Personalised care in maternity

The NHS ‘Long Term Plan’ was published in January 2019, setting out a clear ambition to expand the choices and control people have over their own care. There has been a call for a fundamental shift in how healthcare workers in all settings deliver care to patients. Personalised care is the keystone and patients have told us they want caregivers to take into account their individual values and preferences, ensuring choice and sharing control, while still providing care that is safe and based on high quality evidence.

This has seen valuable collaborations develop between clinicians, councils, local governments, community organisations and healthcare professionals in many areas, with an appetite to work differently and put patients at the centre of conversations. This has been proven to have several positive outcomes, including better adherence to treatment and improved patient and clinician satisfaction.

Incorporating personalised care and support planning into maternity care is the focus in our new e-learning resource for the Personalised Care Institute (PCI), which is supported by the Royal College of Midwives. We know that a personalised approach to the care of a woman and her family is central to delivering the best experience through her antenatal and postnatal journey and even beyond.

While the pandemic has placed great pressures on all healthcare professionals and services, we believe that personalised care is absolutely possible and even more important now than ever. Embedding this will enhance the daily practice of maternity care teams and the experience of women they care for as we move beyond COVID-19 and into a bright future.

Informed decision-making and personalised consultations

As set out in the ‘Better Births’ report in 2016, the vision for maternity services is for them to be safer, more personalised, kinder, professional and family friendly. The report details how giving a woman choice about her maternity care allows her to have more control over her physical and mental health (National Maternity Review, 2016). Healthcare professionals facilitating informed decision-making support women to understand the care, management and support options available to them, as well as the risks, benefits and consequences of those choices. Providing this information facilitates an ongoing process where a woman can decide a course of action based on high quality, evidence-based and timely advice tailored to her circumstances.

Each woman and her family are different, with unique needs, past experiences, hopes and dreams. This needs to be reflected within personalised care and support plans (PCSPs) which outline support through pregnancy, delivery and the postnatal period. To effectively offer personalised care to women and their families, all healthcare professionals need to be aware of and address their knowledge gaps, biases (conscious and unconscious), roles and responsibilities. Safe and personalised maternity care requires healthcare professionals to be conscious of the power dynamic that can be at play in a therapeutic relationship.

The PCI's module discusses the cultural safety model, which originated in New Zealand to reduce poor health outcomes for the Maori community. With these principles in mind, it also considers how professionals might approach a common scenario, such as supporting a maternal request for a home birth in the face of borderline blood pressure. We must also deliver personalised care to women and birthing people who might need extra support. For example, if English is not their first language or if they have a disability (visible or not visible). In our work, there are occasions when we need to share a lot of information, including statistics. When doing that, we need to do so in a clear way; as well as giving women opportunity and time to ask questions, and have further discussion.

As healthcare professionals in maternity services, we are being asked to challenge the traditional way in which we broached conversations with women previously. There is a need to look at individualised care planning with fresh eyes, particularly if a woman wishes to pursue a pathway of care that falls ‘outside guidance’. While this may take a bit more time, this holistic approach to a woman's care with exploration of her preferences and choices creates an environment for high quality, two-way conversations that make the woman feel heard and her wishes taken seriously.

There are several ways to support informed decision-making and the IDECIDE tool – developed by NHSE with inputs from Birthrights alongside other organisations, healthcare professionals and service users – illustrates this nicely. This is a digital framework for healthcare professionals and women/individuals and their partners during labour that enables women to make informed decisions about next steps. It is highlighted in the PCI's module as a powerful means of facilitating personalised care in a hospital-birth setting. It uses evidence-based information surrounding key decisions and is currently being feasibility tested, with trusts piloting it during 2021.

Consultations with women and their families should be personalised at each contact. For example, beginning a discussion with, ‘I'm interested to know what is important to you so I can understand how best to support you’ creates the space for the healthcare professional to listen and understand before beginning the consultation; at whatever point in the pregnancy or afterwards. The module also highlights National Institute for Health and Care Excellence guidelines CG138, which shares best practice and advice on facilitating discussions around risks and benefits of a certain pathway of care or treatment option.

