BabySTEPPs Releases Election Wish List
BabySTEPPs has released their wish list for the up coming election requesting a review of antenatal, postnatal and bereavement care.
A statement follows below:
1. Antenatal Care
1.1 Early Pregnancy Unit
As per our previous Election Wishlist in 2015, BabySTEPPs urge all parties to commit to ensuring that, in line with NICE (2012) guidelines, all patients presenting with symptoms of a threatened miscarriage are quickly and efficiently triaged and seen at an Early Pregnancy Unit. All patients must be provided with written information to include what the next steps are, when and how to contact the hospital if symptoms worsen, options for pain relief, and what they should do if they pass their baby at home. All patients with threatened miscarriage should be offered progestogen treatment given evidence that this reduces the risk of miscarriage (Wahabi et al., 2018).
1.2 3rd Trimester Scans
Scans in the last months leading up to the due date are sometimes able to detect potentially life-threatening problems that might have been impossible to see early on in the pregnancy. Abnormal levels of amniotic fluid, poor growth, problems with the placenta or cord and some malformations can be seen in late pregnancy scans. Plans can then be put into place to deliver safely, avoiding potential tragedy. A third trimester scan triples the chances of detecting a baby that is too small, a known risk for stillbirth. At present only first time pregnancies and those known to be ‘high-risk’ are given a third trimester scan. Selective screening has been shown to identify 20-30% of growth restricted babies, whereas universal screening can detect almost 80% of these. Current policy leaves babies at risk unnecessarily.
Post-term pregnancy can carry risks to both mother and child. Evidence shows that the risk of stillbirth, while still low, triples after 41 weeks, and there are higher risks of complications such as meconium aspiration. We strongly urge for all pregnancies that go beyond 41 weeks, or where reduced movements are reported, to be offered ultrasounds and computerised CTG monitoring to reduce the risk of perinatal mortality (Hofmeyr, 2012).Third trimester scans should be included as part of the routine care for all pregnancies, with additional scans for pregnancies that are overdue. Doppler ultrasounds should be used for all high risk pregnancies to reduce the risk of perinatal death and unnecessary induction or c-section (Alfirevic et al., 2017).
1.3 Group B Strep screening As per our previous Election Wishlist, BabySTEPPs continues to urge all parties to commit to Group B Strep screening. Group B Strep is the most common cause of severe infection in newborn babies including sepsis, pneumonia and meningitis. It can be prevented by use of a simple test (ECM) done on women a few weeks before their due date. Women who test positive for Group B Strep will not become ill themselves but a positive ECM means antibiotics can be administered during labour, helping to protect the baby from a potentially life-threatening infection. Group B Strep screening is done routinely in most developed countries, including the US and Spain. Screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection, has been shown to reduce the risk of preterm births (Medley et al., 2018).
1.4 Continuity of care – 1-to-1 midwife allocation
Evidence shows that midwife led continuity of care models improve pregnancy outcomes e.g. preterm birth or perinatal loss (Medley et al., 2018). This is the model of care recommended by the World Health Organisation (2016, 2018) and promoted within the NHS (2016, 2017), in line with the Royal College of Midwives position statement (2018). It consists of every woman having a midwife, who is part of a small team of 4 to 6 midwives, who knows the woman and family, and can provide continuity throughout the pregnancy, birth and postnatally. We believe continuity of care is of vital importance as it allows pregnant ladies and midwives to get to know each other and establish a trusting relationship. Consistency and continuity of care allows, among other things, better understanding of maternal antenatal mental health, identifying those at risk of postnatal mental health issues so that a plan of care can be put into place in a manner that is proactive rather than reactive.
1.5 Antenatal Mental Health & Wellbeing
Evidence shows that women are at higher risk of depression if they experience obstetric and neonatal complications, have a past history of psychopathology, antenatal depression or anxiety, a poor relationship with partner, low social support, and stressful life events, a history of abuse (emotional, physical, sexual) or are young mothers. Preventative approaches during pregnancy or shortly after have been shown to be effective e.g. professionally-based home visits such as intensive nursing home visits and flexible postpartum care provided by midwives, postpartum lay (peer)‐based telephone support, and interpersonal psychotherapy (Dennis & Dowswell, 2013).
