonatal services. Women in Northern Ireland can give birth in one of the seven consultant-led maternity units staffed by midwives, doctors and other members of the multidisciplinary team; in an alongside midwifery-led unit; or at home, supported by midwives. Maternity staff work closely with women to enable them to make an informed choice about where to have their baby. For babies who, unfortunately, require additional support at birth, that is provided by one of the neonatal units around the region, which are all aligned with the seven maternity units. Those units take care of some of the most vulnerable members of our society. My Department has been overseeing a major programme of work on improving maternity and neonatal safety, and I will now update Members on that.

As you will be aware, concerns about the safety of maternity services across other parts of the United Kingdom have come to light in recent years. In November 2022, the coroner for Northern Ireland contacted my Department with concerns around her findings following an inquest into the death of a baby who was stillborn after being transferred from a free-standing midwifery-led unit to a consultant-led maternity unit. As I deliver the statement, my thoughts turn to the family of the baby who tragically died. My condolences go out to them and to all those affected by such a tragic loss. In light of the concerns, my Department established a maternity and neonatal services safety oversight group in January 2023 to receive assurance on the safety of maternity and neonatal services for the population of Northern Ireland. That group is made up of senior officials from my Department and the Public Health Agency (PHA). A broad programme of work is ongoing, with an immediate focus on improving governance and safety across maternity and neonatal services. The programme includes a comprehensive independent review of midwifery services led by Professor Mary Renfrew that I will come to shortly. My Department also asked the Regulation and Quality Improvement Authority (RQIA) to carry out a review of the governance arrangements in place to support safety in maternity services in Northern Ireland. That report was published in May of last year. The RQIA report made 23 recommendations to strengthen the governance, systems and processes that support the delivery of safe, effective care in maternity services across Northern Ireland. The Department accepted the report's recommendations in principle, with the caveat that the implementation and timescales may differ from those suggested by the RQIA due to the need for additional funding and the ongoing work on maternity and neonatal safety. Other areas of work ongoing include reviewing progress with the implementation of relevant National Institute for Health and Care Excellence (NICE) guidance and developing a gap analysis of the implementation of all relevant reports and recommendations that have been endorsed by my Department. Although work is ongoing and improvements are required, it is important to say that, to date, no material safety concerns have been identified in that suite of work. Regarding midwifery services, the oversight group established a work stream to consider issues highlighted in the coroner's report, which recommended that the Department should:

"conduct a comprehensive review of the number of staff, experience, education, training and policies required for Freestanding Midwifery Led Units ... consider the need for further guidance to all HSC Trusts in relation to the Coroner’s findings regarding the management of BMI and shoulder dystocia ... undertake further work to inform a consistent approach to provision of midwifery services, including integration across wider maternity services."

To address the issues identified by the coroner in April 2023, my Chief Nursing Officer commissioned Professor Mary Renfrew, an independent expert in the field of midwifery with professional experience outside Northern Ireland, to carry out a comprehensive and independent review that would help inform a consistent approach to the provision of midwifery services throughout Northern Ireland. The terms of reference for the review were based on the areas identified by the coroner that I mentioned. The broad scope led Professor Renfrew to undertake a comprehensive review of midwifery services and care in Northern Ireland, including all its interdependencies within the overall maternity service. That included a review of the evidence base and models of care across the region and internationally.

In developing her report, Professor Renfrew and her secretariat team carried out extensive and widespread engagement with maternity service users and advocates, holding face-to-face and virtual listening events with women, families and professionals across Northern Ireland. I am incredibly grateful to the professor for undertaking the review, which assists the Department in strengthening midwifery services and care across Northern Ireland. I acknowledge the effort of all the participants who contributed to the report — those with professional and expert input and, particularly, the women and families who were willing to share their own experiences, no matter how difficult or traumatic, to assist change and provide improvement in our maternity services. My Department received the final report during the summer and has had the opportunity to consider it fully. It will be available to view on my Department's website from today.

Professor Renfrew is clear that our maternity and neonatal staff are committed and determined to provide the best care that they can. In her report, there are examples of good-quality care across Northern Ireland, including: the appointment of a consultant midwife in each health and social care trust and the roll-out of a new model of care; continuity of midwifery care, which means that women receive support from the same midwifery team during and after pregnancy; and the establishment of a weekly, multidisciplinary clinic in the Western Health and Social Care Trust to enable teamwork in the development of individualised pathways for pregnant women who experience gestational diabetes.

