User engagement in the delivery and design of maternity services

Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 597–608

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Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn

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User engagement in the delivery and design of maternity services Nashita Patel, MBBS a, *, Daghni Rajasingam, MRCOG, MA b a Division of Women’s Health, Women’s Health Academic Centre, King’s College London, King’s Health Partners, London, UK b Division of Women’s Services, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Keywords: user-engagement maternity services shared decision-making

User engagement is defined as a mutual exchange of information between the patient and the health professional, which has shown to improve patient experience as well as outcomes. Engaging the patient is vital for the healthcare system to remain sustainable. The National Health Service has attempted to incorporate and enhance patient engagement in the delivery of maternity services for the last decade. The financial crisis, changing socio-demographic status, increase in birth rate and public expectations-engaging the patient to take responsibility of their own health has not been achieved. Through in-depth examinations of these barriers we are able to draw conclusions as to why current policies have failed and recommend potential solutions. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction User Engagement can be defined as the mutual exchange of information and ideas between the care-giver (health professional) and patient, resulting in an emphatic, trusted relationship which benefits the experience of the user. With engagement, patients are empowered to take an active role in the management of their own health and the health of their communities. The engagement process signifies that the patient has the ability to balance clinical information and professional advice and with their own needs and preferences. Over a period of time, user engagement has extended to influence service design and provision. Maternity services in high resource countries have had a longer

* Corresponding author. King’s College London, Women’s Health Academic Centre, St Thomas Hospital, Westminster Bridge Road, Lambeth, London SE17HY, UK. E-mail address: [email protected] (N. Patel). 1521-6934/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2013.04.006

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experience of user engagement than several other specialty areas. Transparent, effective engagement often results in better quality of care in disease management and prevention. Empathy, effective communication and shared decision making with health professionals are three vital factors required to engage a patient successfully, to improve their experience and ultimately to provide effective, safe services. Successful engagement of women during pregnancy requires not only policy makers and healthcare professionals, but also health communities to think equitably about the social, demographic and cultural factors for effective, efficient delivery of high quality maternity care to women in an environment where resources may be restricted. Within low-income settings, education adapted to the cultural settings will provide women with empowerment and the adequate background knowledge to make informed choices regarding their own care. This responsibility lies not only with the health professional, but also with the patient, their families and communities. Women have the right to education, nutrition, economic resources and should equally have influence in how services are provided within healthcare settings. Ultimately they should be involved in their own healthcare decision making.1 Maternity health status within a society is thought to reflect the degree of respect for women and their position in that society. Delivering maternity services is not just about providing high quality obstetric care. Multiple factors influence a women’s ability to navigate pregnancy and achieve good outcomes and a positive experience. These include several factors prior to pregnancy including nutritional status, ability to access and use health services, community behaviours, and education as well as household practices.2 The women’s communities potentially have strong influence in the way that care may be accessed and used. Partners and family members often exert influences which may be positive or negative. Although maternity service provision has had a long tradition of service user engagement, the profession is only just coming to terms with true empowerment of patients and professional acceptance of decisions that may seem to increase clinical risk and promote maternal choice. There is some evidence that through embracing this, services can be effectively designed to meet the needs of women, be more productive and meet some of the pressures on our healthcare systems within the current global financial environment.3 We are only too aware that in high resource countries where there are adequate numbers of healthcare personnel to provide services to the pregnant population, the perspectives of users will be different to lower resource settings where basic maternity care may not be available to every pregnant woman. However, we do believe that the principles of user engagement are applicable across all healthcare settings and when used with quality and safety improvement methods can enhance service provision. Commissioners of services will be tasked with ensuring high levels of patient satisfaction as an integral part of their commissioning processes. Evidence supports a ‘shared decision making’ model within the patient- healthcare professional interaction improving patient experience considerably and increasing concordance with treatment.4 There is a sound evidence base for this around the development and provision of cancer services, especially with the advances in technology and treatment within the last three decades.5 Oncology teams have involved patients in the discussions of treatment options with the intention of maintaining the patient’s quality of life from the patient’s perspective.5 Patient involvement in the co-design of services has been one of the most effective mechanisms helping us negotiate the complex issues around rationalisation and cost of treatments. Positive patient experience is fast becoming an important quality measure for several high income countries.6 Within the NHS in England, patient experience will become an integral part of outcome measures. Many other global healthcare providers have understood the importance of ‘customer satisfaction’ in providing a service.7,8 This has translated into integrating patient experience as part of the ‘bottom-line’ in annual reports.9 User involvement in clinical decisions Achieving user engagement can be particularly difficult with regards to clinical decisions. Within the provision of maternity care, there has been a significant shift in high-resource countries to accommodate the wishes of the woman and her family around the mode and place of delivery. Further involvement of the woman in complex clinical decision making is still not common practice and is

