Evaluation of Salford New Deal for Communities Enhanced Midwifery Service Project

Transcription

1 Salford Centre for Nursing, Midwifery & Collaborative Research Evaluation of Salford New Deal for Communities Enhanced Midwifery Service Project Julie Wray Carole Waterhouse Jeanne Lythgoe To f ind out more or talk to a tutor, contact us on: T: E: fhsc@salfo rd.ac.u k d.ac.uk d.ac.uk Faculty of Health & Social Care

2 Contents Foreword 1 Acknowledgements 2 1. The Evaluation 3 Introduction 3 How the evaluation was carried out 3 How the report is organised 4 2. Summary of the project 5 3. ANA Project (Anaemia and Nutritional Advice) 8 4. Role of the Midwifery Assistant Value of Interventions Learning and Implications for practice 23 Appendices 1. Summary of the project as submitted to NDC The Eatwell Plate and Balanced Plate Scoring System References 30 List of Tables: Table 1: Summary of the planned interventions within the enhanced midwifery project 7 Table 2: Number of women seen by ANA midwife 9 Table 3: Overview of the number of women seen by the Midwifery Assistant 13 List of Boxes: Box 1: Case study examples 14 Box 2: Summary of how the Midwifery Assistant understands her role 15 Box 3 Example of comments from the women in ND area who had accessed the acupuncture service 18

3 1 Foreword New Deal for Communities was launched in 1999 to help close the gap between 39 deprived neighbourhoods and the rest of the country. The ten year scheme is one of the most ambitious area-based initiatives ever launched in England. Salford Council successfully completed Phase 1 of its New Deal for Communities (NDC) process in April 2000 and selected Charlestown and Lower Kersal as the area in which the work should be carried out. The Charlestown/Lower Kersal Partnership was awarded 53 million in NDC funding. The initiative focused on tackling areas such as crime; health; worklessness; education and community involvement. The Partnership Board approved the Health Investment Strategy in A number of outcomes within that strategy related to improving mental health outcomes, reducing social isolation and increasing support for pregnant women and mothers with children under five. The Health Task Group worked on re-configuring the existing Maternity Services project into the Enhanced Maternity Services project which focused on tackling the aforementioned outcomes and commissioning an external evaluation to see what difference the project has made to the lives of local families. Anne Finlay Health Programme Manager Charlestown and Lower Kersal NDC Partnership

4 2 Acknowledgements We are most grateful to all the staff who helped with this evaluation and to the women who in either completing a questionnaire or attending a group session in the community agreed to share their experiences. Thank you. Thanks also to: Andrea Metcalfe: Smoking Cessation Midwife Michelle Roche: Midwifery Assistant Sharon Hughes: Midwifery Administrative Assistant Charlestown and Lower Kersal NDC Partnership Salford Royal Foundation Trust who selected the University of Salford to undertake the evaluation with funding provided by New Deal for Communities The authors Julie Wray is a senior lecturer and the lead for user and carer in nurse education at the School of Nursing and Midwifery, Salford Centre for Nursing, Midwifery & Collaborative Research, University of Salford Jeanne Lythgoe is the Sure Start midwifery lead for Salford NHS Trust and was based at the Cornerstone at the time of the evaluation Carole Waterhouse is a community midwife in Salford and works within the Charlestown and Lower Kersal neighbourhoods and was part of the Charlestown and Lower Kersal NDC partnership at the time of the evaluation.

5 3 7. The Evaluation Introduction This report presents the findings of a small scale evaluation of the Enhanced Midwifery Service located in Charlestown and Lower Kersal as part of New Deal for Communities (NDC). Routine data has been collected throughout the life course of the project and submitted to the health task group on a regular basis. The findings included here relate directly to the purpose for the service and the innovations developed. Space is given to the comments from women who have used parts of the service alongside views and experiences of key workers involved in delivering the service. These views are important for several reasons: A major focus of the Enhanced Midwifery service has been to access and engage with local mothers to offer supplementary support during their pregnancy and after birth. At the heart of this has been meeting the needs of local mothers as individuals, including confidence building, information giving and encouragement in supporting their adjustment to motherhood. Focused support for local women during pregnancy and after birth has been a key component of the Midwifery Assistant role and is known to improve outcomes such as self-esteem, wellbeing and confidence in new mothers (e.g. Oakley 1992). The creation of a community based Midwifery Assistant has been a new initiative within Salford. As such the ways in which the role has been embedded, accepted and utilised provides insights for the future. The experiences of the Midwifery Assistant sheds light on things that have gone well and not so well which provides learning ready for mainstreaming. The enhanced midwifery service has sought to positively impact upon women s wellbeing through a number of specific interventions so that good practice can be shared wider and integrated within mainstream services. How this work has been valued over the past 2 years in part is reflected in the uptake and contacts with local women, their feedback and the experiences of the Midwifery Assistant. How the evaluation was carried out For the most part the evaluation has been formative, in that ongoing advice and suggestions have been given to the team during the project concerning the collection of baseline data and ongoing monitoring. Routine data has been collected throughout the life course of the service and regularly submitted to the health task group. A specific monitoring form and database was designed

6 4 for the ANA project 1 so that the specialist midwife leading on this collected useful information about nutritional advice, treatments, uptake by women and their views so as to make recommendations for the future. The evaluator met up with the team on a number of occasions and attended group sessions e.g. smoking cessation and baby massage sessions, to capture insights into the role of the Midwifery Assistant and views of women. It is worth noting that the population is relatively small but reflects the local neighbourhood and target audience for women living in Charlestown and Lower Kersal, where appropriate questionnaires have been completed by local women as an integral part of the service evaluation. All comments and quotes are anonymous to respect privacy and where staff are cited by name it is with their consent. How this report is organised Firstly a summary of the project is provided to set the scene before presenting the main findings which are divided into the following sections: ANA project Role of the Midwifery Assistant - Support - Acupuncture groups/clinic (Smoking cessation) - Baby massage Salford Midwifery Acupuncture service There will then follow a section on the value of the interventions (Chapter 5) and a final section on the learning and implications for practice (Chapter 6). 1 The ANA (Anaemia and Nutritional Advice) project started in January 2008.