We urge all parties to commit to a multi-agency initiative for ante-natal well-being, with the GHA working alongside the Care Agency and voluntary community organisations such as ourselves, GibSAMS and Clubhouse Gibraltar, to develop protocols for preventing post-natal depression e.g. ante-natal screening of risk, followed by home-visits and referrals for psychological input within 2 weeks of screening, as well as for peer support.
Pregnancy can be the only time that women who are experiencing intimate partner abuse come into regular contact with healthcare professionals. It is also, unfortunately, associated with an increase in the severity of the abuse. However, advocacy for women experiencing abuse during pregnancy has been shown to contribute to reducing abuse, empowering women to improve their situation e.g. through providing informal counselling and support for safety planning and increasing access to different services, leading to greater likelihood of physical abuse ending, better psychological wellbeing, and improved birth outcomes (Rivas et al., 2015). We urge all parties to implement trained advocates for women presenting at antenatal clinics who may be experiencing intimate partner abuse.
1.6 Dental care and dietary supplements during pregnancy
There is a well-established link between poor periodontal health and pregnancy complications e.g. preterm birth (Corbella et al., 2016). In addition, pregnancy is known to aggravate dental health (Gil et al., 2019). The World Health Organisation (Peterson, 2008) recognises that oral health is an integral part of preventive health care for pregnant women and their newborns. In recognition of this, the NHS makes free dental care available during pregnancy as well as up to a year after birth. We would like to see all parties commit to the GHA offering free or subsidised dental care for pregnant patients.
In addition, evidence shows benefits to pregnancy outcomes (including complications such as pre- eclampsia, placental abruption and pre-term or low weight birth) of dietary supplementation e.g. calcium (Hofmeyr et al., 2019) zinc, vitamin D (Palacios et al., 2019) omega-3 (Middleton et al., 2018), vitamins C & E (Rumbold et al., 2015). Multi-vitamins plus iron and folic acid have been shown to decrease the risk of stillbirth (Balogun et al., 2016). We would like to see all parties commit to offering free or subsidised pre-natal vitamins for pregnant patients.
2. Postnatal Care
2.1 Baby Boxes
BabySTEPPs encourage all parties to implement a policy of introducing a universal ‘baby box’ scheme, to provide all babies with a more equal start, as well as promote a safe sleeping environment, in line with the Royal College of Midwives recommendations (2018), as implemented by
several countries e.g. Scotland and Finland.
2.2 Neonatal Unit
BabySTEPPs calls for a commitment for a Neonatal Intensive Care Facility at St. Bernard’s Hospital, to provide care locally, as far as is appropriate, for babies born prematurely or requiring medical attention.
2.3 Post-Natal Mental Health We urge all parties to commit to a comprehensive review of post-natal mental health care, including more rigorous checks and an increase in the complement of available health visitors and counsellors, to ensure access to psychological intervention within 2 weeks of referral for antenatal anxiety, depression, PTSD or history of postnatal psychosis, domestic violence or drug and alcohol abuse (as per NICE guidelines, 2014).
2.4 Parental Leave
The importance of both parents should be emphasised from the start, and neither parent should be discriminated against on the grounds of their gender. It is essential to allow families the flexibility to share parenting responsibilities in whatever manner suits their personal circumstances. We urge all parties to commit to introducing shared parental leave.
Extension of parental leave in special circumstances
Parents who have had the leave before they have to return to work. We believe these families, who have unfortunately been robbed of the newborn months due to illness, are most in need of time to settle in as a family once their baby is discharged. In these circumstances, there should be provision to extend Parental Leave and Allowance by one week, for every week spent in hospital.
2.5 Non-discriminatory Birth Certificates
We urge all parties to commit to upholding the Parliamentary Assembly of the Council of Europe’s (2018) resolution in relation to non- discrimination by parental gender or sexual orientation, in respect of birth certificates. Birth certificates and all relevant documentation should be amended to allow registrants to choose the option mother/father/parent, and must not discriminate against the rights of same- sex parents to be named on their child’s birth certificate.