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often absent. This leaves many women and their families feeling disempowered and unsatisfied with clinical management especially when the pregnancy is deemed to be at ‘higher risk’. Patient engagement has the potential to go beyond this and to sustain innovative, effective care, if healthcare professionals are able to engage in a meaningful way with patients, especially through shared responsibility.10 This type of collaboration can be defined as ‘any behaviour initiated by the doctor or the patient, surrounding the consultation which facilitates the inclusion of the patient’s perspective or the patient’s preferences into the ‘medical plan’.11 It implies the inclusion of the patient as an equal partner during the consultation. Within maternity services today, we need to move towards this collaborative approach especially around clinical decision making, to enable an equal distribution of power and exchange of information between the woman and health professional.12 The empowerment of women in these situations is known to promote normality and a more fulfilling experience for mothers and their new families. At present collaboration is widely used in the effective management of chronic disease such as diabetes. Within these settings patients work in partnership with health professionals to define and reach set goals and negotiate decisions regarding future health interventions,6 enabling the patient to have responsibility. Encouraging healthcare professionals to engage in this requires an investment in training and acquisition of a different set of skills. A teambased, multi-professional approach to this has been shown to be more valuable than individual training. The use of shared decision making within maternity services is a complex process which requires a significant change in the traditional doctor patient relationship, professional culture, investment in time and an emergent approach to enable the patient to feel empowered. Within the existing models of care, this may lead to a perception of ‘loss of control’, ‘being ignored’ and professional autonomy which will be difficult for many healthcare professionals with deeply ingrained professional identities.9 In addition, many clinicians are ill-equipped with adequate communication skills to engage in open conversations with their patients and to be challenged by them.13 The process of engendering and encouraging shared decision making takes time and through the process the patient also needs to be supported in taking a more active part in their clinical decisions. However, it is important to be aware that not all patients will be comfortable with this and therefore we need to be able to tailor care individually. In low to medium resource countries, the hierarchical role of the doctor versus the patient is deeply rooted in secular, cultural and professional traditions. The combination of strong inter-professional boundaries, secular culture and the high standing of medical personnel in society are barriers to the patients having any power or say in their treatment.14 The use of traditional birth attendants and village midwives in many low resource settings can further dis-empower women throughout their antenatal and intrapartum care.14 This is often as a result of the community standing of these individuals and concerns about deviating from traditional methods of care and how these may be perceived by the wider community. Multi-disciplinary working is limited by health professionals themselves who are reluctant to relinquish any perceived ‘power’ and ‘control’ to each other or the patient. In 2010, 58 people from 18 countries attended the Salzburg Global health seminar to consider the role patients can play in their healthcare.15 The Salzburg statement on shared decision making highlights the need for increased patient participation and provides guidance on how this can be achieved. The Salzburg Statement15 calls upon: 1. Clinicians to:  Recognise that they have an ethical imperative to share important decisions with patients.  Stimulate a two-way flow of information and encourage patients to ask questions, explain their circumstances, and express personal preferences.  Provide accurate information about options and the uncertainties, benefits, and harms of treatment in line with best practice for risk communication.  Tailor information to individual patient needs and allow them sufficient time to consider their options.  Acknowledge that most decisions do not have to be taken immediately, and give patients and their families the resources and help to reach decisions.