7 5 8. Summary of the project Within the New Deal area the demographics of the pregnant population reflect that of the Salford population generally showing a high level of disadvantage in terms of health, education, employment and housing. There are a higher proportion of young parents, parents for whom English is not their first language, parents who smoke or drink high levels of alcohol. Many parents have had social difficulties within their own family background and find parenting very challenging. As a consequence many parents suffer from low self-esteem or even depression, they can feel isolated and not able to access help and support. As the national survey of Multiple deprivation indices shows, parts of the New Deal area, particularly Lower Kersal, are in the top 7% of most deprived wards in England (Statistic and Census 2001 data from: Lower Kersal is also the most deprived ward in terms of child poverty in Salford. The Enhanced Midwifery Service a local project set within the New Deal area of Salford, sought to improve health and wellbeing of pregnant women and new mothers, beyond the routine service. It started in 2008 and was funded for just less than 2 years. Without doubt the impetus for designing such a project was influenced by the wider policy context (e.g. DH, 1998; 1999; 2004a/b; 2007), the public health landscape and local health intelligence. For example a prior midwifery project in connection with Sure Start work had gathered data through: the Wellbeing Assessment ; the Perinatal Mental Health Project; Stop Smoking Team; Teenage Pregnancy Team and the Midwifery Assistant. The following highlighted information provided on-going evidence of need within the local area: 42% of women booked for pregnancy belonged to an ethnic minority group, many of whom English is not their first language. This problem highlighted as a priority within the NDC inclusion strategy 65% of pregnant women are aged 20 years old or under often with more than one child Only 26% of women were still breastfeeding their baby at 10 days of age 40% of pregnant women smoke

8 6 25% score above 12 on the Edinburgh Depression scale indicative of a depressive illness 16 out of 94 women were receiving support from the Perinatal Mental Health Project 30% of pregnant women were classed as obese, with up to 70% eating a poor diet as classified by a local assessment tool used to grade the nutritional value of the food pregnant women ate in a 24 hour period An audit of the blood haemoglobin level of women booking for antenatal care revealed a high level of women with anaemia An evaluation of the Community Midwifery Assistant role conducted in the NDC area demonstrated that parents valued the role and had benefited in terms of support, increased access and integration into community life With this background context in mind local midwives were familiar with the complexity of issues that can face local women during pregnancy and motherhood. Midwifery has had successes within Sure Start (as above) which had resulted in the mainstreaming of the Wellbeing Assessment which incorporated emotional wellbeing. This resulted in the inclusion of this wellbeing assessment within the maternity records for all pregnant women across the city, therefore was embedded in practice as a core element of routine care for all women. A measure of success of a prior intervention, one that the midwifery team felt proud of and motivated them to explore further opportunities to improve services for local women. Therefore, in response to this background context and keen to design realistic interventions with capacity to appeal to local women, the team looked to develop initiatives. This created a timely opportunity to work together with NDC and its health task group to achieve this. It remains the case that poverty, deprivation and poor parenting can lead to poor physical or emotional health amongst children (DH, 2004b). Consequently NDC were eager to ensure that their strategic priorities for pregnant women and mothers with children under five continued to remain a high profile. Focused support for young families remained a key objective within NDC. It would be true to say that the support for this project from NDC has been warmly received by the staff involved. In undertaking the evaluation it has become apparent that all the staff involved have invested much energy and thought into the project. They have consistently displayed reflective practice and a desire to improve the service along the way in a realistic and considered manner. At the heart of the project were a number of interventions (see table 1) such as targeted one to one support, smoking cessation, baby massage and healthy eating (ANA project). Appendix 1 provides a summary of the original

9 7 proposal for the project, as submitted to NDC, with its aims and anticipated outcomes (see page 24/25). It is worth noting at this point that the estimated contacts and referrals to the service were expected to be small in number, yet to the women residing in the neighbourhoods of Charlestown and Lower Kersal they had scope to be significant and meaningful. It is well documented that the wellbeing of mothers has been shown within many research studies to affect the social and psychological development of their children (e.g. Glover 2002). Staff involved in this project disclosed that they felt the collection of numbers alone portray only a partial view of its impact, and in their view do not reflect the whole story of their interventions. Indeed a widely held view unfolded during the evaluation that softer or unanticipated outcomes were often the ones that impacted upon people s lives. Typically these are not always captured on the monitoring forms and yet are valued by women and their families. Examples of these are included in the findings chapters and mention is made again in respect of this point in Chapter 5. A final point before moving onto to the findings is to mention that the creation of an actual post, the Midwifery Assistant, was a significant component of this project. During the evaluation care has been taken to ensure that information related to the interventions and outcomes have been the focus of attention rather than to scrutinize the Midwifery Assistant per se. Many of the interventions were delivered by the Midwifery Assistant who said the project in its entirety has been a team effort. Table 1: Summary of the planned interventions within the enhanced midwifery project Improve the diet of pregnant women and their families by offering specific advice, support and nutritional therapy (ANA project) Offer support to help pregnant women stop smoking Promote the bonding and attachment of newborns Promote the initiation and continuation of breastfeeding by offering additional information, support and working in partnership with peer supporters Improve the confidence of parents in caring for their baby by offering parenting education in a children s centre and in the home Provide access to support for perinatal mental health problems by offering referral to the perinatal mental health service Provide access to the Salford Midwifery Acupuncture Service* for minor ailments of pregnancy and the postnatal period, promoting normality within pregnancy and childbirth (* included smoking cessation) Promote the use of all New Deal services through partnership working and signposting

