Oral evidence

Taken before the Health Committee on Tuesday 20 May 2003

Maternity Services Sub-Committee

Members present:

Julia Drown, in the Chair
John Austin
Sandra Gidley
Mr David Hinchliffe
Dr Doug Naysmith

Dr Richard Taylor

__________

Witnesses: MS LESLEY SPIRES, Head Midwife, One to One/Community/Birth Centre Manager and MS MAGGIE ELLIOTT, Director of Midwifery and General Manager, Queen Charlotte's and Chelsea Hospital; MS DIANE JONES, Consultant Midwife, Newham General Hospital; MS CAROLYN ROTH, Management Committee Member and MS MY DIEP, Community Health Worker, Women's Health and Family Services, examined.

Q87  Chairman: Can I welcome you to this second and last part of our Inquiry into Inequalities in Access to Maternity Services. I apologise that we are starting a bit late. Thank you to all of our witnesses for coming. We have a change on one of the witnesses which is, rather than having Laky Begum, we have got My Diep who has joined us. You are also a Community Health Worker, are you, from Women's Health and Family Services?

Ms Diep: Yes.

Q88  Chairman: We are going to be trying to cover quite a lot of ground today in terms of inequalities overall and then looking at specific groups: homeless people, disadvantaged people, people with disabilities and so on. Please feel free to chip in and answer and give us as much information as you can. Can I start by just asking you to quickly introduce yourselves and your background.

Ms Diep: My name is My Diep. I work with the Chinese and Vietnamese communities in the Women's Health and Family Services in Tower Hamlets.

Ms Roth: I am Carolyn Roth. I am a midwife lecturer but I am here in my capacity as Management Committee Member of Women's Health and Family Services.

Mrs Elliott: I am Maggie Elliott, I am Director of Midwifery for Queen Charlotte's Hospital.

Ms Spires: I am Lesley Spires, I manage the community midwifery services and am also the One to One/Community/Birth Centre Manager.

Ms Jones: My name is Diane Jones, I am consultant midwife at Newham General Hospital.

Chairman: Thank you. We are going to start, as I say, on the wider issues of inequality.

Q89  Dr Naysmith: Good afternoon. There is a thing called the inverse care law which is not a law, it is a principle in sociology, and in the provision of public services in general it suggests that those who need services most are the ones who are least likely to get them. Probably you could expand that a bit, that those who need the best services actually get the worst provided services in many instances. I wonder does that apply in the provision of maternity services particularly. I wonder whether maybe somebody from Queens Charlotte's and Chelsea could start off by saying what you think happens in your area. Do you think that is true?

Ms Spires: I think that it is harder for that group of women to access maternity services. I think the key is to go out to them, to reach those women, and not expect them to be able to access the traditional services. I would agree with that.

Q90  Chairman: Sorry, could you speak up a bit. The acoustics are not that good in this room.

Ms Spires: I think that is true. It is certainly harder for that group of women to access the traditional maternity services. We have to go out to reach those women because they are not going to be able to reach us through the normal channels.

Q91  Dr Naysmith: Do you think that is something that the service is conscious of?

Ms Spires: Very much so.

Q92  Dr Naysmith: And it really is trying to address that?

Mrs Elliott: Yes. We are looking at re-profiling at the moment our One to One midwifery service so that we actually provide a specialised service for disadvantaged groups as opposed to the wealthy women who live in Chiswick. It is about how we need to actually re-profile, which is what we are doing.

Q93  Dr Naysmith: How about in Newham?

Ms Jones: Certainly I would say that disadvantaged women are not aware of what facilities are available. There is a lot of outreach work that needs to be done within communities so that they are more aware of services that they can access for their benefit. Women that are more aware of it and are more assertive and know how to access health care are able to do so far better than others.

Q94  Dr Naysmith: Do you think that this inequality in provision of services that clearly is part of our current provision that we are all trying to do something about has any long-term consequences for women and babies?

Mrs Elliott: The national reports that come out absolutely reflect that. There is a long-term effect if those women do not receive appropriate care, particularly on things like domestic violence and all those things, which is why we provide the service that we do in order to try and prevent those things from happening.

Ms Spires: It is reaching women in their homes. You find out much more about those particular groups, particularly in terms of domestic violence and child protection issues, if you know women from the beginning of the pregnancy, which is what we are trying to do, and I am sure that many other units are as well. If women in those groups do have a named midwife they can identify with there is going to be a more trusting relationship between them and more disclosure in these kinds of situations and also better co-ordination of what other services they require. It is one thing to provide the service but it is another thing for that woman to know that the service is there, you actually have to go and say "This is what we have got for you and this is how you can reach it".

Q95  Dr Naysmith: Do you think that works? I have a particular thing about named midwives and named nurses because I spent some time in hospital a couple of years back and I had a named nurse given to me on my first day and I saw her, I think, twice in about three weeks.

Ms Spires: I think that is about primary nursing where there is somebody who co-ordinates the care from a distance. Certainly in the One to One caseload scheme the midwife works all the way through with the woman. We have dealt with a teenage pregnancy group and also started a caseload of travelling communities and it has worked well because it is a particular group of women who traditionally do not attend for antenatal care and they book us. These are women who have been identified in the Confidential Enquiries into Maternal Death as having a much higher rate of maternal death than any other group because they do not access services. It has made a huge difference. It is also that barrier where women feel that they cannot trust the professionals. If they get to know individual professionals then they are more likely to trust the service that they are getting and to access it and to believe in the people who are giving it.

Q96  Dr Naysmith: I wonder if Carolyn and My have anything to add?

Ms Roth: I was just going to comment on that last point. In quite a different capacity I was involved in a small survey precisely trying to count the numbers of women who do arrive in labour without having prior antenatal care. We have very bad figures about that. Very few maternity units can actually produce the figures that can count that. It is a theme that runs through a lot of the issues regarding access to services which is what is encountered does not count. In other words, if you cannot actually enumerate what the dimensions of the problem are it is actually very difficult to identify shortcomings in the service. That is something that runs through both issues around language and issues around access generally, that it is poorly documented and poorly monitored.

Q97  Dr Naysmith: How does your organisation help women, disadvantaged women particularly, access maternity services?

Ms Diep: We recently changed the name of the Women's Health and Family Services, before we were called the Maternity Services Liaison Scheme. That works with ethnic minorities and most people come from different countries. For example, I work with the Chinese and Vietnamese and our organisation has Bangladeshi women and Somali women who have little knowledge of the health services in this country and they do not know how to access the services available in this country. We set up this project to help the people with a language barrier and very poor access to health services. When we set up in 1981 it was very, very hard for us to help them because we had to go door-to-door to tell them about the services available for them and how to use those services. When we set up it was very, very hard and it is going on at the moment.

Q98  Dr Naysmith: Do you think the authorities do enough? Obviously not otherwise you would not be providing your service. What can the authorities do better to help you in what is obviously very valuable work?

Ms Roth: I think, as My was saying, there have been very well developed services in Tower Hamlets which started with the project that we represent. As a spin-off from that, the Royal London established an in-house language service for women having maternity care. The majority of women who deliver in Tower Hamlets are actually Bangladeshi women, so there is a big single language group. The services are well provided but what is also the case is that not all women who would value and be able to make use of the service get it because in all of the research that has been done about the actual receiving of those services there are still shortcomings. There was a survey done in East London a year and a half ago which showed that 60 per cent of women still were not getting the service. It is partly because of the challenge of actually getting the service to the women when they need it. There are still shortcomings but it is not because nothing is being done, it is because somehow what is being done is not working perfectly, certainly in Tower Hamlets. For example, there have been calls for years and years for a 24 hour service because obviously women in labour need language services. There is not yet a 24 hour on-call service, or anything like that. There are certainly huge gaps but even antenatally not all the women who should have language support get it.