Any decision recorded in a PCSP should be revisited at each appointment, capturing changing circumstances. This review empowers a woman to feel she can change her mind as her pregnancy progresses. A good PCSP balances what matters to the woman with the management of risks that pre-date the pregnancy or develop as the pregnancy advances.

Consent considerations

The Montgomery vs Lanarkshire case in 2015 brought to light the importance of consent alongside informed decision making (The Supreme Court, 2015). Its ruling changed the test for consent used in UK courts and this concept is explored widely in the PCI's module, which also includes a video narrated by Nadine Montgomery. Mrs Montgomery, a pregnant diabetic woman with a large baby, was not informed by her obstetrician about the risk of shoulder dystocia at delivery, despite repeatedly expressing concerns about the size of her baby. She was not given the information to make an informed choice about a vaginal delivery or a planned c-section. She had a shoulder dystocia when she delivered her baby.

The case centred around her treatment as an autonomous adult and right to be given information about ‘any material risk’ of the choices for her mode of delivery. It highlights medical paternalism and explicitly recognises a patient's right to autonomy and the provision of information to support decision-making.

Consent is never just about a signed form or bombarding an individual with lots of information; this is hugely unhelpful, overwhelming and confusing. Women who need the expertise of maternity care professionals need to be able to consent to a course of action based on accurate advice, delivered in a kind, professional and non-judgemental way.

The benefits of personalised care are evident but there is also evidence showcasing the negative impact of non-personalised care. Last year, to mark the fifth anniversary of the Montgomery case, Birthrights ran a survey with Mumsnet to look at how personalised care had made a difference. The results were disappointing; 45% of women stated they did not feel like the primary decision maker, and many women felt their views had either not been sought or had been overruled.

While we are hugely appreciative of the excellent work in our profession, we know from the lived experience of women contacting Birthrights' advice line that there is sometimes a culture of ‘expected compliance’ in some maternity services, and that women and birthing people do not always feel like they have a choice, or that they can voice what matters to them. Some of this can be attributed to staff fear of being blamed if individuals make the ‘wrong’ choices.

Wider adoption of personalised care will address much of this and it will be achieved through strong collaboration and leadership as the catalyst to put individuals at the centre of their care.

The importance of consistent personalised care

Women's health and maternity services are high on the national safety in healthcare agenda. Our profession has a responsibility to focus on consistently putting actions in place which ensure that women and their families are listened to at every stage of their health and wellbeing journey.

In June 2021, Health Minister Nadine Dorries highlighted that unconscious biases against women and the healthcare they receive is a big issue, and how important it is for women to have a choice and feel listened to when it comes to managing their healthcare. Further to this, the government has called for public views to inform England's first women's health strategy. This consultation has closed but information received will be used to produce a women's health strategy addressing key issues from adolescence to old age.

It is also clear that pregnant women and women of childbearing age are often under-represented in clinical trials, which can create worrying gaps in data and understanding; we hope this will be addressed to further inform clinical practice.

The PCI's module has been purposefully co-authored by four experts with different maternity experiences and knowledge. We all share a common desire and ambition to empower maternity healthcare professionals to think about what personalised care means and to place women and their families at the very centre of their care. Only by refreshing high quality learning and challenging poor practice will we be able to continually develop skills and knowledge which lead to positive outcomes for women. That is why the PCI's training counts towards CPD.

Personalised care in practice, utilised in the right way and by all members of a multidisciplinary team has been shown to benefit women through what can be a very happy but sometimes overwhelming time of their lives. We're keen to acknowledge that there are already examples of excellent personalised care in maternity services, and now is the time to embrace this, engage in all aspects of learning and then deliver care safely and effectively; putting the woman at the centre of the conversation for the benefit of every woman who experiences maternity care services.