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2. Patients to:  Speak out about their concerns, questions and what’s important to them.  Recognise that their have a right to equal participants in their care.  Seek and use high-quality health information. 3. Policymakers to:  Adopt policies that encourage shared decision making, including its measurement, as a stimulus for improvement.  Amend informed consent laws to support the development of skills and tools for shared decision making. Many patients will lack the confidence or knowledge to question health professionals.16 An additional benefit of this process and the involvement of the patient and healthcare professionals in a more equitable relationship is that there will be an increased perception of shared responsibility between all those involved for ensuring better outcomes. It is important, however, to appreciate that in different countries and healthcare settings, the ease with which this statement can be implemented will vary significantly. This is because the ability and readiness of clinician to engage in this way with their patients will vary in different cultural settings. The users of healthcare in medium to high resource countries have become increasingly aware of their power to influence the care they receive and the ways in which it is delivered. Healthcare delivered through a paternalistic approach, has created a dependency of patients on health professionals and systems, perpetuated to some extent by the autonomy of the medical profession in many countries around the world.17 This method of clinical management may have a direct impact on compliance and concordance, as patients’ have the assumption that although the healthcare professional ‘knows best’,18 the recommended management is difficult to follow. Research within other healthcare delivery models and specialities supports the re-orientation of the health consultation, in the direction of discussion and negotiation between the healthcare professionals and patients, with the aim of reaching unique patient goals.19

The NHS in England and its shared decision making journey Shared decision making was originally described by the Picker Institute in England in the early 1980s.20 Focus was placed on a patient centred approach rather than a solely collaborative approach between the healthcare professional and the patient. Since then, this concept of increasing patient centred care has been gaining increasing momentum with policy makers and the public. It is now a core component of improving healthcare quality in the Health Act 2012.21 This sets out initial recommendations to involve patients in their own care by increasing choice and control. ‘No decision about me, without me’ enhanced the message that all providers of care needed to integrate patient involvement as an essential component of design, development and improvement.22 One of the biggest levers to change will be the movement towards outcome measures, especially measured from the patient perspective and experience. As the commissioning processes within the NHS change, providers will be mandated to include patient experience as an outcome measure and to be penalised financially is these are unsatisfactory. At present the most common cause of complaints within the health services is the lack of information provided to the patients about their health condition and management. Therefore, by patients becoming active participants in their own health, it not only will patient satisfaction improve, but also an expected increase in compliance and concordance, resulting in a positive impact on long-term health outcomes. In practice, health professionals need to have the ability to identify patients who prefer a more active role, over those with preferences for a more passive role in their management plan. Time constraints during short clinical consultations are not conducive to deciding which categories patients fall within. Patients with long-term conditions have been identified as an examplar for shared decision making and as a result the care pathways for diabetes and respiratory diseases have evolved nationally in the United Kingdom.23

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Influencing the health of populations Effective behaviour change is difficult to initiate and sustain, even when communities are well informed. Success of health interventions, even within low income settings have been more successful when there is strong political and financial commitment. Through the promotion of effective behaviour change within local communities in the Gambia, Panter-Brick et al. assessed behaviour change of communities through the facilitation of a low-cost intervention focusing on the repair bed-nets within rural and urban settings.24 By gaining a clear understanding of the given community, time, economic and social constraints by engaging with members of the communities, simple interventions were designed in the form of songs and visual aids to share key health messages. These had the ability to promote powerful behaviour change by creating a sense of ownership and responsibility. This principle can be translated to maternity services, by identifying interventions to initiate behaviour change not only within patients but also by engaging actively with health professionals. An example of this would be early access to available pregnancy services or access to contraceptive services to enable family planning and spacing. To ensure meaningful engagement, particularly from groups that are seldom heard, it is vital that further research is undertaken to comprehend the barriers and to accessing and being satisfied with maternity services.25 In the last decade, communications methods have been revolutionised enabling engagement with a wide range of users. Deaf patients were recently interviewed regarding their preferred method to give feedback on the National Health Service in Scotland. The preferred methods was a ‘texting’ option to overcome the hearing barrier, which subsequently led to a significant increase in feedback from this group.9 Research undertaken by the Scottish Health Council indicated that women preferred methods of communication with which their were familiar, including the use of social networking sites. Utilisation of these methods has the potential to access ethnic minorities as well as teenage mothers.9 To encourage the shift from a paternalistic to shared responsibility within the provision of maternity services, interventions must be designed to be culturally compelling to ensure uptake globally. The methods and evidence around engagement must be continually assessed in order to meet emergent needs of identified groups of women. Economic case for user engagement The Wanless Report 200226 published in England, predicted an estimated 4.8%-5.1% increase in NHS spending per year due to the long-term demographic trends affecting the population. At the current rate of growth and recent cuts in the public spending the National Health Service will be unable to cope with the clinical and financial demands by the year 2022.27 the health service needs to focus more on the prevention of diseases, the promotion of wellbeing and education in order to make savings of twenty billion by 2015. Further economic modelling identified a continual rise in cost at a significantly lower rate if the public were fully engaged in their health. One example of this was the pathway redesign for the termination of pregnancy involving users, saw recurrent savings through an increase in medical terminations. Socio-economic benefits were predicted through the engagement of women leading to a reduction in unplanned pregnancies.28 Maternal and newborn mortality accounts for fifteen billion dollars per year in lost productivity across the world.29 Reproductive health problems account for eighteen per cent of total burden of disease. Those who suffer are not only less productive but adds to the loss of human capital. Maternal conditions including sepsis and haemorrhage account for thirteen per cent of all DALYs (disability adjusted life year) lost among women of reproductive age and the majority are easily preventable at a low cost especially in low to medium income countries.29 The provision of effective maternity services is a fundamental to ensure as good as possible start in life and subsequently lead to healthier populations. Benefits of improved public health through user engagement Allowing patients to be empowered in the management of their own health, co-designing care pathways and engaging with health professionals in the delivery of services, will enable a positive impact on behaviour change.21