Q99  Dr Naysmith: These couple of questions are scene setting and most of the things we have touched on will be picked up later on, but I cannot resist asking a question of Queen Charlotte's. A lot of women who use your hospital are relatively wealthy and there is quite a lot of private obstetrician work that goes on. I just wonder does that in any way distort the service?

Mrs Elliott: There is not as much private work as you would think really.

Q100  Dr Naysmith: I do not mean necessarily in your hospital but the people involved, the obstetricians involved, do provide work perhaps elsewhere.

Mrs Elliott: We have a very interesting mix because we amalgamated the Hammersmith Hospital with Queen Charlotte's in Goldhawk Road two and a half years ago and that meant there were the wealthy women and then the disadvantaged women all within the same hospital, so we had to look at how we could target the disadvantaged groups in some respects as opposed to the women who were not disadvantaged. I would say it is probably a 50/50 split roughly. It can be quite difficult sometimes to provide specialised services for women who cannot speak up because the women who can speak up demand them. It is sometimes going against the political climate that is going on at the time.

Q101  Dr Naysmith: How does it interact with the midwifery services particularly?

Mrs Elliott: With the One to One midwifery service we are looking at giving caseloading to disadvantaged groups, which is a huge shift for us. The named midwife is not like in a hospital, it is a community service, so each woman has one midwife from the time that they book to the time that they are discharged in the community when the baby is ten days old, 28 days old, or whatever. It is one midwife providing total care. It is not just a concept, it is a reality. It does change outcomes hugely for whichever group they look after.

Q102  John Austin: To what extent do you think health inequalities might be reinforced by the maternity services, by cultural or other assumptions made, restriction of information or availability of services because of assumptions about particular groups?

Ms Spires: I think it is important to understand the groups that we are providing the service for. That is about networking with organisations that serve those groups, so if people have a particularly high Somali group of women in the area, the same as the Bengali group in Tower Hamlets, you need to network with the leaders of that particular society so that you understand their needs and you are not making assumptions about what you think that they need, because that can be hugely different from what we presume. Each group has different priorities and different needs. If you have got a very diverse population then that needs a lot of development, particularly with the smaller ethnic minority groups. If you have got a large group you know what you can aim at and how you can network for that group. When you have got perhaps a fairly small Polish community that is something you have to consider, those small groups, because they are the ones who are going to slip through the net. A lot of it is about language barriers and translation services. I would just like to say that I cannot believe how expensive community translation services are. Just to cite an example: in-house services can be provided and they can be relatively cheap but I needed to provide a translator for a woman in the community who needed to understand the blood test that was being done for her baby and she was there for half an hour and it cost £80. If those are the costs of services in order to provide what we need for women then it is just impossible.

Q103  Chairman: You were saying you provide in-house translation reasonably. How do you provide this in-house?

Ms Spires: We have got translators within the hospital that we can call on.

Q104  Chairman: Are they other members of staff working elsewhere?

Ms Spires: There are members of staff.

Q105  Chairman: So they are not trained translators?

Ms Spires: No.

Q106  Chairman: We have had concerns raised with us that if they are not a trained translator it can be inappropriate.

Ms Spires: We can access trained translators as well. It is the cost of going out into the community that seems to be so high. It does not seem to be quite so costly coming into the hospital.

Ms Roth: I am anxious to clarify some of the word terminology.

Ms Spires: Interpreters then.

Ms Roth: In a sense there is a continuum of interpreting, translating, whatever, and I think it is important when we are thinking about trying to address women's needs that we are not just talking about making medical procedures understandable to women, and that is where the advocacy service is actually different from that because it really has to do with establishing a forum or a vehicle for women to express their own needs. It is really important not to think that we can serve women's needs merely by providing them with an interpreter.

Q107  John Austin: That would apply not just to the language but to social class and other issues?

Ms Roth: Absolutely.

Q108  John Austin: Rather than interpreters, is there an opportunity there for a growth industry, certainly in deprived areas, of recruiting people from ethnic communities or sections of society, not as interpreters but as ancillary workers who work alongside midwifery services or other services with women using those services?

Ms Roth: I would say that is definitely the model that has grown up in East London. What My said before is really important, that Women's Health and Family Services is now 22 years old and it was started by women in the community and it was staffed by women from the community which it was serving. A similar project began in Hackney at around the same time and that is quite a different model. It is not a translation model. It is really about making services accessible by making them responsive rather than just giving women information in one way. I do think it is potentially something that would apply not just around language but a group of workers who are actually focused. I am not suggesting that midwives are not focused but we know there are problems with the interface between women particularly who are facing disadvantage and professionals who have sometimes a lot of pressures to accomplish other things and there may be a way of developing services that mediate between the two.

Q109  John Austin: And at the same time providing employment opportunities in deprived communities.

Ms Roth: Yes. The whole issue of partnership and so on is about finding ways for the community to have a role to play within the health service.

Q110  Chairman: I know we were going to deal language later but I want to pick up on a couple of issues that you were saying, Lesley. Is it clear to you within the hospital when you need to bring in a trained interpreter and when it is okay to bring in somebody from the hospital who is not a trained interpreter but can speak another language?

Ms Spires: No, I think a trained interpreter is always accepted as being the most appropriate person to come in because it is somebody outside who is being objective about how they are translating.

Q111  Chairman: But that is not what you do in practice.

Ms Spires: Certainly if we are out in the community it tends to be more family members. It is also about picking up the relationship between the family members and the dynamics within the family which you cannot do when you just meet somebody for the first time, but certainly through caseloading midwives do work with and understand the family dynamics. There is also that element of having a relationship with somebody who does overcome some of the language barriers. We do use traditional interpreter services in certain circumstances, particularly in the hospital, but out in the community it is the midwife communicating with the woman or relying on a family member.

Q112  Chairman: What do you say to those people who say that it is dangerous ever to rely on family members?

Ms Spires: I think we do not have the resources.

Q113  Chairman: So you would always prefer to use others?

Ms Spires: Yes.

Ms Jones: Can I say that within East London the priority is that we have absolute cover for all areas and certainly with maternity it is so unpredictable as to when you are actually going to need it, especially when a woman is in labour. As my colleague here was saying, one of the things we have got to look at is a risk assessment of is it better to have somebody who can speak a common language with this woman or proceed with care for her that she is not going to understand and that will have an impact on the care that she is going to receive. In all cases our policy would be to use a health advocate. We try and cover the range of languages we have within Newham, which is about 60 core languages, but at times it is very difficult to find a health advocate to cover that language and, therefore, we are looking at an employee who speaks that same language. One of the initiatives we have is health care assistants from the community who also are bilingual and can speak other languages and we offer them training so that they can offer advocacy support as well.

Q114  John Austin: Talking about addressing disadvantage issues generally, whether it is through local or strategic partnerships, neighbourhood renewal or whatever the programmes are, do you think that maternity services and midwifery services engage in that process of local anti-poverty strategies or whatever?

Mrs Elliott: Absolutely. We are very closely involved with the Sure Start programme and we have got five going at the moment. Lesley is involved in organising and supporting that. The interesting thing is that the caseload midwifery does take care of one of those areas totally which works very well.

Q115  John Austin: Is that other people's experience?

