Latest data show that multiple births make up 1.5% of all births in the UK (National Records of Scotland, 2017; Northern Ireland Statistics and Research Agency, 2017; Office for National Statistics, 2019).
Although the overall number of multiple births has decreased slightly, the birth rate is still historically high. The major concern for the Twins and Multiple Births Association (Tamba), is that the most recent figures show multiple stillbirths, as a percentage of all stillbirths, has risen. This is in spite of growing evidence that shows that good care can reduce stillbirths, neonatal deaths and neonatal admissions in multiple pregnancies.
Multiple pregnancy care
The National Institute for Health and Care Excellence (NICE) (2011; 2013) has published antenatal care guidelines and quality standards (QS46) to improve the quality and consistency of clinical care. However, there is still an excessive variation in their implementation.
Research by Tamba showed that expectant mums or twins of more were being treated differently at maternity units across the country. One mum told Tamba:
‘The many consultants we saw couldn't answer our questions, it was only the penultimate visit when we saw the twins specialist that we were informed accurately of how the pregnancy was progressing. Numerous conversations with different consultants made my pregnancy very stressful. I saw many sonographers – some had an idea, some didn't.’
Tamba received funding from the Department of Health to launch a project in which 30 maternity units would receive help and guidance on how to successfully implement the NICE (2013) standards and what results they could expect.
The Maternity Engagement Project
Tamba works closely with the team at St George's Hospital in London and was monitoring their early adherence to NICE (2013) standards.
It was because of the encouraging results from St George's—and Tamba's knowledge that care for women expecting twins, triplets or more differed throughout the country—that the Maternity Engagement Project was born.
The central hypothesis was to show that by providing support to implement NICE QS46, maternity units would see a reduction in stillbirths, neonatal deaths, neonatal admissions and emergency caesarean sections, as well as considerable cost savings.
Tamba successfully delivered a 3-year project where 30 maternity were audited and supported to implement an agreed action plan. Follow-up audits were carried out 1 year later to assess changes made and their impact.
Results
There were 40 statistically significant, positive findings, which demonstrates that both Tamba's support and the NICE guidelines work.
Overall, 65% of units saw a reduction in their neonatal admissions rate and fewer emergency caesarean sections in just 1 year.
If all maternity units in England implemented similar changes, within 1 year neonatal admissions in multiples could be reduced by 1308, emergency caesarean sections could be reduced by 634 and the NHS would save £8 million. After 5 years, up to 100 stillbirths could be prevented each year (Knight et al, 2018).
Implementing change
Maternity staff at one hospital (not one that was part of the Tamba project) have started to implement change when it comes to looking after multiple birth parents.
Midwife Layla Toomer from the Queen Alexandra Hospital in Portsmouth heard Tamba CEO Keith Reed speak about the Maternity Engagement Project at the British Maternal and Fetal Medicine Society's Annual Conference in 2017.
Mr Reed spoke about how high-risk pregnancies were benefitting from being looked after by one consultant and that continuity of care was working. Layla said this gave her the momentum needed to put new practices in place:
‘I recalled the cases of two triplet mums who'd been cared for at Portsmouth, but had been seeing different people on different days. They had to go over everything in their notes time and time again, which can, in some cases, add to any feelings of anxiety as twin and triplet mums are always being told how high-risk they are […] I wanted to get a multiples clinic running, giving continuity of care, coordinated appointments, peer support and that normal midwifery experience.’
Layla knew that getting staff on board, from senior management level to receptionists, would be key to success.
Now there is a weekly multiples antenatal clinic, where all appointments take place. Women have a scan, see a consultant (if necessary) and have time to talk with a midwife.
Layla says a multidisciplinary approach works well and has improved her own job satisfaction. A dedicated team of three midwives and one consultant aim to look after women having more than one baby throughout their labour or caesarean section, and also visit the women on the postnatal ward. Portsmouth's lead multiple birth consultant Miss Tatjana Nikisina, said:
‘We all like this way of team-working. Continuity of care in a dedicated clinic is better for patients and staff. Apart from being compliant with the NICE guidelines, the focus on safety and continuity of care, postnatal care, etc has been highlighted in Better Births and other national reports. The public may think this should automatically happen, but it doesn't. We understand why the Tamba project has been a success. You need people to drive through change and prove it works, both locally and nationally […] Everyone played their valuable part to make this project a success!
‘There are challenges […] having the interested team or space to set up a specialist multiple clinic. You need everyone to be on board and have regular meetings about how you are going to achieve this. Having sonographers involved is also key (for example, timings need to change as it takes longer to scan a twin mum and can be more physically demanding for the sonographer).’
In summing up, Layla said:
‘We did not need any extra resources, just a different way of thinking, a different way of working […] We are now following the Tamba multiple pregnancy care pathway (endorsed by NICE in May 2018) and hope to set up our own multiple birth antenatal classes and invite twin mums back to be part of this.’
The Multiple Birth team at Portsmouth recently won three awards locally: one for working together as a team, one for best quality improvement project and one for Layla, who received the patients' choice award for multiple birth clinic midwife.
Parent/patient voice
Twin mum Gemma was classed a high risk pregnancy as her twins were monochorionic monoamniotic (MCMA).
‘I was in hospital every other week; I assumed I would see different people, but I didn't. The care was amazing. I am scared of needles so when it came to the [caesarean] section to know the consultant was so nice. It definitely made me happier and calmer.’
Expecting twins did not come as such a shock to Jasmine, who had eight sets in her family. At 12 weeks' came the news that one of the twins was struggling and might not survive. Jasmine wanted a second opinion so came to Portsmouth and was told that despite some problems, there was still a heartbeat.
‘I've always thought, “Where there's a heartbeat, there's hope,” so under the care of the team at Portsmouth I now have Ronny and Bella. Ronny has undergone surgery for a hernia and on his bowel, he also has a hole in his appendix so faces more operations, but he should make a full recovery. I met Gemma at the twin clinic […] it was great to reconnect and make a lifelong friend. We talk through everything together.’
What does the future hold for multiple birth mothers?
Tamba's Maternity Engagement Project has been praised by health professionals, parents and Baroness Cumberlege, who led a major review of NHS maternity services.
Tamba is committed to ensuring that multiple birth families receive the best possible care. It wants this project to reach every maternity unit in the UK and urges the NHS to recognise that the project can make a considerable contribution to meeting the Government's ambition to reduce stillbirths, neonatal deaths and preterm births. As Keith Reed said:
‘Evidence shows that whilst units know they should follow this guidance, they often find it difficult and can face barriers without a third party assisting. As an independent third party with specialist multiple midwives, staff at the units […] were keen to become involved, and the results speak for themselves.’
Dr Asma Khalil, chair of the project, said:
‘If we are to successfully implement NICE guidelines, dedicated efforts are needed to overcome the barriers, such as raising awareness, updating knowledge, educating healthcare professionals and ensuring that the required resources are available in all maternity hospitals to provide a consistent high quality service. We should strive to reduce stillbirth in multiple pregnancies to levels similar to or even lower than singletons.’
Pregnancy Care Pathway tool
As part of the project, Tamba created a multiple pregnancy care pathway tool to support health professionals to meet specific aspects of the NICE guidelines. The proforma created as part of this, endorsed by NICE, should be used throughout a multiple pregnancy.