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Maternity services have a long history of user engagement in services but as public expectations have risen we have to continue to improve our methods of engagement. The role of healthcare professionals in educating and empowering women prior to and during pregnancy can result on long term benefits for the women and her family. Future access to care for her children and dependents is improved if her experiences during pregnancy are positive. The education of professionals in this is crucial. Each contact between a woman of reproductive age and healthcare professionals should be viewed as an opportunity to maximise her health and that of her family. Unfortunately the reeducation of doctors can be difficult, even in cases when the benefits of interventions are evidence based. Healthcare professionals within general practitioners in London underwent educational sessions demonstrating the importance of pre-conception care, within the Diabetes Preconception Care in Community Project. However despite receiving information and education on the importance of preconception counselling less than 50% of women with pre-existing disease received the information.30 Surveys undertaken by the Picker Institute as required by the Care Quality Commission of the maternity services in the UK found that the provision of information regarding choice on location of delivery especially home-birth had increased significantly from 2007 to 2010.18 However, patients have reported concerns regarding the safety of maternity services. Safety is defined by the management of risk and the prevention of harm. Many reported that staffing levels were inadequate during delivery and especially on postnatal wards hence leading to anxiety and insecurity on the Public expectations in maternity services have also risen due to a variety of media sources including the internet and reality television shows. Innovative methods of communication through reality television, has raised awareness of the importance of antenatal visits and breastfeeding. However, women have expected to receive high quality post-natal care and information on parenting. Changing demographics Migration from rural to urban communities is increasing within low to middle income countries, in search for improved financial security as well as better education and healthcare. This change in the demographics in principle should reduce barriers to the utilization of maternity services. Within lowincome settings, a rapid increase in urbanization has led to increased levels of poverty and a further stretch on healthcare infrastructure.31 Therefore the key challenge would be the ability of interventions to adapt emergently to the rapid pace of urbanization to meet the changing needs of its population, especially within low-income settings. In several urban populations especially In London, the rates of ethnic diversity vary greatly between boroughs from 10-50%.32 The pregnancy outcomes for women with socially complex pregnancy are much poorer than others and are overrepresented in the women who unfortunately die in pregnancy or during childbirth. The release of ‘Making it better: for mother and baby’ CEMACH 2007 stated that women from ethnic minorities ‘were on average three times more likely to die’ from childbirth in the UK.2,33 The established methods of user engagement have to be modified and culturally sensitive if service providers are to engage in a meaningful way with these groups of women. Patient experience is significantly poor, where many women suffered ‘vulnerability’ and a lack of respect from healthcare professionals.25 Current service provision does not meet the expectations of these women nor meet quality and safety standards. Services will have to engage with and take into account the needs of these women if we are to basic standards of care and safety. It was been widely documented that the quality of care received within the ethnic population vary greatly- early access to healthcare is poor and further propagate inequalities in pregnancy outcomes.34 In MAMTA, a culturally sensitive programme designed for improving maternal and child health for ethnic minorities, women are empowered to take control of both their own health and their child.34 The programme targets health inequalities by removing barriers such as language to deliver important health messages to the community such as Workshops on nutrition during pregnancy and supporting postnatal classes. Health information disseminated through the local communities has the advantage of not only being cost-effective but also culturally sensitive. Group community programs have the potential ability to prevent feelings of ‘isolation’ and ‘fear’ especially within the migrant populations and subsequently improving access to healthcare and health outcomes and are translatable globally.