Ms Jones: In the area that I work in we have eight Sure Start programmes and we liaise very, very closely. Part of our strategy comes through from working with the community groups, bringing them together on what the priorities are for the community rather than health care professionals deciding what is necessary for the community. We do a round of brainstorming and prioritising the needs for community areas.

Q116  John Austin: Do you generally feel that there is sufficient recognition in maternity units of inequalities, whether they are based on class or race or ethnicity?

Ms Spires: Since the Provision 2000 document from the Royal College of Midwives there has been a real drive towards that.

Mrs Elliott: There certainly should be, that is the guidance that has come out from the Government and the Royal College of Midwives. It is certainly what maternity units should be doing.

Q117  John Austin: What you are saying is that Provision 2000 is actively engaged with in most maternity units?

Mrs Elliott: It was three years ago now when it was saying that we should be looking at providing specialist services for these groups. It is up to the maternity unit, is it not, always, whether they take on board those recommendations or not?

Q118  John Austin: Where does the initiative come from?

Mrs Elliott: The Royal College of Midwives.

Q119  John Austin: I know that but I mean for implementing it, where does the initiative come from locally?

Mrs Elliott: It gets sent out to maternity units as guidance. It is not in any way statutory or anything. It is taken from recommendations from Government.

Q120  John Austin: Is it a bit of potluck as to whether there are some maternity units where it happens and some where it does not?

Mrs Elliott: I do not know about potluck. Sometimes there are just not enough midwives to provide the services that the reports recommend.

Q121  John Austin: Which one do you think should be driving it along?

Mrs Elliott: It has to be the trusts, the heads of midwifery, consultant midwives. It has to be taken up within the service itself. The Royal College of Midwives is not a regulatory body so it has got no way of ensuring ----

Q122  John Austin: Let us say all the midwives are switched on, what sort of awareness is there in the trusts?

Mrs Elliott: Certainly within our trust we are looking at how we can provide different services for all disadvantaged groups but I obviously cannot speak for other trusts. I do know that there are lots of initiatives going on around the country. Presentations at the Royal College of Nursing Conference last week demonstrated there is a lot of work going on to look at targeting these groups. But some trusts, I am sure, will be doing nothing. It is very, very mixed across the country.

Q123  John Austin: We have had some evidence now from people from Newham, from Hammersmith, from parts of London which for a long period of time have had substantial numbers of groups. To what extent do you think ethnic minorities fare in, say, the Highlands and areas where they are a significant minority?

Mrs Elliott: I think they do have a problem. They do not want to come into the hospital so it is up to us to provide services that go out to them. If you do genuinely target those groups and provide things like One to One caseload midwifery then those groups will benefit and the outcomes are much better, but you have to make the concerted effort to target the groups. We are not able to do as much as we would like to because we just do not have the resources and staffing to do it. As a general rule I would say that those groups probably do come off worse because they are not able to stand up and say what they want, as other groups of women are.

Ms Spires: I agree with what Carolyn said as well, it is the actual data that we have on what is the ethnic mix within our particular area, what percentage of what group we are dealing with. We know about the larger ethnic minority groups but we do not know, as you quite rightly said, about the small pockets. We cannot go out to target them if we do not know that they are there.

Ms Roth: If I could just expand on that. Newham, as has already been mentioned, is a very diverse community and has a very well developed and quite powerful advocacy service. In the study that I have recently done, many of the women who went through the maternity services, for example, just on the language question did not know how to get, or were not able to get, those language services. That is in an area where the services are geared up to respond to that particular need. I think there is good reason for concern about what happens to women who find themselves in those areas which have not got a service, it is going to be very ad hoc as to how well their needs will be served in relation to communication, which is so essential to dealing with your pregnancy.

Mrs Elliott: We are not just looking at ethnic minority groups, I understand, we are looking at domestic violence and all those things. That involves a huge amount of training for the midwives, and there is a lot of training going on at the moment, but we need training on child protection, on a lot of issues. There are training programmes but not enough at the moment.

Q124  John Austin: I do not know how many years ago it was that you went through your training.

Mrs Elliott: Quite a few.

Q125  John Austin: A little while ago. You are aware, being in the field, what it is like in the field at the moment. To what extent are the trainers today in touch with what it is like in the field and has training changed in any way? To what extent is training in tune with the needs?

Mrs Elliott: I think the trainers themselves are excellent, certainly the ones that we know of and the ones that we are involved with. There is an extensive amount of training that is required for midwives, not just in these things but skills, labour ward emergency, a lot of training. It is actually getting the midwives the training that is the problem, not the trainers. The trainers that I know of are excellent.

Ms Roth: I am debating what we are talking about when we are talking about training. If you mean midwifery education in the round, I think most midwifery educators try, to the extent that they are able to, to remain with a link in practice. I am not suggesting that the model of education has never been one of 50/50 practice, I think that happens to a certain extent. The point that Maggie made is right, that the demands on the midwifery service have increased. It has absorbed an enormous amount of new things that we have recognised that we need to do to respond appropriately to women's needs and yet the service has not expanded to the same extent and there is invariably more demand than the ability to respond to it and women do suffer because of that, because we are not addressing all of their needs all of the time.

Mrs Elliott: Certainly students who come out of midwifery education programmes will have had that education, one hopes, during their training, but it is all the midwives who trained 20 years ago that we need to get to as well.

Q126  John Austin: The midwife who was trained 20 years ago obviously needs ongoing training and support but is out there doing the job in the environment as it is. My question was are those who are responsible for the initial training of midwives sufficiently in touch with what it is like now at the coalface?

Mrs Elliott: Certainly the people that I know who do programmes for domestic violence say that they are, but that is for me in my area, I cannot speak for the rest of the country.

Q127  John Austin: Can I just ask about Queen Charlotte's. What percentage of midwives are from ethnic minority backgrounds and what percentage are there in senior positions?

Mrs Elliott: Do you mean 'I' grade managers and above or actual midwives? We have one 'I' grade midwife from an ethnic minority out of three. Obviously I am not from an ethnic minority. I know that our Directorate of Midwifery has got the most ethnic mix for the trust in relation to the population but I could not quote exactly what.

Chairman: Not to worry, you can drop us a note on that.

Q128  John Austin: Are there particular ethnic minority groups from whom it appears to be difficult to recruit people into midwifery?

Mrs Elliott: Absolutely. We have a high Somali population and from that group of women it is hard even to get representation on things like the Maternity Service Liaison Committees, let alone to encourage those women to go and do midwifery training. That is hard, yes.

Q129  John Austin: I think we have touched on the other question. I was going to ask to what extent can enabling women and helping women make demands and their views about their own care known redress some of the disadvantage that they face? Empowering women to make their own decisions.

Mrs Elliott: A huge amount. Where we have been successful in recruiting women on to groups and going out into their communities and listening to their views it makes a huge difference. As I said earlier, that can sometimes be quite hard to achieve. It is a high priority for us to involve all the different groups when we plan our services.

Ms Jones: As midwives we want to empower them to make decisions and to be part of their care and that is quite an alien concept for some women. When you first meet with them and expect them to make choices and decisions about what tests they may want to have or how to feed their baby, it may be quite a new concept when they have never made those types of decisions for themselves in the first place. You may not reach that point at the first meeting with that woman but when you do have a midwife who is part of your care all the way through, that is something that can be developed and encouraged as you go along and she might have an understanding of what we mean by wanting to empower her, to give her responsibility for her care. I think there is an assumption that all women want this responsibility and willingly accept it from the outset when we first meet them but it can be very difficult.

Q130  John Austin: In that context we are not just talking about ethnic minority groups, we are talking about social class, etc?

