Barriers to new innovation in the UK’s NHS – and how to overcome them – Part 2

In Part 1 of this blog I discussed how companies need to build innovative products together with clinicians, in order to work out what helps them and their patients, rather than companies making assumptions about medical needs which may not actually be valid, which can create barriers to innovation.

Another barrier to innovation in the NHS which was raised in the Nuffield Trust’s report (link) was that, “Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services”.

Stories of NHS managers introducing cheaper versions of products which turn out to be more expensive overall are rife: examination gloves which split, and two or three are wasted before a useful pair is found. Paper towels which don’t come out of the dispensers properly, and end up being wasted on the floor. But far more worryingly – spending money on areas which do not improve care, and can actually hinder it.

Last year, Jeremy Hunt announced that he would be putting millions of pounds of investment into more CTG machines, despite there being zero evidence that continuous monitoring is safer than intermittent monitoring. Imagine instead if that money had been allocated to increasing midwife numbers to implement Continuity of Carer? Unlike CTG machines, Continuity of Carer has been shown to reduce stillbirth, as well as costs to the NHS such as caesarean births.

Far cheaper investments, such as birth pools, also leads to significant cost savings. Labouring in water increases the rate of spontaneous vaginal births, reduces the need for instrumental delivery, reduces the numbers of 3rd and 4th degree tears, lowers the chance of a woman wanting opiate pain relief or an epidural, and increases women’s positive experiences of birth which might lead to lower levels of PND. (1)  ALL of these mean that the NHS spends less money on fixing the consequences of these interventions, as well as the cost of the intervention itself.

Let’s see the NHS looking at the wider picture with every new innovation or investment. We call upon commissioners to look past the cost of installing new equipment which supports women to birth more easily, and instead see the full spectrum of ways that an investment in a birth pool, or other normal birth promoting products, can save the cash-strapped NHS money, while leading to better outcomes for women and their babies.

References:

(1) Evidence Based Birth: Waterbirth

 

 

Waterbirth : Part of a World Movement

Revisiting WaterbirthBarbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.

It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.

There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.

The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.

The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.

The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.

In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.

It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.

Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International

I’m Group B Strep (GBS) Positive. Can I have a Waterbirth?

GBS testing is not routinely offered to women in the UK.  This is because it is considered that the high rate of carriage compared to the low rate of infection means that the harm done to women and babies in offering antibiotics to every woman who is carrying GBS would outweigh the benefits.

However, some women do end up being tested for one reason or another, and those who find that they are carrying GBS are often then denied access to water during their birth (unless they’re at home, in which case it’s always the woman’s own decision). Aquabirths asks, “Is this a reasonable position for trusts to take?”.

Many trusts are open to women birthing in water and some are not, and within trusts some midwives or obstetricians will deny women access to the trust’s pools, and others will be completely happy to support women who want to use a pool for their birth. What’s going on?

There is limited data on the impact of waterbirth on how many babies born to women who are carrying GBS, but what data there is shows either a reduction in the numbers of babies born underwater who are infected with GBS, or no statistical difference, but with a trend towards a reduction in affected babies who are born underwater. This is despite the fact that the water in a pool birth could have high levels of GBS in it, and therefore the theory is that the water is essentially washing the baby and mother, providing some increased level of protection compared to babies born on dry land. (1)

An article by JS Cohain (2) states that infection with GBS was 1/4432 in babies born underwater v 1/1450 in babies born on land – that’s three times as many babies becoming infected with GBS when they’re born on land than babies born underwater! The article discusses the reasons for this, including considering whether it might be “a massively successful international campaign has covered up the reporting of all deaths and disease from GBS after waterbirths.” There’s nothing like covering all bases!

Even though the evidence on GBS and waterbirth is limited and more studies are needed, if the trend was the other way – that more babies seemed to be infected with GBS when born in water – there would be no doubt that there would be a huge push to try to ban birth in water! Given that the opposite is true, and the best data that we have shows a trend towards fewer babies being infected with GBS when they’re born under water, opening up water birth to women who have found that they’re carrying GBS is something that every birth centre and obstetric unit should support.

Article by Emma Ashworth.

Many thanks to Dianne Garland for her help with this article.

References:

(1) Springer Link, “Water birth: is the water an additional reservoir for group B streptococcus?” 

(2) Pubmed, “Waterbirth and GBS”

Further Reading:

AIMS GBS book, “Group B Strep Explained”

RCOG “Group B Strep and Waterbirth”

Practicing Midwife for the GBSS, “Waterbirth for women with GBS: a pipe dream?”

Dianne Garland’s book, “Revisiting Waterbirth” is due out in April or May 2017

Waterbirth Conference 2015

A packed-out conference on waterbirth and normality held in Shipley, with such speakers as Dianne Garland and consultant midwife Alison Brown.  A fuller report to follow but here are some of the tweets…

 

 

 

There was also the launch of BirthSoft for reasonably priced birth couches, mats, etc.

 

Comments please – canvassing ideas for birth baths

At a recent conference attended by Ruth, a German midwife recounted how she used a much deeper container as a waterbirth pool .  With this in mind, what do you, midwives and birth practitioners, think.  It is not the bath that Ruth is stood in, rather its something to indicate depth.  We have a design but there’s no point going into production if there is no call.  Alternatively, we might start making it for the export market.  Do let us know you thoughts.

ruth new deep bath2 ruth new deep bath

Legionnaires Disease and Water Birth – An Update.