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One of the main precipitating causes for preventing access within a migrant population is the variable linguistic and literacy rates of the English language. Health literacy is defined as the ability to obtain process and understand health information as well as making the appropriate decision regarding their health.35 Health literacy is fundamental to patient engagement and empowerment of women. If a patient is unable to process and understand basic health information, they cannot be expected to engage in shared decision making in the same way as native speaking patients. Empowering these groups of women by the use of advocacy services may reduce some of the variation in the quality of care provided to them, as would actively participation in decision making, together with informed consent during the consultation. The complex issue of providing services that are accessible and would be facilitated by local user engagement. It is paramount for health professionals to understand the perspectives of these women, as it provides insight as to why interventions have failed in the past. Whilst we have highlighted ethnic minority women as potentially vulnerable and seldom heard, we are aware that there are other groups of women for example women in single sex relationships and disabled parents who may also suffer discrimination and as a result of this, a poorer quality of service. In these groups of women, it is particularly important to engage and understand how service provision can be further improved to meet their specific needs.36 Maternity services in the past have placed limited emphasis on partners, who play a pivotal role in the support of women during this time. The lack of attention in the past, has led to a negative experience of maternity services, for example anxieties not answered. By placing emphasis, we have the ability to create a service which is family centred- a key requirement globally.37 Partners have the unique ability to act as advocates for the mother during labour, therefore effective communication is an essential to not only improve the experience of the partner, but also the mothers. (*what women and their families need and want from a maternity service). The global diabetes and obesity epidemic Obesity is an important determinant for the poor pregnancy outcomes. Obese patients require specialised care, as have a higher risk of developing miscarriages, pre-eclampsia and gestational diabetes through the antenatal period. Within the UK, maternal obesity has been associated with over 50% of maternal deaths between 2003 and 2005.38 Rates of obesity have been doubling over the last decade, globally due to rapid urbanization and changing lifestyle from 7.6% to 15.6% in just fewer than two decades.39 Research has shown that those most likely to be affected are those of lower socio-economic status within middle to high income resource settings and is commonly associated with cigarette smoking and poor nutrition. Poor socioeconomic statuses are commonly associated with poor literacy levels, access to healthcare therefore collectively resulting in poor health outcomes.40 Therefore engaging this specific population is vital for the promotion of a healthy lifestyle not only for pregnancy, but for the prevention of chronic diseases. Interestingly research has indicated that negative lifestyle behaviours are commonly interdependent in relation to smoking, alcohol and diet.41 Therefore support is required for both mother and fathers, throughout the prenatal and antenatal period, to empower them to make healthy lifestyle choices, which can have a positive impact on the pregnancy outcomes and experience. Pregnancy as been identified as an ideal time to encourage positive behaviour changes as women are more receptive to health care professionals than at any other stage of their lives. We need to ensure that engagement of women to sustain a healthy lifestyle is sustained throughout the pregnancy and importantly within the postnatal period. Successful patient interactions within specialist models for the management of chronic disease and cancer network models have shown improvements in patient experience and significant improvements in clinical outcomes measures. For example the use of regular telephone contact with health care professionals as a method of integrative health coaching as a method of patient engagement for patients with type 2 diabetes, significantly improved glycaemic control and promoted a healthier lifestyle.42 Such strategies are low cost and can be adopted in a wide range of middle to high income settings and will enable the development of a self-help model with feedback and reinforcement. The public health agenda would be more effective if women of a reproductive age were empowered to be