2.6 Infant Prescriptions
As per our wishlist at the previous elections, BabySTEPPs ask all parties to recognise the expenses for new parents, particularly in the first year where one or both parents may have taken unpaid leave to care for their baby, and commit to removing charges on prescriptions for babies, particularly those below the age of one. This would ensure all parents would be removed of further burden should their infant become sick, and enable all babies to have access to necessary medications.
3. Bereavement Care
3.1 Palliative Care
Where pregnancies are at high risk e.g. significant, life-limiting abnormalities have been identified, parents need to have the option to remain surrounded by their extended support network, and there should be provisions for specialist care to be received locally e.g. via a visiting consultancy basis. Parents should be provided with appropriate counselling, by specially trained mental health professionals, midwives and consultant obstetricians and neonatologists, as well as through relevant community groups to encourage peer support from other parents who have been through similar circumstances.
3.2 Bereavement Care Pathways & Bereavement Midwives
We urge all parties to commit to expedient implementation of the National Bereavement Care Pathways to ensure that all bereaved parents receive the best of care during and after infant loss. We would like to see use of the “Maternal Bereavement Experience Measure” (MBEM) to allow parents to feedback on the support they have received. BabySTEPPs strongly believe that there is a need for a Bereavement Care Lead Midwife, to be allocated dedicated time to take on the responsibility for providing support and empowerment to all staff working with bereaved parents, ensuring all staff are properly trained and following protocols, and that these protocols are regularly reviewed and updated in line with the feedback from the MBEM. While the Bereavement Midwife would not be tasked with taking over care of all bereaved parents, they would oversee the provision, being responsible for ensuring appropriate levels of resources are available and liaising with healthcare departments and external agencies e.g. funeral services, registrar of births/deaths, chaplaincy services and voluntary groups such as BabySTEPPs.
3.3 Sensitive disposal
As per our previous Election Wishlist, we urge all parties to commit to ensuring that the Human Tissue Authority (2015) guidelines on the sensitive disposal of pregnancy remains, including miscarriage, are fully implemented, including the requirement that cremation and burial should always be available options at any stage of pregnancy. The HTA specifies that “Incineration [by the hospital] should only occur where the woman makes this choice, or does not want to be involved in the decision, or does not express an opinion”. We want all families to have the option to decide how their babies’ remains will be treated, regardless of gestation. BabySTEPPs have offered to fund the option of communal/group cremations for smaller babies, with parents offered the option of attending a brief, non- denominational memorial service.
3.4 Registration Reform
We compel all parties to recognise that all babies have the right to be registered at birth, and therefore parents have the right to choose to register their baby, regardless of the gestation of their loss. This right is enshrined within the United Nations Convention on the Rights of The Child, Article 7 on the right to registration, and Article 2 which clearly states that this applies to all children, without discrimination of any kind, including by birth. We look to the example of countries such as the Netherlands, who have recently amended their stillbirth registration laws to allow for parents to make the personal decision of whether they wish to enter their child on the register of stillbirths, and be issued a certificate of stillbirth. By following the UK’s 24-week stillbirth legislation (which is also currently under review), Gibraltar has one of the strictest definitions of stillbirth in the western world, with most high-income countries implementing lower thresholds (Tavares, 2016).
3.5 Bereavement Leave Grieving parents should have the right to bereavement leave regardless of the stage at which they lost their baby.
Equality legislation should provide protection from discrimination on the grounds of pregnancy or pregnancy related sickness (including bereavement), for up to two weeks from the end of a pregnancy. Any leave that is certified as being pregnancy-loss related must be considered separately from statutory sick leave. We urge all parties to commit to following the lead of the UK in ensuring that parents have a right to paid bereavement leave of 2 weeks.
3.6 Care of Next Infant (CONI) and Rainbow Baby programme
Pregnancy after baby loss is fraught with anxiety. Parents should be assured of additional care and attention that is duly sensitive to their history. We urge all parties to support the implementation of a ‘Rainbow Baby’ package of care for all pregnancies after loss, to include the ‘Care of Next Infant’ (CONI) protocols e.g. regular home visits from midwives antenatally, and from health visitors post-natally, the use of movement monitors to alert when a baby stops breathing, provision of basic life support training for parents, a ‘passport’ to allow them to be seen quickly if they have concerns about their baby’s wellbeing and stickers for ante and post-natal records to denote the ‘Rainbow’.