10 8 3. ANA Project Healthy eating and good nutrition are regarded as important and key to a healthy pregnancy (DH, 1997; NICE 2008a/b). In particular the National guidance for antenatal care NICE makes very clear, with the support of evidence, that iron supplements should not be routinely recommended to pregnant women (2008a). The recommendation by NICE is: Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mother s or fetus s health and may have unpleasant maternal side effects. (2008a:85) Within the New Deal area it is known that 30% of pregnant women are categorised as obese, with up to 70% eating a poor diet, as discovered by using an assessment tool developed by local midwives (Waterhouse and Cohen, unpublished study 2007). This tool assesses the nutritional value of food that pregnant women disclose as having eaten in a 24 hour period. This assessment tool has been considered to be useful in giving women specific nutritional advice and information. Therefore the aim of the ANA project was to increase pregnant women s knowledge of nutrition and encourage good eating habits in the New Deal area. It was anticipated that this would then impact not only on the diet and food habits of the women but also would benefit that of her family. To achieve this aim a midwife led clinic was established to assess and monitor women for anaemia in the New Deal locality which included a detailed diet assessment with women. The overall intention was to ensure wherever possible that women would experience their labour and birth with a healthy, normal blood profile. Additionally NICE (2008a/b) and prior nutritional guidance (DH 1997) support good nutritional advice and careful management of women with anaemia. In consideration of such evidence and data sourced on local women the following activities were proposed by the specialist midwife, to underpin the ANA project: 1] Detailed diet assessments have been undertaken (diet plates available and antenatal appointment sheets showing when diet assessments were performed in clinic) 2] The specialist Ana Clinic was established offering longer appointment times with women who were classed as at risk on initial diet assessment or on review of their blood tests.

11 9 Findings 3] Information resources were developed to give to the women, for example: The iron content of selected foods leaflet and Your Vegetarian Pregnancy. 4] Guidelines for identification, treatment, advice and referral for iron deficient anaemia in pregnancy have been written. These have been accepted for use across Salford. They are currently awaiting final approval from the NHS Trust. When approved by the Salford NHS Trust this will facilitate the continuity of care with women being treated either in hospital or the community using the same guidelines. 5] A care pathway has been developed and integrated into the guidelines. This has been used by some midwives in Salford not associated with the ANA project. 6] A short questionnaire was offered to women to obtain their feedback of using the specialist clinic. 7] As a result of feedback from the women, a new proposal for invitations to the Post Natal Examination was put to the staff at Chalk surgery. This has been initiated and post natal full blood counts have been taken leading to further evidence of the benefit of the project. In total 132 women were seen by the specialist midwife between 2008 and Table 2 outlines the nature of those contacts. It can be seen that uptake of the diet assessment was high and the midwife worked hard to achieve this outcome. This was an informed decision by women, in other words women could choose to take part in the assessment or not. Table 2: Number of women seen by ANA midwife (n=132) Diet Assessment 96 (73%) Targeted Advice 48 (36%) ANA appointment 41 (31%) offered ANA appointment attended 38 (29%) 3 were home visits Declined ANA 3 (2%) appointment This data taken from the monitoring form designed by the evaluator enabled the midwife to collect specific information within one data source, as prior to this she had to rely on accessing two different sources of information i.e. the medical records held by the GP and the hospital maternity care notes. This process had been time consuming and did not always include information related to the activities of the ANA project. As well as information about blood results during pregnancy it also included information about women s postnatal

12 10 (after birth) blood results. The intention here had been to re-visit the diet assessment and to explore healthy eating in the early stages of motherhood. However, this proved challenging in that many women did not attend for postnatal follow ups or the GP did not take bloods or women declined further assessments. In part this is reflected in the response rate (n=13) to the questionnaire given to women after birth to capture their views of the specialist clinic. That said, the following comments provide some insight into what women thought: My family has altered their diet. I think after birth your blood and iron should still be checked regular for a while to make sure your fine. I find that after birth no one bothers and u still feel ill for ages! Last time I gave birth my iron was 8 and I was ill. No one bothered to check me after that till I was pregnant again in which I ended up ill (had to have a drip) It was good to see what I missed out of my diet The ANA Project is a good way of making people eat healthier. My family have altered their diet The project was helpful. I learnt quite a lot about diet that surprised me and family, friends and colleagues My diet has improved a bit. I now know how much of each thing I should be eating like cereal, meat I explained to my family about what I learnt The leaflet containing iron content of food was really useful in helping me to plan my diet Midwife was very good. She really helped my diet ANA Project is useful and informative. It ANA Project help me a lot In seeking to draw conclusions as to the postnatal uptakes and low response rate in completing the short questionnaire, it needs to be noted that it is not uncommon following birth for women to be consumed by motherhood and the baby. The midwife expressed that in her discussions with women she felt convinced that many of the women she had met had learnt new things about nutrition, their diet habits and healthy eating. Her view was that the longevity of healthy eating and/or diet improvement could be addressed by the health visitor or at the postnatal follow up (usually between 6-8weeks). Certainly it was something that the midwife felt should be re-visited as part of women s health and wellbeing during the first year of motherhood. Of note though has been a change in practice at one GP s surgery (Chalk Surgery) as to benefits of assessing women for anaemia after birth and these women are followed up in the postnatal period.

13 11 The depth of information, advice and support offered by the midwife during the clinic sessions and home visits has been remarkable. The ANA project has embedded good practice both within the team and the midwifery service more widely. In many ways the ANA project became a success before it was due to complete. The guidelines used within ANA soon became of interest to all practitioners within maternity care i.e. midwives, obstetricians and GPs. The specialist midwife has acted as an agent of change for improving access to good nutritional information and advice for all women in Salford. The care pathway adopted and co-ordinated approach engineered within ANA has now transferred into a Salford wide guideline. It is a credit to the dedication and motivation of the specialist midwife and the women living in Charlestown and Lower Kersal that this project has been such a success. Learning points The extra emphasis and time dedicated to nutrition seemed to help women to understand anaemia. In the cases where women needed treatment for their anaemia medication compliance improved. Furthermore, where medication caused side effects women sought guidance for alternatives, which was a dimension rarely experienced in the past by community midwives. It was recognised that insights into the long term benefits of ANA could be useful and informative to family health more generally. Dissemination of the importance of healthy eating requires inclusion of the wider health care community. The experience of ANA revealed training needs of staff and students and in response the specialist midwife has been approached to deliver some training events.