Ms Jones: That is right. They could be from any group.

Chairman: It might that be one of the biggest influences we have as a Committee is on how government affects midwifery services and we want to ask particularly about the impact of government initiatives.

Q131  Dr Naysmith: We have already mentioned Sure Start, which is one of the most resource intensive of the lot and you have other things like Health Action Zones. I wonder whether any of you are aware of how these initiatives impact on the provision of maternity services, if at all?

Ms Jones: Working within East London we are very aware. Before Sure Start we had Health Action Zones and looking at how we could promote health in that environment we took up the opportunity to put in bids to enable us to get funding to start some new innovations and hopefully the trust would then take up that service. There are lots of pockets of deprivation and the Health Action Zone has been beneficial, as has been Sure Start and Neighbourhood Renewal Funds. Maternity units have taken advantage of that and tried to establish services for some of these ethnic minority groups and groups that are less able to articulate their needs.

Q132  Dr Naysmith: Is there a recognition that maternity services ought to be part of these things? Is it difficult for you to get in there? You said you had to make bids, so presumably you are part of making the bid originally?

Ms Jones: That is right. It can be very difficult and it is knowing where the actual pocket of money is actually sitting. You need to find out who the key people are who make the decisions about the funding and that can be very, very difficult in finding out who has that pocket of money. The balance tends to shift, one moment it sits in social services, then it is with education or the PCT. You have to have an awareness of these issues.

Mrs Elliott: In the majority of cases you are not informed that there are these things going on, you have to go out and find it and if you are not clued up as to where to go that can be very difficult. Once we have got in there it has been great. It is just about finding the right places to go.

Q133  Sandra Gidley: Does Sure Start cover the whole of your area?

Ms Jones: No.

Q134  Sandra Gidley: What about the women who are deprived who are not a part of the Sure Start area, what can we do about them? I have a particular concern about that.

Ms Spires: I think you are absolutely right, there is a problem about Sure Start. It is like a jigsaw puzzle but it does not fit together and does not take in all of the advantaged women as well as the disadvantaged women in a particular area. That is how the funding is placed and we have to go with that. Probably speaking for all of us, we do not just target the Sure Start areas, we are also looking at the groups that go across the area. If we are going to get funding from all of these particular pots of money we have to go with the funding that is there. For instance, we are putting a proposal for a midwife to work with the Somali population in a particular area, Sure Start area, and one of the prime reasons for doing that is the high degree of female genital mutilation and the lack of knowledge and counselling that goes with it. We have to target it towards the Sure Start target, so the proposal has to be politically correct in order to achieve the ultimate aim, the ulterior aim if you like. We are restricted by the way that the funding is given and you have to seek out the funding, as Diane said, you have to find out how it is being given and who it is being given to, but in the meantime we still have to cater for all women in our area, not just women who are targeted by that pot of money.

Q135  Sandra Gidley: What about when that speciality funding ends, or a Sure Start initiative? Will some of these services that you are developing be able to continue?

Ms Spires: I think it gives us the opportunity to try out different services. For the midwife helping the Somali community, with negotiations with the Somali community themselves there was a Somali woman on the panel which was really useful and we came to the same conclusion that I think you did with the Bengali women, to have a Somali woman trained to health care assistant level who worked with the midwife which would be the most successful way to go forward with this. I think we learn from those projects and then we are able to take that into the wider community. There is that part of it but, as I said, in the meantime we still have to look after everybody else.

Ms Roth: I think there is inherently a problem with that kind of short-term funding and the risk of establishing initiatives which cannot be sustained. Again, speaking from Women's Health and Family Services, many of whose projects are funded on that basis, there is a constant insecurity about not only sustaining the work but also the continuity of employment for the people who are working on the project. Several times notices have had to be given because it looked as if people's employment was not going to be able to sustained but, in fact, at the last minute funding has been found. I think that is a really important issue, the risk of creating a notion of special needs when, in fact, the needs are not special, they are central to the care and the experience that women have, but in terms of provision they are special and, therefore, insecure.

Q136  Sandra Gidley: When you have a short-term initiative, of which there have been many over the last few years, how long does it take to actually find out exactly what is happening, get the money, jump through all the right hoops? How much time is actually wasted in, say, a three year project?

Mrs Elliott: Lesley is probably best to answer that.

Ms Spires: The problem in all the Sure Start programmes I have been involved with is recruiting people into the Sure Start programme simply because it is a short-term contract. Unless you have members of staff, not just talking about midwives but also speech therapists, librarians, whatever it might be, the most difficult thing is to make it attractive enough to recruit somebody into this short-term programme, even if some of them go on for about four years.

Dr Naysmith: Sure Start is reckoned to be one of the longest. If you can get Sure Start it is much longer than any of the others, the other ones are much worse.

Q137  Chairman: You still experience that problem?

Ms Spires: Absolutely, yes.

Ms Roth: The other side of it, and again speaking from Women's Health and Family Services, is if one looks for a value in that it is that in a sense there is room for innovation and experimentation and not committing oneself to some fossilised service which does not actually serve a need. There is a little bit of leeway. Certainly in the voluntary sector I think there is more leeway for those kinds of experiments but it comes along with far too much insecurity and uncertainty about it.

Q138  Dr Naysmith: There is more than one Sure Start programme in my constituency and the people think it is wonderful because it enables them to work closely, almost one-to-one working sometimes, with families and it does enable them to do things, such as you are talking about, innovative things, things that were very difficult to do under the old system. I take the point you were making about people on relatively short-term contracts begin to look for another job when it gets near the end and that could be very destabilising. What I was really going to ask was there has been a lot of talk about the Children's Service Framework, the National Service Frameworks, and expectations have been raised quite a lot. Do you think that will impinge in terms of resources particularly on the kinds of things we are talking about today and the midwifery service in particular?

Mrs Elliott: We have had the first part of the children's one but that does not say very much at all about the maternity services. We are anticipating that one very soon. We are hoping that it will encourage and support midwifery-led developments. That is what we are hoping but at the moment I am not sure.

Dr Naysmith: You do not think that it will happen because of the little bit in the Children's National Service Framework?

Q139  Chairman: You are waiting for the big one.

Mrs Elliott: We have only just seen the first part of it and that is centred around children, so I do not actually know what it says about maternity services at the moment. I am hoping that it will and am looking forward to it with interest. Certainly we will be taking it up when it happens.

Dr Naysmith: From what we have been talking about in the last ten or 15 minutes, it is fairly clear that you do not think there are enough resources going into this area. That is a fairly clear conclusion that can be drawn. How do you think those resources should come in? In terms of more staff or what, or just more money so you can spend it?

Q140  Chairman: Or perhaps there are other areas where you think the money is being spent and should be spent somewhere else instead.

Mrs Elliott: Within the midwifery service, you mean? A lot of us are doing the Birth Rate Plus at the moment to see the numbers of midwives. The majority of units are all coming out as vastly under-established in what they have got, so I do not think that we will be taking any from anywhere else. Unfortunately, what currently happens is at times of high workload because of the safety issues the staff from the community tend to go to labour wards, so there is a shift of resources from community to labour wards. Where we are, our community service is probably one of the least resourced parts of the service. Yes, we do need more midwives, we absolutely do. If we had more midwives we could provide more caseload practice to individual groups which would vastly improve outcomes. We are slowly achieving that and we are slowly making the case for more midwives and very, very slowly getting a few more. Like I said before, there are huge resources needed for training because if you take 12 midwives out of a maternity unit and train them in domestic violence you have got to fill that space.