Please be clear this alert is NOT for baths and birthing pools filled from domestic or hospital hot water systems which are then emptied or pumped out when cooled or used.

This IS for heater filter units which re-circulate warm water.

This is not about these circulatory systems being innately dangerous either – just that the sanitization and effectiveness of all units now have to be checked to ensure safety before being hired out or used.

There is a potential for contamination if the unit is not fully disinfected, or the unit is not working properly or the users do not follow the strict instructions.

Investigation is under way. So, if you have one, lend one, or hire one, then contact your local Health and Safety Dept at your local authority to get advice on ensuring this awful situation does not happen to you, a loved one, or a customer.
Every good wish
Ruth@Aquabirths

https://www.gov.uk/government/news/alert-after-legionnaires-disease-case-in-baby
Press Release Text:
Public Health England (PHE) and NHS England have temporarily advised against the home use of birthing pools with built-in heaters and recirculation pumps, potentially filled up to 2 weeks in advance of the birth. This follows a single case of Legionnaires’ disease identified in a baby born in this specific type of birthing pool at home. The baby is currently receiving intensive care treatment in hospital.
Samples taken from the heated birthing pool used have confirmed the presence of legionella bacteria, which cause Legionnaires’ disease. Tests are ongoing to establish if it is the same strain which infected the baby. This is the first reported case of Legionnaires’ disease linked to a birthing pool in England, although there have been 2 cases reported internationally some years ago.
NHS England has today issued a Patient Safety Alert rapidly notifying the healthcare system – and specifically midwives – to the possible risks associated with the use of these heated birthing pools at home. The alert recommends that heated birthing pools, filled in advance of labour and where the temperature is maintained by use of a heater and pump, are not used for labour or birth. In the meantime, a full risk assessment into their use is being carried out.
The majority of birthing pools used at home are filled from domestic hot water systems at the time of labour – these birthing pools do not pose the same risk and are excluded from this alert. There are no concerns about these types of pools as long as pumps are used solely to empty the pool and not for recirculation of warm water.
Professor Nick Phin, PHE’s head of Legionnaires’ disease, said:
This is an extremely unusual situation, which we are taking very seriously. As a precaution, we advise that heated birthing pools, filled in advance of labour and where the temperature is then maintained by use of a heater and pump, are not used in the home setting, while we investigate further and until definitive advice on disinfection and safety is available.
We do not have concerns about purchased or hired pools that are filled from domestic hot water supplies at the onset of labour, provided that any pumps are used solely for pool emptying.
PHE and relevant local authorities are investigating the infection control measures required for this type of birthing pool and local authorities will be working with the small number of companies who supply these heated birthing pools for use at home.
Louise Silverton, director for midwifery at the Royal College of Midwives, said:
Women planning birth at home using a traditional pool that is filled when the woman is in labour or using a fixed pool in an NHS unit are not affected by this alert and should not be concerned. Birthing pools in hospitals are subject to stringent infection control procedures and monitoring. Home birthing pools filled during labour come with disposable liners and are only in place for a relatively short time period, reducing opportunity for bacterial growth.  Any women with concerns about using home birthing pools should contact their midwife or local maternity unit.
Legionnaires’ disease is extremely rare in childhood, with only 1 case in children aged 0 to 9 years reported in England between 1990 to 2011.The infection does not spread from person-to-person – people become infected with the bacteria through inhalation of contaminated water droplets.

There is only good plumbing and bad plumbing.

One firm touts their bath as having low profile (sic) fast flow plumbing.

Fast flow, low profile plumbing etc.  This is just unhelpful jargon.  Speed of drainage is a function of the diameter of the plumbing beneath the bath and the distance to the foul drain.  As our plumbers put it, gravity works the same and the only plumbing that counts is good, compliant plumbing.  In the past we were called out by hospitals as they had ‘other’ baths that had started leaking – all were around the plumbing area.  The low profile pipe inserted at an angle to the bath was the point of failure.  It is evident from their brochure (and the exclusions to their guarantees) that this weakness has been recognized if not addressed.

We designed our baths from the plumbing up.  We use only standard, purpose made plumbing fittings because these alone give the best fit, the longest life and are easily replaced by Estates and Maintenance in years to come.  We also introduced the use of the quarter turn ball valve as they are far superior to the gate valves used previously.  We are glad to see that this innovation has been taken up!
We also use waterless traps which still prevent odours and backflow but do not provide a reservoir for the build up of stagnant water.

Also, as our baths are designed to incorporate all the plumbing beneath the bath.  This keeps it all concealed but also the trap can be fitted very close to the bath waste as required by water regulations (BS5572), which reduces the length of ‘uncleanable’ pipework.  We note from ‘tother’ company’s brochure that their standard requirement is still only for trapping in the floor below.  The baths should be trapped in the room as close to the bath as possible without the customer having to order the special adapted higher steel subframe (another expensive fix and design ‘cul-de-sac!). The ‘tother’ company’s website used to advise that it was not necessary to put a trap on the bath, it was sufficient to just close the sluice gate valve.  I know from site visits that there were hospitals that fitted in this way.  Thankfully, we have been imitated in terms of  improved (if not ideal) trapping arrangements and better valves.

These so-called ‘fast flow / low profile’ drains are not only inferior in terms of durability, we have had comments from an NHS infection control department that

“This form of design has infection prevention and control implications with the potential for biofilm development”.

The sooner the ‘fast flow / low profile’ plumbing is seen for the jargon it is, the better.  It is trying to put a positive spin on inferior design and plumbing.