14 12 4. Role of the Midwifery Assistant As previously mentioned most of the interventions within the project were aligned to Sure Start objectives and rested upon the role of the Midwifery Assistant. There is no doubt that many of the intended interventions (see Table 1) embedded within the Enhanced Midwifery Service required teamwork and collaboration within the midwifery team practising in Charlestown and Lower Kersal. The Midwifery Assistant role was a new concept within the community midwifery team and traditionally non-midwives had not been part of the team. The lead midwife and midwifery managers paved the way for informing the community midwives and provided evidence based information to support the rationale for the role. From the outset it was made clear that there were distinct and different expectations between the responsibilities of the Midwifery Assistant and the midwifery team. The Midwifery Assistant was expected to undertake the following activities: To visit every pregnant woman offering support with stopping smoking, breastfeeding, parenting skills, promoting bonding and attachment, baby massage and reducing isolation by accompanying parents to groups/ clinic etc. Facilitate a Parent Education Group in partnership with the midwifery team for both antenatal and postnatal Facilitate a Stop Smoking group offering auricular acupuncture for childbearing women and their families Whereas the midwifery team were expected to ensure that: All women have a wellbeing assessment at weeks of pregnancy to identify public health risks such as poor diet, depression and isolation Specialist midwife nutritional clinic based in a New Deal Centre offers tailor-made care to support women and their families to change their dietary habits, take nutritional medication, monitor weight gain and increase physical activity (both of these activities connected to the ANA project) Women identified with depression are referred to the perinatal mental health service

15 13 The acupuncturist midwife clinic has referrals to offer therapy for minor ailments of pregnancy New Deal services are advertised within all midwifery venues, New Deal logos are placed on all literature, and all families are given information on other New Deal services (to some extent this was everyone s responsibility) Findings During the course of the project, the Midwifery Assistant has supported many women in the NDC area and Table 3 outlines some of the activities she has engaged in. Table 3: Overview of the number of women seen by the Midwifery Assistant Postnatal support 435 Smoking cessation 200 per year referrals Targeted smoking 270 cessation support Smoking cessation 1-5 per session (varies) group Baby massage Range 0 6 per session A point to note is that for the most part the Midwifery Assistant was dependent upon referrals from midwives to be able to visit and support women. In the early part of the project this was a slow and frustrating process. It took several months for referrals to become consistent and plentiful. Integration into the team whereby the Midwifery Assistant was trusted and accepted within community midwifery did hinder the Midwifery Assistant s activities. However, with the passage of time, feedback from women and the support of the project lead the community midwives began to see the value and respect the input. It would seem that in the current climate there is less tension about the existence of the role, as now dialogue and referrals from community midwives suggest progress has been achieved. Postnatal Support A key aspect of the role has been postnatal support to new mothers and community midwives made the referrals for this supportive home visiting. In total approximately 435 women and their families have benefited from the support of the Midwifery Assistant after the birth of their baby (see table 3). The nature of the support covered advice with parenting skills, breastfeeding, and guidance on the safety of baby. The Midwifery Assistant offered baby massage either in the home or at a group session. In addition, she encouraged attendance at other New Deal activities and even accompanied mothers to groups/sessions when required. This intervention seemed to boost mother s confidence and self esteem to be able to socialise in groups and

16 14 make contacts with other mothers. The very nature of this is supportive and thoughtful and for those mothers it has been well received. The Midwifery Assistant has made a difference locally to new mothers in that additional support has been offered to, and taken up by, local mothers in the early days and weeks after birth. The impact of this support, whilst subtle, has benefited many new mothers on an individual basis and has contributed to their sense of wellbeing. In particular mothers have fed back that their confidence in mothering has grown. Mothers have shared with the Midwifery Assistant that besides the fact they felt supported, their sense of wellbeing and self esteem has grown. Small but yet significant things mattered to these mothers and this was yielded by having extra support from the Midwifery Assistant. The following case study examples supplied by the Midwifery Assistant highlight the impact of targeted support. Box 1: Case study examples CASE STUDY 1 Last year I was involved in the support of a pregnant lady who attended the acupuncture service. I was involved with supporting her for a number of months and visited her at home after the baby was born. She continued to attend the acupuncture group and also attended baby massage on a weekly basis. Due to her attendance at the groups I saw her until the week before she returned to work, a year after the birth of her daughter. She asked if it would be okay to keep hold of my number as she would need it when she has another baby. Since then I have received a couple of texts from her asking if she could come to the acupuncture group on her day off. CASE STUDY 2 I recently supported a lady with breast feeding problems, during my initial visit I showed her how to position and attach the baby to the breast. The lady was quite tearful as she had been in a lot of pain whilst feeding baby. I arranged a second visit for further support and sign posted her to local support groups. CASE STUDY 3 I received a call from one of my colleagues to visit a lady who needed support to bath the baby as she had not been shown how to do it in the hospital. A visit was arranged for the following day and I was able to demonstrate to her how to bath the baby. She was quite nervous about handling her baby as she had never held a small baby before. I offered to come back and support her whilst she had a go at bathing baby later in the week which she was very grateful for. I gave her lots of encouragement and praise which was really all she needed to boost her confidence. Recent policy such as Maternity matters: choice, access and continuity of care in a safe service which supports the implementation of the maternity section of the National Service Framework for Children, Young People and Maternity Services spells out the importance of support and easy access to maternity services. For example value is placed on individualised, flexible care planning for women with complex social needs in partnership with other