Q141  Chairman: What about looking at things like caesarean rates? We heard in our last inquiry about how much more expensive caesarean rates were and there were a number of unnecessary ones. Is that something that is being looked at?

Mrs Elliott: Absolutely, and One to One midwifery has proved if it is provided properly it reduces the caesarean section rates. It is within our gift to do that, it is just that we do not have enough midwives at the moment to be able to provide a One to One midwifery service for everybody who requires it. Certainly within our teenage pregnancy group, which is caseloaded, we have managed to reduce the caesarean section rate in that group.

Q142  Chairman: When you have done that, has that released resources for more midwives?

Mrs Elliott: Unfortunately it does not work like that, I wish it did. If we could do that, that would be wonderful. Probably more consultants.

Q143  Dr Taylor: We have talked quite a lot about going out to the disadvantaged and that is the right way to do it but can I just ask one or two specific things about One to One which were not quite clear from the information we have got about it. Obviously the midwife goes into the home to make the antenatal booking?

Mrs Elliott: Yes.

Q144  Dr Taylor: Then does antenatal care in the home as well?

Mrs Elliott: If it is appropriate, yes. Not always.

Q145  Dr Taylor: If it is going to be a home birth they go on and look after them?

Mrs Elliott: Yes.

Q146  Dr Taylor: If it is a hospital birth, what happens then?

Mrs Elliott: Whether it is a high risk case or a low risk case, the midwife will see the woman through to the end.

Q147  Dr Taylor: Including the actual delivery?

Mrs Elliott: Including the delivery, yes.

Q148  Dr Taylor: That is absolutely superb. If that happens it is wonderful.

Mrs Elliott: There is a very high success rate of achieving that as well. Obviously because of on-call commitments it is usually in partnerships and a group of two or three midwives will provide the total care for their women.

Q149  Dr Taylor: Are you able to do anything like that in Newham?

Ms Jones: It is not quite so satisfactory in Newham. What we have are community teams whereby there are eight midwives within a team. There is a midwife on-call, so if a woman is in labour from that particular team then the community midwife will care for her. That is only for the low risk women, we are not able to provide that service for women who have any known medical complications or want to have a caesarean section for any reason.

Q150  Dr Taylor: There are specific challenges for the disadvantaged groups, like smoking cessation and breastfeeding. How do you cope with those?

Ms Jones: In those areas we have been able to have specialist midwives for those specific areas. That is just one person so they do a lot of the training and development for the other staff as well because there is the factor that if you have a specialist midwife then nobody else will learn that aspect of their role and, therefore, leave it down to one person to do. While we do have specialist midwives for infant feeding and smoking cessation they actually carry a caseload and will care for the women antenatally and postnatally but not the labour aspect. Also, all the other midwives are trained in awareness of smoking cessation and infant feeding as well, so we are not relying on just one person.

Q151  Dr Taylor: Can you guess at the success of smoking cessation because you are coping with the very people who need smoking for relief from their situation?

Ms Jones: When we first started the project that I was involved with we had very good success rates with women quitting. The first thing to say is that it has got to be women that want the support to quit. Women who have said they are quite happy to smoke we are not forcing to want to give up smoking. There has to be some awareness within themselves that they want this support, that they do want to quit, and they will give women who smoke information and that support. There is definitely one-to-one care with these women both antenatally and postnatally. The evidence suggested that in the first year that we ran it and we had 39 women referred, 30 women actually quit and four weeks later after they had their babies they were still non-smokers. It was a very good success rate but it is very intensive, very one-to-one support.

Q152  Dr Taylor: Anything at Queen Charlotte's, any specific experience with smoking cessation?

Mrs Elliott: We were provided with funding from the then health authority and we do have a smoking cessation midwife.

Q153  Dr Taylor: I think it was Carolyn who said that you could not find out the numbers of mums arriving who had not had any maternity care. Did you get the feeling that this was an appreciable number?

Ms Roth: It varies from place to place. It was merely a postal survey of maternity units where we asked what the numbers were of women that they were aware of arriving in labour with no prior care. That category is very poorly defined anyway. I think we surveyed 33 units and only nine were able to produce those figures. Of those nine, some had high proportions of women, maybe as many as four per cent, who seemed to be delivering with no prior care. It is really just a snapshot. We are trying to get funding to look at this further because it is a source of concern as to what is stopping women from having care prior to labour. We really cannot say what that is, except that it is likely to be women who experience disadvantage of a variety of kinds.

Q154  Dr Taylor: Is this one of the pieces of data that is going to go into the maternity statistics?

Ms Roth: It would be very nice if it did show up.

Q155  Dr Taylor: We can certainly recommend it.

Ms Roth: I would say it would be a very useful piece of information to have recorded.

Q156  Dr Taylor: We have touched on advocacy and I was delighted to hear My talk about the Maternity Liaison Services and the work you are doing involved with the Chinese, but also do you deal with Bangladeshis as well?

Ms Diep: Those are my colleagues because they speak Bengali. Our project is ethnic minorities and it covers the full range of communities: the Chinese community, the Vietnamese community, Bengali, Somali and Caribbean communities.

Q157  Dr Taylor: So you are able to have, as it were, a specialist in each of the language groups, are you?

Ms Diep: Yes. At the moment we have myself speaking Chinese and Vietnamese. We have Laky Begum and Rita Gupta who speak Bengali and Asha Mira who speaks Somali.

Q158  Dr Taylor: We have already heard that advocacy is much more than just offering translation services, it is listening to the women. Maternity Liaison Committees, do they still function? We are getting varied answers from different people about their effectiveness and whether they still function. Obviously you have got a pretty active one, Carolyn.

Ms Roth: I have to distinguish between Maternity Services Liaison and the Maternity Liaison Scheme, which was the earlier name of Women's Health and Family Services, so they are different. The Maternity Services Liaison Committee, certainly in East London, in many ways reflects some of the issues that women face generally. I think attendance varies quite a lot. There have been various initiatives to try and overcome barriers to attend. It is hard for women to attend and we know that even in areas where women are prepared to participate there are barriers to attendance. It is quite patchy progress.

Ms Jones: It is quite strong, I would say, within what we do but the service users' representation does not actually reflect the Newham population. What we tend to have are women from the NCT group, many middle class white women who run the MSLC, so it does not accurately reflect other women from the community. We are looking at other ways of hearing their voice at that committee.

Q159  Dr Taylor: This is just what we want to get at. How do you get at the disadvantaged groups? I imagine in your area it is the wealthy ladies of Chiswick who take over these groups?

Mrs Elliott: We have been successful in getting a few.

Q160  Dr Taylor: How?

Mrs Elliott: First of all I use complaints. If somebody complains to us about some part of the service we will respond to them, but then say: "Would you like to come and sit on the committee?" We have a few, and in that way they then feel involved in changing the service.

Q161  Dr Taylor: Are the disadvantaged the very ones that do not complain?

Mrs Elliott: We did get a Somalian woman through that route. You tend to have to go out to those woman as opposed to them coming to you.

Q162  Chairman: Is that what you were hinting at, Diane, that you have to look to other ways? You have basically, to put it crudely, given up on getting some ethnic communities represented on the MSLCs?

Ms Jones: We tend to do more outreach work and rather than them coming to an MSLC forum we go to forums which are already established in the community, we ask if we can be invited to one of their forums and hear their concerns and views about maternity services. One of the other things we are looking at, and we have just developed a proposal, is a cassette tape. We often give them lots of information, it is written information but often it is in English writing. If we do translate to another language we are making an assumption these woman can read that language as well. What we have tried to do is do a cassette tape for them so that they can listen to what care is available. Part of that is asking them about their views and would they like to be part of a forum where they can discuss their views.