I also recognise that Professor Renfrew's engagement identified a level of adverse experiences reported by some women and families, as well as stress and distress being reported by all staff groups who participated in the review, especially midwives. It is important to acknowledge that the number of individuals engaged with during those events represents a small proportion of the overall maternity population in Northern Ireland. The number of women engaged with represents 0·5% of the total number of women who gave birth in 2023. The number of midwifery staff represents around 10% of the total number that were recorded in March 2023. Nevertheless, the messages were clear and consistent from those women and staff. The system must, and will, listen to their concerns. The report contains 32 detailed recommendations that are aligned to seven interrelated key conditions. Those conditions are themed under five areas: safe quality care in midwifery units and at home for home births; regional strategic developments; safe quality care and services in all settings; monitoring and review of information and data; and building for the future. In summary, the report advocates:

"A reconfigured relationship with women, families and communities"

that ensures respectful, personalised care and genuine involvement. Next, it advocates:

"A consistent, region-wide, evidence-informed approach to planning, commissioning, standards, provision, monitoring, and review of maternity and neonatal services."

Next, it advocates:

"Improving clinical, psychological, and cultural safety and equity for women, babies and families across the whole continuum of care and in all settings".

It also advocates:

"Changing the prevailing work culture to implement an enabling environment for all staff and managers".

That includes ensuring that midwives are represented at senior management levels, tackling silo working and developing an open learning culture at every level of the system. It recommends:

"strengthening midwifery care and services across the whole continuum of maternal and newborn care"

with

"Investment in community as well as hospital services ... And increasing midwives’ influence over the safety and quality of care and services."

The report also recommends:

"Better oversight through improved accountability, monitoring, evaluation, and research".

And:

"A unified approach to education and training of all staff, including leadership development - especially for midwives - and capacity building for the future."

The report identifies three issues as critical priorities. The first is improving:

"Postnatal care both in hospital and at home".

That is about ensuring that women receive adequate pain relief and essential care for themselves and their babies. The second is improving:

"interdisciplinary working for women requesting care ‘outside of guidance’, and improved safety for the midwives who care for them."

The third is:

"Psychological safety for all staff."

Whilst it is recognised that some of the actions required to address the critical priorities will require regional coordination, trusts have already been asked to take immediate action in a number of areas to address those critical priorities. Having considered Professor Renfrew's report and the assessment carried out by my officials, I have accepted the report in principle, with caveats on some recommendations that will present particular implementation and funding challenges and will need further consideration. However, the recommendations in the professor's report provide us with an opportunity to strengthen and improve maternity services for women and babies and for the dedicated staff who provide the services.