17 15 agencies such as children s services. Indeed this ethos was at the heart of the support offered by the Midwifery Assistant. In addition, it is recognised that it is in the community that more accessible and visible services have scope to reach those most in need (Oakley, 1992; DH, 2007). It has been in meeting and talking with the maternity care assistant that these principles can be seen to be working. The Midwifery Assistant has had a strong and central role in dealing with referrals from the midwives and designing tailor made support often for those with socially complex needs. Such support is offered to new mothers at times most suitable to them, usually in their own homes but can be extended within group sessions led by the Midwifery Assistant e.g. at the Energise Centre. Box 2 highlights the kind of support offered. In discussions with the team the Midwifery Assistant has demonstrated an ability to time manage, contribute to the assessment of health and wellbeing, ability to plan care, set goals, document care and report concerns as appropriate. A typical day is also incorporated within the summary in Box 2: Box 2: Summary of how the Midwifery Assistant understands her role My role as the Midwifery Assistant was developed to enhance the Midwifery Service. Over the past 6 years I have participated in a number of training sessions to develop the necessary skills for the role. I visit new mothers and their baby s at home within the first few days after the birth. The first visit is usually pre- arranged by the Midwife and any extra support needed is usually already identified. My day begins with a call from the Midwife on duty who gives me my work for the day. I usually visit the mother at around day 4 after the birth and if I haven t met them before I introduce myself and discuss my role with them. This is a good opportunity for the mother to express any concerns she may have with regard to looking after a new born baby. I can continue to support the family up to 28 days or until the Health Visitor takes over the care. I am able to weigh the baby and complete the baby check during my visit. Most of the weighing is done by myself and I feed any concerns back to the midwife. I also offer support with basic parenting skills such as bathing the baby, making up feeds and using sterilising equipment. My other skills include breast feeding support and teaching mum s baby massage techniques which has many benefits. I also help the Midwives at ante natal clinic and take all the stop smoking referrals for the area. Any pregnant lady wishing to have support to stop smoking is referred to the service and I contact them directly. An appointment is made to visit them at home at a time convenient to them to discuss a plan of action.

18 16 Stop Smoking Support It is well documented that at the first contact with a healthcare professional pregnant women should be given information about lifestyle including smoking cessation and that support to enable pregnant women to stop smoking is highly beneficial (NICE 2008a). On average 200 referrals to midwifery Stop Smoking services have been received each year of the project. The Midwifery Assistant has contacted all these women and been able to visit 270 women who agreed to have support to help them stop smoking and then provided on-going support. The number of women stopping smoking with support (for 1 month) varied greatly over the time of the project with a total of 28% stopping in It is worth noting that in talking to women and staff during the course of the evaluation, behaviour change was often regarded as a positive outcome. A strong view was held that in the experience of helping women to stop smoking unanticipated outcomes emerged that were woman led but unlikely to be captured in the monitoring process. For example being able to reduce the number of cigarettes smoked in a day was regarded as a success and a positive step for many women. In addition, being able to create a smoke free home and thus smoke outdoors rather than in the home was regarded as a further success. Auricular Acupuncture Group Women accepting Stop Smoking support from the Midwifery Assistant have been offered nicotine replacement techniques such as nicotine patches, gum etc. They are also offered auricular acupuncture delivered at a weekly group in the Energise Building at Douglas Green. The Stop Smoking Midwife and the Midwifery Assistant facilitate this group as they have both had additional training to offer auricular acupuncture. Attendance numbers have been low but consistent with 1 to 5 women attending weekly. Some women attended for Stop Smoking support, others for support with anxiety or minor ailments of pregnancy such as sickness and headaches. By attending a group session the evaluator observed that women learnt from each other as well as from the Midwifery Assistant and smoking cessation midwife. There was much information and idea exchange, sharing of tips, progress and in itself this was felt to be a supportive encounter. It can be seen in table 3 that attendance numbers varied considerably. No conclusion can be drawn from the auricular acupuncture success rate for stopping or reducing smoking due to low numbers, however a similar group also facilitated by midwifery services running in Winton demonstrates similar success to other support e.g.: nicotine replacement of around 20%. Peer and professional support offered within the group serves to improve women s wellbeing, reducing isolation and promoting friendship development. The groups also facilitate discussion on parenting topics, pregnancy, birth and many other topics. These additional benefits are difficult to demonstrate but should not be minimised as for individual women these can improve their and their families quality of life dramatically.

19 17 Mainstreaming of this service is difficult to justify when numbers attending have remained so low despite extensive promotion. However the Salford Stop Smoking Service commissioned by the PCT will continue to fund midwifery services to offer specialist support to pregnant and postnatal women and are committed to Midwifery Assistants making up part of this service. Additional funding is being sought for Midwifery Assistant time to continue this support in the New Deal area when the project funding ends. Baby Massage Group Glover et al (2002) have shown that infant massage by the mother has been popular in many cultures and is growing in popularity. Mothers with postnatal depression often have problems interacting with their infants. Research has shown that attending a massage class can help such mothers relate better to their babies. In support the Midwifery Assistant has also been running a baby massage group at the Energise Centre. The group attendance has been in low numbers with 0 to 6 women attending with their babies. The group was well advertised and promoted by both the Midwifery Assistant and the midwifery team; it was advertised in the community centres within the New Deal area. In addition, the Midwifery Assistant promotes the group and may suggest it to particular women as part of her support to new mothers. Evaluation through questionnaires offered to mothers who attended showed very positive comments. Some felt the small group was preferable especially for young babies. A couple of mothers had attended a larger group running in the area but said they had felt overwhelmed and unwelcome in this larger group setting and preferred the smallness of the one at the Energise. The Midwifery Assistant commented It can be really daunting to attend any group so it is understandable that some find the whole experience a challenge Some of the comments from mothers about the baby massage group include: My baby had colic and constipation which massage helped with The group provided great support and I got lots of advice on my newborn I recommended it to two of my friends who joined the group The evaluator attended two of the baby massage sessions and on both occasions no women arrived. However, the Midwifery Assistant grasped the opportunity to network with key workers from the children s centre and they explored ways to integrate baby massage within their service. Breathing and Relaxation Group (Guided Birth) related to parent education intervention This group was started 6 months into the project as staff wishing to run the session needed training to conduct the session. It has been shown by O'Connor et al (2003) that relaxation has benefits for reducing maternal