Q163  Dr Taylor: Have you any evidence to say they listen to those tapes, that they do not take them home and lose them?

Ms Jones: I have no evidence of that. Considering we are giving them written evidence at the moment and it does not seem to be helping we are looking at other ways and options, it is something that we would like to pilot first.

Q164  Dr Taylor: Will you be able to see if that is making any difference?

Ms Jones: We are going to evaluate it and ask them: "How are you aware of things? How are you aware of what pain relief you can have?" They will tell us it is from the booklet, the tape or friends. We are trying to find out what the best route of communication will be.

Q165  Chairman: Can I just pick up on the issue of the smoking cessation programmes and the breast feeding support programmes, would you agree that it is right for the Government to focus on those issues and within that to say: "We want a particular focus in the disadvantaged communities", or in your services does that not feel like the highest priority and you would rather do something else with the money and initiatives?

Ms Spires: It may be that should be the focus in this particular area, to be able to have funding to provide the services you need to provide in your particular area, which seem to vary amongst all of us here because we have different types of populations. If there was a more general terms as to how to use those funds we could make that decision as to how best it would serve our local community.

Mrs Elliott: The money was not great, we have had two days a week for the smoking cessation midwife and £5,000 for the breast feeding support, so it is not something you can take and use in a big way.

Q166  Sandra Gidley: In evidence from the Royal College of Midwives they felt that in some cases they thought institutional racism was a barrier. Do you think there is institutional prejudice that could prevent women from accessing the normal range of maternity services? Obviously it is not anything that anybody wants to admit.

Mrs Elliott: Yes. Yes, they are part of a disadvantaged group.

Q167  Sandra Gidley: Do you do any specific training to try and address this issue? It is not quite as simple as saying, "This is the right thing to do" because some people's attitudes are quite entrenched.

Ms Jones: We do have a diversity programme which is trust-wide, not specific for maternity and for asylum seekers. We have a new influx of communities settling within Newham so we need to address the issues that concern them. There is a basic diversity training programme that all staff are expected to attend but policing who has attended and has not and has it made any difference to the way they practise is very difficult to evaluate. There is an awareness and consciousness and woman can feel as though there is this institutional racism in the way we treat woman who try to access services.

Q168  Sandra Gidley: Has anybody ever fed that back to the complaints system?

Mrs Elliott: I have not had any complaints. There is very much a whole feeling against asylum seekers nationally, not just within the NHS and midwifery, and that is reflected in trying to provide services for those people.

Ms Roth: I would like to comment on a study I was involved in which had to do with services provided by advocates. Certainly a number of advocates have had experience of being treated rather disrespectfully themselves by health professionals, so there are even attitudes that are projected on to the group of workers that are actually negotiating services on behalf of women. I think there is a need for awareness on the part of health professionals about the needs and the backgrounds and the lives of the people that they are serving, which I think would address some of those attitudes, but also about their fellow health workers who are making a contribution to health care. Somehow that has to be valued as an essential part of the care that the women are getting rather than an optional extra which can be dispensed with if it does not suit the professional.

Ms Spires: It is not just about racism, there are also issues about our teenage pregnancy group. There is a huge amount of advocacy required to support those girls, and midwives identified there were different attitudes towards that age group than there were to the older mother. I do not think it is just about what particular social group they are, what particular race they are, there are all sorts of advocacy needs.

Q169  Sandra Gidley: If I can come back to the race issue, I wonder if My Diep wants to comment.

Ms Diep: I speak on behalf of the ethnic minority women where I work, Women's Health and Family Services. Most of them have very little English, there is the language barrier. They also have very little knowledge about the health services in this country compared to the western system and their own country. A lot of the women had a baby in their own country but when they came here it was all very new. They do not know how to contact the services, contact a GP. Some cases are very difficult. The culture is very different and there is also the religion. It is very complicated for a GP. I can give you one example, when they have a language barrier and they go to a GP they are very, frightened. They do not go for their first check-up they wait until the baby is nearly born. Some of them are frightened to have blood tests, they say: "Why do I have to have blood tests, you sell my blood". We need to explain to them and educate them. Sometimes it is very difficult, we do not only interpret for them but we do a lot for them, explaining the health care system in the country to them and encourage them to use the services, and how to use the services. In one particular case I very recently linked a woman with the health services and social services. Her husband is an alcoholic, he is using drugs and he is in prison. The woman has two young children under five, she does not have any money, she keeps the children at home and she does not send the children to school. The school telephone everywhere looking for the children but she is hiding the children. She does not have any money. She is crying in front of me. I ask her to tell me the truth and she says to me: "Don't tell anyone, my husband is in prison". I felt very sad for her, the husband got the benefit and now she has no money. I took her to social services and social services gave her £30 so she can buy food for the children. We do all kinds of things, we not only speak on behalf of her but we take her to where the services are available for her, otherwise she would be dead with the two children. Sometimes it is very, very difficult. It is not only you do not speak English but you do not know the system in this country.

Q170  Chairman: For the Chinese and Vietnamese communities it is not so much an issue about experiencing racism, it is more an issue of not knowing what the services are and the huge language barrier.

Ms Diep: That is right.

Q171  Sandra Gidley: Can I return to asylum seekers, I think we can take prejudice as a given, because it is endemic. I would just like to specifically know, what are the problems with continuity of health care with asylum seekers?

Ms Spires: One problem is where they are living. It is not always easy to keep in contact.

Q172  Sandra Gidley: Are we talking about the centres now?

Ms Spires: We do not have any big centres near us but there are some in local bed and breakfasts but it is difficult to access bed and breakfasts because a lot of people in bed and breakfasts who speak the language are able to get out and it is really hard to go in and find those individuals. In a sense it is easier in a centre because you know where they are. Accessing asylum seekers is difficult.

Q173  Sandra Gidley: Does relocation cause any particular problems or has it not had an impact as far as you are concerned?

Ms Roth: In some contexts I have heard there will be women who are on the verge of delivery who might get 24 hours notice that they are moving somewhere else, it inevitably has a hugely disruptive and destabilising impact for women who may have tried very hard to establish a network and feel familiar with a particular locality, and that is literally pulled out from under their feet on the eve of giving birth. Undoubtedly it has a very fierce impact.

Q174  Sandra Gidley: Are there any figures available or are you not aware of any?

Ms Roth: The only study I am aware of is the one Jenny McLeish did, which was a qualitative study that demonstrated problems at all stages. You probably know the study. One of the things that was very interesting and striking about it was the poor information that those women were receiving about the availability of services. The thing that struck me was being told to go to Accident & Emergency when you are in labour. Of course the problem is that when woman show up inappropriately for services there is no doubt they receive abuse for that, not necessarily overt abuse. In one of the focus groups we conducted for this other piece of research there was a Somali women who talked about not liking to go for services if there was not somebody who could speak for her because she said it was like being deaf, she could not make use of the services and another woman chastised her very passionately and said: "No, no you must not go for services because they will think you are not a good mother". There is a knock-on effect of being unable to access the services and then being blamed for not using the services that you did not know about in the first place. I am sure that is an experience that asylum seeking women must face frequently.

Ms Jones: I think there is also an aspect in certain communities that the midwife is the traditional birth attendant who would attend their birth. They were unaware of the fact it would be a midwife that would attend, the policies dictate you have to have somebody declaring you have had a birth in the community. These women were living in Newham and having their babies by an elder in the community and did not register the birth, and that was a normal practice in their homeland. It was very alien for them to be told: "This is what needs to happen". When somebody went into the community to explain that they saw that as authority coming in wanting to take the baby away and it was misconstrued as something terrible that we wanted to do which pushed them further away from us, not closer.