At this time, I am unable to commit to part of the fourth recommendation, which is that service users and advocates should receive remuneration for the time that they spend participating in stakeholder and engagement events. While the feedback that was provided by service users and advocates is invaluable, I am unable to commit to payments under that recommendation at this time. There is a policy in place, however, to provide reimbursement to service users and advocates for issues such as travel expenses, subsistence and childcare where appropriate. One recommendation that I have partially accepted in principle refers to the future of free-standing midwifery-led units. I want to explain this point very carefully. It is important that women have safe options to give birth outside of labour wards, if that is their preference. Professor Renfrew advocates a rethink on how we provide those care options for the women of Northern Ireland, and he outlines eight key requirements that need to be met for those options to be safely provided. Those key requirements provide a framework to strengthen and connect the whole maternity system. The evidence, coupled with the feedback that Professor Renfrew heard from the women and staff whom she engaged with, is that safe, quality care for all women and babies requires Northern Ireland to ensure that community and hospital options for care and pregnancy, birth and the postnatal period are available. The report recognises that the old model of service delivery and the terminology used created the potential for free-standing midwifery-led units to become disconnected from the maternity service. The eight requirements seek to reconfigure and transform that service model. In addition, Professor Renfrew states that at least one community midwifery hub should be available in all HSC trusts and that the sites of the free-standing midwifery-led units should be developed and reconfigured as community midwifery hubs in a phased programme to ensure safe, quality care for all. I believe that it would be premature at this point to make decisions on the future of the free-standing midwifery-led units transitioning to community midwifery units or on the recommendation that one should be available in each trust area. In the meantime, antenatal care will continue to be provided at Lagan Valley Hospital, Downe Hospital and the Mater Hospital, taking into consideration Professor Renfrew's eight requirements. There are, however, no plans to resume births at the three units at present. Before any community midwifery hubs offer facilities for labour and birth, all essential requirements outlined in the report must be met. The immediate focus must be on the stability of maternity and neonatal services. The future configuration will need to consider the key requirements outlined by Professor Renfrew, the wider health and social care population needs, demographic trends and system capacity. I am conscious that the content and findings of the report may be met with elements of concern about the safety of maternity services in Northern Ireland, particularly for pregnant women and those who are planning a pregnancy. It is important to recognise that, while the vast majority of women will have a safe birth and a positive experience, many of those who contributed to the report did not. We must acknowledge the failings that the report has highlighted in many areas and be clear that there must be improvement and a prioritisation of those services. Caring for women and babies must be a top priority for our future. It is, after all, one service that each and every one of us requires. With the support of dedicated maternity professionals, pregnancy and childbirth is a relatively uncomplicated process for most. Northern Ireland has key strengths in its maternity services. It has a skilled and dedicated workforce that is committed to providing high-quality care. I recognise, however, that, in recent years, the wider system has struggled to refresh and transform services at the pace required to enable them to cope with the changing needs of pregnant women. As a result, many staff members have experienced exhaustion and burnout, and they must be better supported in that vital role. While birth rates in Northern Ireland and the rest of the United Kingdom have fallen in recent years, maternity care has become more complex, with an increasing proportion of women having health problems, which increases the risk of adverse events for them and their babies. More than half of pregnant women require specialist care during pregnancy or delivery, or following the birth, and one in 10 newborns also requires specialist care, which is provided by a range of professionals who work as a multidisciplinary team. The proportion of women requiring specialist care has increased significantly over the past 10 years. For example, around one in eight pregnant women in Northern Ireland now has some type of diabetes, and one in 20 has high blood pressure. That means that women require specialist care from multidisciplinary teams. Other health inequalities also have a major impact on pregnancy outcomes, so it is essential that we continue to prioritise initiatives that not only enhance the quality of care at all levels but address health inequalities across Northern Ireland. Midwives have a critical contribution to make to both of those priorities. Professor Renfrew's report highlights the increase in caesarean births in every part of the United Kingdom and Ireland over the past 10 years and the fact that those rates are out of step with similar countries internationally. The reasons for the increase may include a number of factors, such as an increase in the number of complex pregnancies due to a range of factors, including older maternal age and underlying health conditions, as well as maternal choice. While the rate of caesarean births has increased, it is in line with other UK countries. The priority must remain to provide the most appropriate care for mothers and their babies, taking account of their individual needs and personal choice. My Department has endorsed the National Institute for Health and Care Excellence (NICE) guidance on caesarean sections, which describes the benefits and risks associated with caesarean birth and vaginal birth and provides guidance on the care of women and babies before, during and after caesarean births. Health professionals have a professional and legal duty to discuss the benefits and risks of different care options with women, taking into account their individual circumstances, concerns, priorities and plans for future pregnancies, and they should support women's decisions on how they would like their baby to be born. All the work that I have outlined will form part of a consolidated regional action plan, which will be fundamental to improving maternity and neonatal services and outcomes for mothers, babies and their families in Northern Ireland. It will also help to inform the future strategic direction for maternity and neonatal services. It is important that the challenges facing maternity and neonatal services and the implementation of the consolidated regional action plan are approached collaboratively across the region, ensuring, as far as possible, that care is consistent and equitable no matter where it is accessed. Given the fact that there are interdependencies between maternity and neonatal services, I will establish an interdisciplinary maternity and neonatal partnership with a programme board governance structure to lead the development, implementation and oversight of evidence-based, safe and quality maternity and newborn care and services in order to maximise the contribution of those services to maternal and newborn health. That will also include the implementation of a consolidated regional action plan. The partnership will include representation from my Department, the Public Health Agency (PHA), health and social care trusts, primary care and service users. It will incorporate the work and functions of the existing maternity quality improvement collaborative, which is a facilitated group of clinicians from across the region that is largely focused on regional agreement on protocols and clinical issues, and the clinical groups of the neonatal network. The programme board will draw membership from senior officials from my Department, the Public Health Agency and the health and social care trusts. Final proposals for the partnership and programme board are being developed. Members will appreciate that there will be a funding requirement associated with that and with the implementation of the consolidated regional action plan, and I hope that my Executive colleagues will be supportive of that. I see this as being a high priority and would like to see the partnership established as soon as possible. I agree with Professor Renfrew that how we care for women and babies is a measure of our society and that pregnancy, birth and the early weeks of life are fundamentally important for each woman, baby and family. At the heart of this matter is the clear message that we must listen to women. I have listened: I hear them, and I agree that improvement is needed. The birthing process is a vulnerable and intimate time for women, babies and their families. It is essential that they are provided with safe, respectful, kind, evidence-informed, multidisciplinary and individualised care across the continuum and in all settings. I am determined to ensure that all midwifery services and care in Northern Ireland are safe, respectful and compassionate, and that women and their families feel heard, valued and supported.

Finally, I can assure you that improving services for pregnant women and new mothers and babies is and will continue to be an immediate priority for me and my Department. I trust that the information that I have provided to Members today in the statement gives some assurance of the priority that I am giving to the issue.

3,426 words. Text as published by the Northern Ireland Assembly.

Assessment

Not flagged

Jev’s structured answers

Assessed 21 October 2026 at 11:26 UTC by jev-1.13.0 (requested as typesafe/jev) under rubric 2026.10-r9, methodology 1.9.

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