20 18 antenatal anxiety. In support the midwife and Midwifery Assistant started the group and again with small numbers attending. Attendance did build up at times with between 1 to 8 women attending weekly. The group was promoted by the midwifery team and feedback from the women attending was very positive. However, in May 2009 the group had to cease due to staff sickness, and unfortunately the group has not recommenced due to staffing levels remaining low. As Guided Birth requires a midwife with additional training, additional resources are needed to continue this session in the New Deal area. The midwifery service offers a Guided Birth session in Langworthy and women from the New Deal area are encouraged to attend this as their nearest local session. Access Salford Midwifery Acupuncture service This service started with midwives being interested in acupuncture as a method of helping pregnant women cope with the minor ailments of pregnancy. Two midwives trained by undertaking a course with the British Medical Acupuncture Society. Indirect supervision from the acupuncture dept at Salford University and the BMAS enabled the development of trust guidelines which in turn enabled the midwives to establish first one and then a second clinic and 2 groups to offer auricular acupuncture for supporting women to stop smoking (Lythgoe 2009). Updates on the service have been presented at NHS Trust clinical governance meetings; support was secured from Supervisors of Midwives, Midwifery Managers and Consultant Obstetricians. Treatment is offered for: Nausea & vomiting Headaches Backache Carpel Tunnel Syndrome Symphysis Pubis Dysfunction Induction of labour Turning a breech baby Over the time of the project 30 women attended the clinics from the New Deal area. Women attended for weekly treatments ranging from 1 to 6 weeks and the average number of treatments was 2 to 3. Overall women were satisfied and provided useful feedback on their experiences as outlined in Box 3: Box 3: Example of comments from the women in the New Deal area who had accessed the acupuncture service. I think it has worked, or maybe it just got better anyway? My back pain has completely gone, how long do you think until I need it again

21 19 I can t believe it actually worked, the sickness is much better, I am not actually sick anymore. I knew it would help but was surprised how quick and effective Very professional friendly staff I was disappointed the treatment wouldn t help but would certainly recommend to a friend! Hoped it would stop sickness, it did! To evaluate the clinic treatments a short questionnaire was developed using a value score (linear scale) to assess the degree of discomfort their problem was causing. The women were asked to score from 1 to 5 (1 being the least to 5 the most) about how they were feeling including how it was affecting their daily activity, relationships, etc (see appendices). They were then asked to complete the same questionnaire again 3 to 4 weeks into their treatment. Over 60% of the women had improvements in their scores with many showing marked improvement. This method of evaluation is on-going at present as part of the acupuncture clinic. As can be seen in box 2 responses to questions were very positive, with women reporting the benefits of the treatment and expressing gratitude in many instances. Overall evaluation of the Midwifery Assistant role Questionnaires completed by women specifically about the role of the Midwifery Assistant have been very positive with many saying they think this service should be available to all mothers and that they would recommend the service to a friend. Some women obviously came into contact with the Midwifery Assistant during pregnancy, attending Guided Birth or requiring support with regard to stop smoking. They then went on to attend the group sessions namely the auricular acupuncture and baby massage. Two women new to the area attended the groups after the birth for a number of months feeling the support available invaluable, helping them develop confidence as parents and as members of the community. Overall the role of the Midwifery Assistant is valued highly by women and families. The challenges of the role have been in development of this role which was relatively new to community midwifery in Salford. As stated the midwifery team have found it difficult at times to ensure the Midwifery Assistant role became integral to, and within, the team. She has been able to offer support to the midwives by regularly assisting at antenatal clinics and groups and the midwives have supervised her work effectively. A focus group of four midwives from the team was held to discuss the Midwifery Assistant role: the midwives described the role as supportive but that it had been difficult to integrate the role due to the assistant only being available at certain days and times in the week (this was in the early stages of the project). The team cover their work over 7 days and thus have needed to

22 20 anticipate and plan ahead when the assistant will be on duty and available to do home postnatal visits. They felt that her work within the clinics and as part of the Stop Smoking service was very worthwhile and valuable but thought some other system would need to be developed to maximise the capacity of the role in offering postnatal visits. They often requested the assistant visited mothers to weigh the baby and offer support with feeding, or to teach parenting skills e.g. making up of formula feeds, undertake baby massage techniques for those parents identified as having additional needs e.g.: teenagers, asylum seekers. They were however concerned about only being able to offer this enhanced service on a limited number of days. The Stop Smoking midwife reports she had found the Midwifery Assistant role invaluable saying: she has worked extremely well with the Stop Smoking team, helping facilitate the groups and taking Stop Smoking referrals for the area. The concern is that when the New Deal funding ends the assistant role may be redefined and so not able to work within the Stop Smoking service. The PCT Stop Smoking service does however anticipate funding Midwifery Assistant time to ensure this service remains available. The mainstreaming of this Midwifery Assistant post is now being reviewed by Salford Royal Foundation Trust in partnership with the PCT Stop Smoking service. The role may need to be utilised over a wider area but should hopefully be retained and expanded. Learning points In summary there have been a number of lessons learnt and discussed within this chapter. As a new role it did take time for community midwives to refer women and fully utilise the role. If expansion of the role was to take place managers and leads need to be mindful of this. The relaxation and guided birth did not take off as expected. This was due to a lack of insight into the training needs for staff involved. There was reliance upon one person to run the group and this is unrealistic. Group work in Salford needs to be consistent, embedded and staffed so that cancellation is minimal. It is not possible or sensible to try and deliver all enhanced services in the New Deal area of Charlestown and Lower Kersal. Local women have their own unique needs and where possible the support role of midwifery assistance should continue and be capitalised upon.

23 21 5. Value of Interventions The findings of the evaluation and the feedback forms show that local women who have engaged with the service have valued it. Uptake of smoking cessation for example has been reliant upon co-ordinated working amongst midwives, the Midwifery Assistant, other healthcare professionals e.g. GPs and to some extent by word of mouth. The impact of time for local people to learn about and trust that services exist for them needs to be factored into innovations. The efforts and commitments of staff to profile the service has been notable, both locally and wider. For example in 2009 Jeanne Lythgoe published a short summary paper to raise awareness of the benefits and value of acupuncture for pregnant women in Salford. This short paper highlights what is possible with skill mix and an enterprising approach to care for women. Learning and sharing good practice has been an ethos of this work as Jeanne states: We welcome students and other health professionals to our clinics and groups to share our experiences. This promotes the service, encouraging referral - although we do not really need to advertise. We also promote the service by lecturing and disseminating our audits and evaluations at both local and national level. Evaluation of our first year demonstrated positive outcomes, enabling us to gain Trust support to open a second clinic. Extra funding from Salford s New Deal for Communities helped us train a third midwife and open a second group session. The service is delivered in Children s Centres across Salford, offering midwifery services closer to home and promoting acupuncture within areas where it may not ordinarily be considered an option. She goes on to say that: We have treated over 140 women in the clinics and seen over 150 in the group sessions, with very promising results so far, particularly for pelvic girdle type pain. We are now developing a research proposal to identify if access to acupuncture treatment could lower the cost of caring for women with pelvic girdle pain by reducing hospital admissions and attendance. Lythgoe (2009:10) Without question the ANA project has been a resounding success with recent support for mainstreaming and implementation of a good practice guideline. The healthy eating message has potential to impact city wide. Interventions