Q175  Sandra Gidley: Have you managed to bridge that gap?

Ms Jones: Yes, since, but we had to do a huge piece of work round what their perceptions were and what we felt was appropriate care.

Q176  Chairman: What is happening now?

Ms Jones: They do attend. We have a link worker, a midwife that links with that community so they go out and see her rather than come to us in the hospital.

Q177  Dr Naysmith: Do you now have a large number of unregistered children in Newham? How will you manage to register some of them?

Ms Jones: I would not know the figures for that.

Q178  Chairman: Are you saying they are being registered now?

Ms Jones: Thankfully they are registered now.

Q179  John Austin: Can I follow up on something up within particular communities, the midwifery profession may be involved in campaigns on FGM, does that make it more difficult to present your midwifery services to those communities where you are trying to raise awareness of the issue?

Ms Spires: The issue round FGM is really if a woman comes in in labour it compromises her labour and health, so it is really more about having the trust of that particular community in order to give them the counselling that has been discussed before the labour and to consider with us, which is quite foreign to the concept of some women. You would think it is a fairly reasonable thing but for some communities it is not acceptable, they do not realise the health problems that it can entail. It is more about being able to gain their trust and talk about it in the first place.

Ms Roth: To pick up on that, there certainly are women, and again Tower Hamlets is an example, from the Somalian community that are very active in educating and challenging the practice of female genital mutilation. I think the other thing that needs recording is one of the really innovative and promising successes in terms of developing services for women that appear to be special needs are the number of special clinics run by midwives, there is one run by Comfort Momo at Guy's and St Thomas's which provides an on-going service for women, there is one at Whittington as well, and they appear to be well received by women from circumcising communities because they really address women's needs not only round pregnancy but she has done enormous work in training midwives to respond in an appropriate and acceptable way to women's needs around that area of midwifery. I think that is an area of midwifery we can all be really proud of.

Q180  John Austin: We talked about the problems of the mobility of asylum seekers, it is not just minority ethnic groups who are mobile, particularly in many parts of London we have large numbers of homeless people who are constantly moving around, very many of them may be pregnant with young children. We talked about the outreach work with minority ethnic communities, which is in one sense easier because you can go to wherever people might congregate, however with the homeless community how do you do your outreach work? Can you support social services?

Ms Spires: It is a particular problem with teenage pregnancy because they will be in one bed and breakfast and then move to another one. The only reason we are able to track them is because they do keep in contact with their midwives. A lot of them if they do not have anything else they have a mobile phone, they do not have much money but they use text messaging. They do have that confidence in the midwife and they keep in touch. We do have a lot of problems about going across social services boundaries. If you need to be in contact with social services then once a woman moves out of one area into another that seems to break down. Unless the midwife is following that woman through the other services do not seem to do that. That is a problem. You are going to lose women if they move from one place to another if they do not have the confidence to keep in touch with the midwife or the services that they are getting.

Q181  John Austin: If the housing department of one borough re-houses a woman in a neighbouring borough or much further away is there any mechanism by which information is transferred to the relevant agencies about that? Should there be?

Ms Spires: There should be.

Ms Jones: One thing is that women carrying their own records help. If a woman has her maternity records and she goes and seeks care in another borough she will more than likely bring her notes with her so the midwife can see what trust she comes from in the first place. It is very difficult and dependent on the woman carrying her notes and showing them to the midwife to let her know she has had care in this area. That is one of the questions we ask if we meet a woman late in her pregnancy, we would ask her: "Have you had any care in any borough within the UK or do you have any records we can look at?" So rather than duplicating information it is looking at what is already recorded.

Q182  John Austin: For many of these women - and this is not a judgmental statement - their lives are very chaotic, we all see them in our surgeries, so to actually maintain documentation can be difficult.

Ms Roth: I am not up to date with the most recent research, certainly the studies that I know that have been done about people carrying their own notes report it is generally an extremely efficient way of keeping hold of it, the loss rate is much, much lower than when it is kept in a hospital. It may well be that for some women it does not go with them but generally it has had a very good record in consistency and women are very responsible, they usually care about those records.

Ms Spires: I think what it does not address is those women who do not attend. If they attend with their notes that is fine but if they do not you might lose them in the system and then they have missed out on lots of ante-natal care and maybe when they turn up for delivery it could be a child protection issue. There are children on orders and their family will move from one place to another and we do try and keep track of them, we send notices out round the country. It is an issue if we do not know what is happening with social services. If they do not access the care it can be problematic.

Mrs Elliott: What would be fantastic is if we could provide a one-to-one midwifery service for women because in those circumstances the midwife could give the care in another borough and that would just be brilliant. That is a long-term aim.

Q183  John Austin: That has resource implications.

Mrs Elliott: Absolutely.

Q184  Chairman: At the moment there would be no circumstances where you would do that?

Mrs Elliott: Unfortunately we cannot because it is two community areas and there are all sorts of implications with honouring contracts with trusts, all sorts of things, so it is very hard to achieve that. We have looked at it and it would be fantastic, particularly for these extremely disadvantaged women that would be the right way to go.

Q185  Chairman: Can I just pick up on an issue on the income front, that is we have been approached by people who have had their babies but the baby has gone in to a special care baby unit - it might not be such an issue in London but elsewhere where they have to travel a long way - and the expense of visiting being a problem. People on income support can get some help towards visiting costs, is that something that you have experienced or have concerns over?

Mrs Elliott: We have, yes. Some babies are in the neo-natal unit and they have to pay the same charge as everybody else for car-parking. Yes, it is very, very difficult.

Q186  Chairman: People on income support would get no help with car-parking charges. There are all sorts of issues there.

Mrs Elliott: Certainly there are neonatal networks consultations going on at the moment.

Q187  John Austin: I was going to come on to the travelling community, a greater proportion of travelling communities are more static than before, since the Caravan Sites Act. It has always been an area of access to services, do you have any particular experience in the travelling community?

Mrs Elliott: Lesley has been very successful in starting to set up a one-to-one midwifery service specifically for that group. It is a very, very good way forward because you can really keep tabs on those people, provided they do not move out of the area, because they are a high risk group.

Ms Spires: Midwives have built up a relationship with the travelling group. We have a big permanent site near us, although they do move in and out of the site. It takes time for them to accept any health professionals into their community but once you have got passed that barrier in a way it is easy after that because the midwives go in there and it is more of social event, people come to say hello to them. I think it is an achievable aim to go and address the issue of the travelling community, particularly the worst ones with poor attendance. If you are providing care in the community you have one hundred per cent attendance rate and that is what we got. That is very achievable.

Mrs Elliott: It is extraordinary.

Ms Jones: I think it is really good where you can offer that one-to-one service and only a midwife can do the midwifery aspects of the job. In an area like Newham we have a chronic shortage of midwives and it is very, very difficult to reach out to these vulnerable groups because what we are hearing is if you give one-to-one support you are able to achieve a lot with these women. Where you cannot we are currently putting on a skeleton service and we are trying to provide for these vulnerable groups, and we have many within our area, but the resources are just not there. We have to look at so many dynamics, other ways of employing other people other than midwives to do certain aspects of it. When it comes to maternity care it is midwives that you need and that is one of the difficulties, we are struggling to actually meet the needs of our population.

Q188  Chairman: Mrs Elliott, in particular you have mentioned domestic violence on a few occasions and obviously it is a huge concern in maternity services, in particular because it seems to be a provocation to start with.

