Cynulliad Cenedlaethol Cymru | National Assembly for Wales
Y Pwyllgor Plant, Pobl Ifanc ac Addysg | Children, Young People and Education Committee
Y 1,000 diwrnod cyntaf| First 1,000 Days
FTD 09
Ymateb gan: Coleg Brenhinol y Bydwradedd
Response from: The Royal College of Midwives
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1. The RCM welcomes the Assembly’s focus on the ‘First 1000’ Days and an inquiry into the support of Welsh Government policies to maximise life chances through critical interventions at this time.
2. The RCM is an enthusiastic supporter of the cross-party 1001 Critical Days – Building Great Britons manifesto[1] published by MPs Mark Durkin, Frank Field, Norman Lamb and Tim Loughton in February 2015. We support the manifesto’s aim to focus policy makers on this most crucial time of children’s lives to improve not only short-term wellbeing, but long-term health, social and economic prosperity for Great Britain. The Marmot Review (2010) reminds us that the foundations for health and well-being start in pregnancy. From heart disease to obesity, educational achievement and economic status, the months before and the years immediately after birth are crucial to the life chances of the mother, her child and her family.[2]
3. We believe midwives are critical to giving every child the best start in life in keeping with the manifesto’s principles. All childbearing women will need a midwife and she is often the first point of contact for women when they are pregnant. For the first third of those crucial 1000 days, the midwife may very well be the only healthcare professional working with a woman and her family. The Welsh Government Maternity Strategy 2011 notes that ‘pregnancy is a powerful motivator for change. It is a time when women and their partners, often for the first time, make positive lifestyle changes and choices in order to provide the optimal conditions to ensure the health and wellbeing of their unborn baby’.[3] Early intervention, through a combination of assessment, screening, health promotion and appropriate referral, is key to optimising the healthy development of a child.
4. We have to acknowledge that families are particularly vulnerable to conflict, marital breakdown, poverty, overcrowding and stress during the period before and after birth, and these factors are significant in a child’s development and their later wellbeing. We need to support new parents to adjust to their new role in becoming confident parents. It is the RCM’s belief that this is best achieved through focused investment in developing enhanced roles for midwives and health visitors who are able to identify and focus on families in need early and intervene accordingly.
5. With a birth rate of around 33,000 births per annum in Wales, there is a great opportunity for midwives to interact with women and their families to advance the 1000 days agenda. By recognising the role of the midwife and her contribution as an investment in the 1000 days agenda, we are making best use of our finite resources. The evidence is well documented for the cost-effectiveness for improving health and wellbeing in the early years.[4] Midwifery contribution to public health helps to improve health, reduce inequalities and save money.[5]
6. The provision of high quality antenatal and postnatal care allows both for early detection and better universal health promotion for all women and families. The health and social care assessment of needs, risks and choices is when the midwife is able to:
· Promote the emotional wellbeing and positive mental health of the mother and infant
· Prepare mothers and fathers for parenthood
· Promote breastfeeding and the specific support that fathers and the wider community can give
· Promote the neurological development of the child, the negative impact of stress and the importance of attachment
· Provide smoking cessation support
· Provide information about folic acid
· Screen for domestic abuse, offering multiple opportunities for a woman to make a disclosure about domestic abuse and encouraging the woman to refer herself to social services or an agency that supports victims of domestic abuse.
· Encourage an anxious or depressed pregnant woman to consult her GP or link her with local groups that support pregnant women who are anxious or depressed
· Refer a woman who abuses substances to an appropriate pre-birth assessment and intervention by social services or offering the support of a dedicated substance/alcohol misuse support worker. In some areas there are multi-disciplinary teams who provide integrated maternity drug and alcohol services.
7. Successive Welsh governments have supported a midwifery specific workforce planning tool -Birthrate Plus - and have maintained midwife numbers which has helped to prevent a serious shortage of midwives. However, 37 per cent of midwives working in the NHS in Wales are in their fifties or sixties. Without investment in our workforce, before too long we could see an insufficient number of younger midwives in place to replace those set to retire. We must be mindful that of the 94 student midwives who started their training in 2012, 70 were working as midwives in the NHS in Wales in 2015.