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responsible for their health and wellbeing by accessing information on healthy nutrition and weight management. Change in public expectations of pregnancy Unfortunately, pregnancy is viewed in today’s society as a ‘normal illness’ rather than a ‘normal physiological process’. Cultural norms, economic inequity and the low status of women prevent normality of pregnancy within society. Encouraging and supporting normality in pregnancies is integrally important in providing high quality and safe care to women. In the UK, the majority of women give birth within obstetric units, giving rise to increased medical interventions including operative deliveries. The same increasing rates of obstetric interventions are seen within low risk women, therefore increasing the cost on the health service. In comparison, with low income settings, the majority of birth are not attended by a trained health professional, preventing women accessing medical interventions when required.31 Enhancing choice around place of delivery needs to be balanced by managing the expectations of choice and the reality of what can be provided for them. Although one to one midwifery is a gold standard of care, however the realities of the global midwifery workforce shortages translates into low rates of satisfaction, and especially within low income countries leading to a subsequent increase in maternal morbidity and mortality. Women have reported being able to ‘bond’ with midwives during delivery, subsequently reassuring them throughout, improving patient experience. However, this same experience was not shared with groups from disadvantaged communities. The method of midwifery led case-loading for low risk pregnancies within the UK, has been introduced as a method to decrease the rates of medical intervention during pregnancy. Randomized controlled trials have shown a reduction in the caesarean rates due to the on-going continuity of care.43 Although this method is limited to low-risk pregnancies, it does have the potential to not only decrease costs but also improve patient experience, providing we have the adequate work-force resources. Increase in public expectation: workforce Public expectations have increased in the health professionals delivering maternity care. ‘Tomorrow’s Specialist’ released by to the Royal College of Obstetrics and Gynaecology demonstrated an increase in what is expected from health professionals by the public.44 Concerns regarding safety have been reported by health professionals due to increasing demands on the service coupled with the increasing financial constraints.45 Low staffing levels have a direct impact on safety of patients, as midwives are significantly more likely to suffer from tiredness and burnout hence leading to diminishing morale within the workforce.45 Although ‘Midwifery 2020’ expressed an importance of midwives being a ‘lead professional’ and coordinator of care, in the provision of maternity care, many barriers prevent this from happening.46 At present there is a shortfall on the number of midwives with vacancies being as high as 18% in some trusts.46 This coupled with an increasing birth rate has strained the maternity services at present. However although the government has sustained its promise of increasing training places for midwives,47 it may be more effective to increase productivity with existing staff at a time of financial constraint.48 Recommendations have been made for the training of support workers and other healthcare staff to ease the load on other midwives. Providers will have to innovative in the delivery elements for the provision of a high quality service in the community especially since staffs costs are 60%48 budget. Similar shortages are also seen within low-income countries due to immigration as well as the poor health status of healthcare professionals. Studies have revealed that approximately 18-41% of health workers are living with HIV/AIDS in many sub-Saharan countries.49 Due to the poor working conditions, many skilled workers are moving into the private sector, hence placing an enormous strain on the maternal health services, where the probability of worse outcomes is higher. It has been well documented that health professionals’ densities are significantly related to maternal mortality (controlled for poverty, female literacy and per capita income). Shortages in the workforce, is related to a reduction