Mrs Elliott: It is one of the highest causes of term death so it is a huge concern.

Q189  Chairman: Are there particular aspects of best practice that you feel we should be recommending as a Committee or other things that the Government should be doing?

Mrs Elliott: It is about relevant support and training for midwives to recognise when this happens and also for them to know what to do because it is really, really not something that is easy to deal with. You are not going to get somebody that is subject to domestic violence on the Maternity Services Liaison Committee. It is about how you support the midwives, and giving them the right support, advice and education in order to give that.

Ms Roth: There is another point, the evidence base for how best to respond and what best to offer them is very poor at the moment. There was a review published some months ago, there is no way of demonstrating the long-term benefit of that kind of intervention and I think that is something that really needs to be looked at. The other thing is I think we need to acknowledge that the social problems faced by woman do not divide themselves according to groups. The Somalian woman who is on your group or whatever woman might well also be someone who is facing domestic violence, that needs to be acknowledged, that it is not exclusive to one particular group or another.

Q190  Chairman: Are you concerned that the more it gets addressed as an issue the more it gets picked up by the general public and that might stop people coming forward to access maternity services? Is there a way round that, ie partners may try and stop them accessing maternity services?

Mrs Elliott: That is a huge possibility, yes.

Q191  Chairman: It is not something that you are experiencing so much?

Mrs Elliott: Not at the moment, no. I do not know. It has not been brought to our attention, we do not know if that is happening or not.

Ms Jones: In our experience we are asking women about issues round abuse, only if they are on their own. When I have a new case I ask women these questions and they are not offended by it, they are actually quite glad that somebody is asking those questions. It is just a forum for them to speak about what is happening in their lives. They may not want to do anything about it but the fact that somebody has listened to them in a non-judgmental way shows women, the few I have had contact with, it is beneficial.

Ms Roth: To bring in the language issue, it is one of the unidentified areas that are experienced by women who have to rely on relatives for their communication. It certainly inhibits being able to have that conversation in that space. It is certainly one of the things that advocacy has attempted to address to give women the space that belongs to them and is not intruded on by somebody else in the family.

Ms Diep: We have to support women. I have my own client and I have been seeing her for a long, long time. Her husband is violent towards her. Her husband has another wife but he still stays with her. The husband beat her very badly but there is no report from the GP to say she has been hit by her husband and one week later the baby died, she had a stillborn baby at only 16 weeks pregnant. I tried to encourage her to report it to the police and tell the doctor but she said: "The baby is dead, what do I, I have no more support. Yes, the hospital supports me but outside who will support me and maybe my husband will beat me again and then who will help me". She will not report it. Most Chinese or Vietnamese never report to Victim Support or the police, or anyone.

Q192  Chairman: Is that because you would not able to refer them on?

Ms Diep: Because they do not have other people speaking the same language it is very difficult for them.

Q193  Chairman: There is a need for the question of domestic violence to fit in with the wider strategy about what you do if somebody needs support.

Ms Spires: Disclosure is one thing but it is what you do about it.

Q194  Sandra Gidley: I want to start by talking about pregnant women with severe mental health problems during pregnancy, they obviously need specialist help but what role is there for midwifery and obstetric staff in helping such women access the range of services available?

Mrs Elliott: It is a huge role. It has been identified as an area for maternal death, so it is a big problem. Once again we are looking at, and I keep saying it, setting up a case load practice group for these women because if they have that support then hopefully we will be able to resolve some of their issues. Having the same midwife looking after them must help that situation.

Ms Spires: The midwives in these circumstance need support from the mental health team. Unless the midwife has mental health training it is not easy to support a woman through the whole of the pregnancy. We are fortunate in that we can access the mental health team within our trust but it has to be recognised it is not an easy role for the midwife.

Q195  Sandra Gidley: A lot of the mental health trusts are separate these days.

Mrs Elliott: There are issues about midwives and obstetricians accessing mental health.

Ms Roth: There is probably a role here for community mental health workers. It is an area that needs to be actually investigated and there needs to be intervention. It is a little like domestic violence. At the moment we do not know what midwives are doing with respect to the social and mental health needs of women, we do not know what they ought to be doing. There is a little bit of a gap in the literature, it is an area that needs collaboration between the two areas of care to devise responses that would support in the right way.

Mrs Elliott: There are not clear guidelines at all about how you deal with those women.

Ms Spires: There are mental health teams within hospitals and there are community mental health teams and I do not think there is always a transition between the two and the midwife can be caught in the middle. Our trust is talking about perinatal health services, but I am sure that is not happening in every trust, that is passing from the hospital setting to the community setting, and that is so important for a new mother.

Q196  Sandra Gidley: It is probably slightly beyond your area of responsibility but I wonder if you would like to use this opportunity to comment on post-natal depression, particularly severe cases? Are we doing enough with women who suffer? Are there enough facilities and understanding available? In my area they are booked into the Priory.

Ms Jones: Within our mental health trust they do not recognise post-natal depression as a mental health problem. We have a lot of difficulty doing an assessment of these women in the first instance. We need to address that problem. We contact them saying: "We need your support" but unless the woman displays bizarre behaviour which warrants them admitting her to a mental health hospital there are issues. We are trying to troubleshoot to prevent this. Most mental health teams do not recognise post-natal depression at all. What happens is if a woman displays some bizarre behaviour she cannot go to the mother and baby unit, so she is separated from the baby and admitted to a mental health hospital, which is going to exacerbate her problem because she is not with the baby. Those are the problems that we are dealing with at the moment. We are trying to come to some agreement with our mental health trusts as to how best to address these situations.

Q197  Dr Taylor: That is another recommendation you want out of us.

Ms Jones: In all of these issues that we are talking about we need to have better liaison with the other departments and other professionals to address these issues, because it is on the increase.

Q198  Sandra Gidley: Moving on to disability groups generally, not just mental health problems, there are a lot of voluntary organisations which give a lot of help, advice and support do you think that maternity services make the best from most of those resources, are they welcomed or regarded as a hindrance?

Mrs Elliott: It depends on the individual service. I have worked for lots of services as a junior and senior midwife and some services will embrace them and others do not.

Q199  Sandra Gidley: Can you give us an example of how it works particularly well and how it has worked badly, without naming voluntary organisations?

Mrs Elliott: I can. Some units will use SANDS incredibly well and some do not.

Q200  Sandra Gidley: SANDS is not really for disability, is it?

Mrs Elliott: It is still neo-natal deaths.

Ms Spires: Can I bring in an example where we did use that service, I cannot remember the name of the body that supported this particular mother who had learning difficulties, but there was a lot of coordination between the midwife caring for her and the organisation that was supporting her and there was a lot of two-way conversations ---

Chairman: That bell means we have to go and vote. Just wait for the bells to finish. Could you just drop us a note of a good example of that. It is the last question. We just want to know if you do think voluntary and community groups are of particular help to people with disabilities and are properly recognised by maternity?

Q201  Sandra Gidley: And how things could be improved in the future?

Ms Spires: I think if you know about the organisations and you have information beforehand the organisation can be of assistance and it works very well. In this case they were able to work together to enable the woman to stay in hospital and about whether she could keep her baby. It was time to arrange somewhere for her to go. If you did not know about this organisation or that they supported her, perhaps that information about which organisations to access and that midwives can get in touch with them.

Chairman: That is the issue about getting in touch. Can I thank you all for coming. Sorry we have to leave you in a hurry, we all have to run and vote. I hope our report will help raise the very, very important issues that you are working on.