8. The RCM’s recent NHS public health research found that student midwives, midwives and MSWs have high levels of involvement in the public health agenda across a wide range of activities, but frequently lack the time, training and resources to meet the demands of this aspect of their role. This deficit particularly impacts their ability to provide quality public health support to specific user groups, such as vulnerable and ‘at-risk’ families. However, service users stress the importance to them of warm, empathetic care and good communication skills.[6] Making every contact count is a challenge but can be overcome if contacts are long enough and if a woman sees the same midwife for the majority of her care.[7]
9. Time constraints on booking appointments and post natal visits have a negative impact on the health of women and their families. Little time to support a woman with breastfeeding, or to have meaningful discussions about diet or smoking, or to visit the home and suggest safety improvements need to be understood as missed opportunities in early years’ development, not just of clinical maternity care.
10. There has also been an acknowledgement of the vital role that Maternity Support Workers can play in maternity services, especially in the realms of parent support and feeding, critical aspects of the 1000 days agenda. The development of the Maternity Support Worker Curriculum has meant that the role and responsibilities of MSW’s are clearly defined in Wales which is a very positive development. We too also welcome that there has been no decision to remove student bursaries for midwifery students in Wales as the case in England.
11. The RCM welcomes the Welsh Government’s Plan[8] that acknowledges the importance of the first 1000 days in every child’s life. Goals to develop parenting programmes and support for families and parents to reduce adverse childhood experiences are important, and are in keeping with Building Great Britons. We also welcome the latest Give it Time campaign[9] launched late last year which gives practical tips and advice to parents on encouraging positive behaviour, boosting their child’s confidence and supporting their development. RCM supports measures in the recent Welsh Public Health Bill to place restrictions on e-cigarettes (vaping) to prevent normalisation of smoking and to protect young people from harm.
12. We would like to see some further initiatives develop under the Plan to further the 1000 days agenda.
Breastfeeding
13. Infant nutrition is a key part of the 1000 days agenda. Breastfeeding has a positive impact on babies and mothers, but rates across Wales vary greatly and lead to lifelong health inequalities.
14. Previous surveys into our members’ views on postnatal care found there is not usually enough time or resources to support new mothers with important aspects of breastfeeding.[10] Midwives (and health visitors) must be able to have the time to work with women to enable them to breastfeed safety and comfortably if we are to see rates increase to meet WHO guidelines. With the increase in complex care needs the labour ward has often been seen as the priority for midwifery staffing, with the result that postnatal care has not been given the value/attention that it should have had.
15. We welcome the Early Years Outcomes Framework which will capture data about breastfeeding at 10 days and 6 months. The Transforming Health Improvement in Wales Review in 2014 found that more must be done to normalise breastfeeding in communities where prevalence is low. We would like to see the Welsh Government ensure women’s right to breastfeed or express, in privacy, and with dignity for themselves and their babies, is upheld everywhere. Midwives can encourage and support women in those early days, but after that, women’s families, social networks, their communities, workplaces and their government must continue that support.
Domestic violence
16. The RCM supports the Welsh Government’s new Strategy to combat violence against women and girls. 30% of Domestic abuse begins in pregnancy and has serious physical and mental effects on women and unborn children. There are strong links between domestic abuse and child maltreatment, and abuse has severe negative effects on children’s physical and mental wellbeing. Effects on mothers’ mental health leads to poor cognitive and language development of her children. The RCM would like to see ending VAWG as a key healthcare priority within the 1000 days agenda. Early intervention is crucial to prevent further abuse and maternal and child death. Research from Safe Lives has found 85% of victims sought help from professionals five times before they got effective help to stop the abuse.[11]
17. We support the measure in the VAGW strategy to introduce a National Training Framework for healthcare staff - it is clear that Welsh Government recognises the need to invest in education and training for front-line clinicians. The RCM would emphasise the importance of investing in education and training of midwives in particular, who are the lead professional caring for women during acknowledged periods of high risk of the onset or acceleration of domestic violence.
18. It is through building trusting relationships with healthcare professionals that victims of abuse can come forward. Therefore the RCM supports of continuity of carer for midwifery services[12] because the midwife is able to build a relationship with a woman and offer her support and signposting to specialist services. The principles of Ask and Act can only be implemented into maternity services if a positive relationship is nurtured and there is dedicated time and space for supportive conversations.
Perinatal Mental health
19. The RCM applauds the Government Plan to prioritise mental health treatment, support, prevention and de-escalation and increased access to talking therapies. We hope that care for the mothers and babies with the most severe perinatal and infant mental health needs is also addressed by the Government, and that mothers and babies, where possible, are kept together. We call on the Government to conduct a review of maternal mental healthcare provision, with a clear action plan for the development of services.
The Royal College of Midwives
February 2017