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in the quality of care due to increased workload, low nurse-patient ratio and poorer infection control. This subsequently leads to a reduction in patient satisfaction and high rates of post-partum infections. This has been demonstrated in Malawi, where at present one in ten hospital closes due to a severe shortage of staff resulting in a decline in the quality of care received and a subsequent increase in the maternal mortality.49 The WHO estimates that approximately $91 billion is require to scale up maternity services across sub-Saharan Africa including doubling salaries to retain skilled workers.50 Realistically, these resources will be hard to find. However, to many this shortages are perceived as ‘normal’ and unfortunately it is the poor and rural women that are affected the most. Future recommendations are require, to have the ability to attract and retain staff by improving job satisfaction as well as having the ability to provide a high level of care. Bonuses for overtime and loans for housing have been implemented in certain states in Gambia to attract staff to government hospitals. The ability of management to respond effectively to the needs of the skilled workforce are crucial to ensure that retention of staff.50 Policy changes within the maternity services Women usually have contact with maternity services for short, intense periods of time. Having a baby is a distinct life event, full of expectation. During this period not only is good, effective clinical care required but also social and emotional support to allow the transition to parenthood. Some groups of women may need more support in achieving this and we need to be able to screen these women and provide tailored support to minimise psychological and emotional squeal. Changing childbirth, released in the UK, identified three key messages and significantly influenced the delivery of maternity services,51 focused on providing a woman-centred care. The barriers surrounding access to health care within ethnic minority groups and those with a low socio-economic status were also recognised. Even though these documents have the potential to significantly impact the delivery of maternity services, no account was taken for the continuing shortage of midwives and in particular senior obstetricians. Maternity matters highlighted the importance of engaging patients especially those from ethnic minorities to play a central role, to combat existing inequalities.52 Health and Social Act 201222 strengthened recommendations set out in maternity matters to provide a patient-centred approach. Patient experience is now an identified domain within the NHS outcome framework mandating commissioners to ensure that providers are integrating this into their care pathways. Ensuring accurate measurement and improvement in this outcome measure may prove to be more challenging. The release of the act has also out Health and Well-being boards within the local communities to increase promotion and awareness of positive lifestyle changes, potentially improving the focus on public health and preventive medicine. Another key priority within the Health Act 2012 is the recommendations for the provision of a ‘Greater voice for patients’. This will mandate moving from a paternalistic approach in health-care to one where the patient feels empowered by the consultation process, investigations and management plans, providing an increased level of informed choice. If this succeeds not only will the delivery of healthcare improve but it could go some way to reducing health inequalities. However, regardless of the release of high-profile documents and laws, women continue to have a negative experience of the maternity services. Postnatal wards have been viewed as having a lack of flexibility, dis-satisfaction with the physical environment and inconsistent advice provided by the staff on breastfeeding. These views were consistent with women’s experiences in Australia and Sweden indicating that the hours post birth are vital to improving patient experience in maternity services. Unfortunately, we need to now be realistic when setting out recommendations for the re-designing of maternity services. The expectations of the workforce and the public need to be managed through this climate of scarce resources. Increased demand has been placed on the maternity services due to an exponential increase in population, rising birth age as well as a reconfiguration and staffing of maternity services. Pressure of increased spending efficiency and reductions of momentary funds secondary to the present economic deficit will be common in the coming years. If we do not take in account the budget, resourcing recommendations as set out in the Health and Social Reform Act 2012 will not occur. Recommendations in the past, have failed to be fully implemented as previous changes have required the creation of new committees and structures for the delivery of maternity services. In

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today’s financial status of the NHS, this will not be possible. Therefore to allow for the implementation of the actions set out by the Health and Social Act 2012, we have to have the ability to think outside the box. New ideas on the implementation need to be sought which have the ability to be sustainable and can be undertaken with structures in place at present. Since the release of High Quality Women’s Healthcare by the Royal College of Obstetricians and Gynaecologists53 encouraging the provision of services around the life course of women, innovative methods have been devised to ensure that recommendations are implemented to the maternity services within the UK. Women, throughout their lives, should be at the centre of consistent and high quality care. However, we have to influence commissioners to commission a life-course approach to ensure that preventive medicine plays a greater part in our strategic of healthcare planning. This will ensure that women will have positive outcomes irrespective of their social class, education and geography. Future recommendations need to have not only the user involved, but integrate the workforce into the co-design processes these are the people that are at the front line of sustainably providing high quality care and innovation to occur within the health service model. Within maternity care, innovation has been predominantly been driven by the need for an increased level of safety with the aim to improve birth outcomes for both mother and baby. However, like any healthcare system changes within the system need to be balanced with an evaluation of the risks. Putting the patients at the centre of her care and taking a ‘life course’ approach to women may go some way to not only significantly improving the experience of women and their families, but also improve the outcomes of their pregnancies for the women and their babies.

Practice points 1. Innovative methods have been adopted to reduce the inequality gaps for example culturally sensitive dietary and breastfeeding advice. 2. A life-course approach should be adopted for the prevention of chronic disease and the sustainability of the health service at a time of financial and socio-demographic change. 3. Innovative methods are required to re-educate doctors to enable shared-decision making.

Research agenda 1. The value of shared-decision making in ethnic minority groups. 2. Adoption of health care assistants in performing simple midwife tasks.

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