24 22 that enhance wellbeing and encourage a healthy lifestyle require well thought out intentions. The assessment tool, information leaflets and subtle monitoring of women at risk and in need of guidance addresses some of the early public health messages in the Acheson Report (DH, 1998). Clearly, one to one support from the Midwifery Assistant, once established, has helped many mothers in the New Deal area. As mentioned previously it unfolded during the evaluation that softer or unanticipated outcomes were often the ones that impact upon people s lives. Some of these occurred within the ANA project, as continuity of care was a strong dimension. Some of the behaviour changes that took place in the Stop Smoking sessions were regarded as a success but not for formal monitoring purposes. Within the context of baby massage, the actual skills of being able to organise their attendance was, for some mothers, huge. Even though high levels of attendance at baby massage did not unfold the potentiality for its benefits was valued by the children s centres and key workers.

25 23 6. Learning and Implications for practice The ANA project has stimulated debate and concern to adopt the good practice, and other midwives, obstetricians and GPs have contacted the specialist midwife to ask about appropriate care for the iron deficient or nutritionally deficient pregnant women. Guidelines for the identification, treatment, advice and referral for iron deficient anaemia in pregnancy have been produced and accepted by NHS Salford for usage across the city. The Trust is in the process of securing approval for their use. Meanwhile several midwives who have shown an interest in the project have been using the care pathway developed as part of the guidelines for some time. This has proved to be an invaluable resource for the care of their caseload. There is an identified need to hold education sessions for workers to successfully implement diet assessment as recommended by NICE guidelines (2008). It is hoped that, from 2010, this will form part of the annual mandatory update days which all maternity staff are required to attend. There is no doubt that many women have benefited from this project and that staff involved have worked hard to encourage local women to uptake the service. Staff expressed a view that short goals can lead to long term gains and that often short term projects are not set up to consider the longevity of interventions. There are a number of recommendations that the staff feel should be considered. Recommendations 1) The Midwifery Assistant post is continued in the area with additional funding 2) Midwifery Assistant posts are developed in all areas of deprivation across Salford. 3) The methods employed by the specialist midwife in educating women about the benefits of a healthy diet for them and their families to be used by all midwives. Training developed to facilitate this 4) Women with anaemia are given specific support as directed within the guidelines developed by this project for the PCT and SRFT staff to

26 24 follow. This will ensure all women receive evidence based care and prevent women becoming severely anaemic 5) The Salford Acupuncture service should continue to be funded and supported by the SRFT as this offers women access to complementary therapy services helping them cope with very debilitating conditions during and after pregnancy. This service helps to reduce women s need to access hospital and GP services, offering support and treatment 6) Dissemination of the project and sharing of good practice e.g. journal papers, conferences and educational events 7) Where possible collaboration and joint working with children s centres takes place, e.g. baby massage and relaxation sessions. 8) Women appear to value the time the midwife spends with them and the information that is given. How long this effect is maintained for is unknown but could form the basis for future research Conclusion This evaluation demonstrates the overall success of the New Deal enhanced midwifery service and that many women living in the area agree. The project has helped many women to have a positive pregnancy experience, to become confident parents and more able to cope with the social and psychological challenges related to motherhood. It has demonstrated the need to ensure women understand the importance of a healthy diet and the need to treat anaemia effectively. It has also demonstrated the importance of offering Stop Smoking services and extra support to parents with additional needs, to help them maximise their ability to become effective, competent parents, able to enjoy parenthood and make positive contributions to their community.

27 25 Appendix 1 Summary of the project as submitted to NDC CHARLESTOWN AND LOWER KERSAL NEW DEAL FOR COMMUNITIES PROJECT DEVELOPMENT AND APPRAISAL DOCUMENTS YEAR 7 ( ) Part 1: PROJECT IDEA - What is this project about? Prepared by: Jeanne Lythgoe Date: August Brief Description of the project: (200 words max. covering Enhanced midwifery service to address the physical, social and psychological needs of childbearing women in the New Deal area. Public health related innovations addressing local and national targets, particularly reducing smoking in pregnancy, increasing breastfeeding rates, reducing infant mortality and the need for the supporting women with mental health problems. The project will project, who it would benefit, what it might involve and how it delivers strategic aims and outcomes of NDC Delivery Plan) offer all women the support of a midwifery assistant, offering tailor-made support and advice for parenting, infant feeding, bonding and attachment promotion, help to stop smoking, baby massage and child safety. This will particularly help the young or isolated parents and those finding it difficult to access mainstream services. In partnership with the midwifery team the midwifery assistant will facilitate a stop smoking acupuncture group and a parent education group for both pregnant and newly delivered parents. A specialist midwife will offer specifically targeted support for women with identified nutritional problems, for example, anaemia and risk of vitamin d deficiency. Women at risk of or suffering perinatal depression will be given timely access to perinatal mental health services in partnership with the mental health trust. This will include referral, assessment and appropriate treatment or therapy. This service also offers access to a postnatal depression support group. Women will be offered acupuncture therapy for minor ailments of pregnancy to reduce medicalised approach and promote normality. The enhanced service will increase opportunity for the development of a multi-agency approach, working with key New Deal services such as breastmates, child and play workers, health improvement workers, food workers and many more. The overarching aim of the service will be to improve the well-being of parents and children in the New Deal area. 2.2 Project description and purpose Project Aims and Objectives Aim: To improve the health and wellbeing of childbearing women and their families living in the New Deal area. Offer support to help pregnant women stop smoking Improve the diet of pregnant women and their families by offering specific advice, support and nutritional therapy Promote the initiation and continuation of breastfeeding by offering additional information, support and working in partnership with peer supporters Promote the bonding and attachment of newborns Improve the confidence of parents in caring for their baby by offering parenting

28 26 education in a children s centre and in the home Provide access to support for perinatal mental health problems by offering referral to the perinatal mental health service Provide access to the Salford Midwifery Acupuncture Service for minor ailments of pregnancy and the postnatal period, promoting normality within pregnancy and childbirth Promote the use of all New Deal services through partnership working and signposting Audit and evaluation of enhanced midwifery service Project Outcomes - the difference that it will make Reduction in the number of pregnant women who are smoking Increase haemoglobin levels of pregnant women Increase the number of women initiating and continuing to breastfeed after 2 weeks and 8weeks Increase the number of women with mental health problems accessing the Perinatal Mental Health Project Increase the number of women accessing the Midwifery Acupuncture Service Working towards these outcomes will provide quantitative evidence of benefit. This will be supported by qualitative evidence through external evaluation Project Activities - how it will deliver the aims, objectives and outcomes above Full time midwifery assistant: To visit every pregnant woman offering support with stopping smoking, breastfeeding, parenting skills, promote bonding and attachment, baby massage and reducing isolation by accompanying parents to groups/ clinic etc. Facilitate a Parent Education Group in partnership with midwifery team for both antenatal and postnatal Facilitate s stop smoking group offering auricular acupuncture for childbearing women and their families Midwifery Team: All women to have a wellbeing assessment at weeks of pregnancy to identify public health risks such as poor diet, depression and isolation Specialist midwife nutritional clinic based in a New Deal centre offering tailor-made care to support women and their family to change their dietary habits, take nutritional medication, monitor weight gain and increase physical activity Refer women identified with depression to the perinatal mental health service Acupuncturist midwife clinic to offer therapy for minor ailments of pregnancy Advertise New Deal services within all midwifery venues, place New Deal logo on all literature, ensure all families are given information on other ND services.

29 27 Code 2.18 OUTPUTS TO BE ACHIEVED BY THE PROJECT (You will need to refer to guidance notes to complete this section) Output Description Activity which will generate this output (refer to 2.2) Q1 Apr- Jun Q2 Jul- Sep Future Years Q3 Q4 Total TOTAL Total Oct- Jan-Mar 2007/ / /10 Dec Total 2010/1 1 N104 Midwifery ass Number of contacts with N097 activity women/families N088 Stop smoking Number of stop smoking contacts N112 Nutritional clinic Number of contacts by spec midwife N101 Pernatal MH Number of referrals N115 N113 Attenders stop Number of referrals N086 smoking group N104 Attenders at Number of attenders parents group N107 N110 Number of attenders Attenders at acupuncture clinic Total all years Taken from: Page 22 of Revised Project Appraisal Form ( ) template (revised August 2007)

30 28 Appendix 2 The Eatwell Plate and Balanced Plate Scoring System Balanced diet discussion:- This is simplified into a suggestion that a day s diet should consist of a third, a third and a third divided into 3. The first third is fruit and vegetables; the second third is starched based (bread, potatoes, rice and pasta). The bottom third of the plate consists of three sections protein (meat, fish or other proteins), dairy products and a very small third of foods high in fats and sugar. The bottom third of the plate should be eaten in comparatively smaller amounts than the other two sections.

31 29 Auditing and development of the Balanced Plate Scoring Assessment by Carole Waterhouse and Alison Cohen, Community Midwives. The Salford midwives who audited the findings from the wellbeing assessments needed to ascertain if some areas of Salford were worse than others, which would suggest information needed to be targeted differently. In analysing the results, there was a need to remove any bias. A clinical assessment was used which was placed into a scoring system; thus based on fact rather than the questioner s value judgements. The assessment tool was developed following the Balanced Plate nutritional advice used by many health professionals (taken from The Balance of Good Health published by the Food Standard Agency). However, the new Eatwell Plate works in the same way. In approximate values, the plate can be divided into three portions; 33% each for fruit and vegetables and bread and potatoes; 27% meat, fish and dairy with just 7% of fats and sugars (together 34%). Fruit and Vegetables ⅓ Bread Potatoes & other Cereals ⅓ Meat, fish Milk and dairy foods Fats and sugars ⅓ Note: A more detailed report of the ANA project is available from Carole Waterhouse and includes further information regarding the eatwell plate.

32 30 Appendix 3 References DH (1997) Eight Guidelines for a Healthy Diet: A Guide for Nutritional Educators. Department of Health, London. DH (1998) Acheson Report. HMSO Publications. DH (1999) Saving Lives: Our Healthier Nation. HMSO, London DH (2001) The NHS Plan. HMSO, London. DH (2004a) Choosing Health: Making Healthier Choices Easier. Department of Health, London. DH (2004b) National Services Framework (NSF) for Children, Young People and Maternity Services. DH Publications, London. DH (2007) Maternity matters: choice, access and continuity of care in a safe service. Department of Health, London. Glover V, Onozawa K, Hodgkinson A (2002) Benefits of infant massage for mothers with postnatal depression. Seminars in Neonatology, 7: Lythgoe J (2009) Birth of the Salford Midwifery Acupuncture Service. The POINT, Perspectives of Interest in Needle Therapy, 27: 10. Newsletter of British Medical Acupuncture Society Oakley A (1992) Social Support and Motherhood. Basil Blackwell, Oxford. O'Connor TG, Heron J, Golding J, Glover V, (2003) Maternal antenatal anxiety and behavioural/emotional problems in children: a test of a programming hypothesis. J Child Psychol Psychiatry. 44: NICE (2008a) Antenatal care: routine care for the healthy pregnant woman Clinical guidelines CG62, National Institute for Health and Clinical Excellence, London. NICE (2008b) Improving the nutrition of pregnant and breastfeeding mothers and children in low income households. Public Health Guidance 11. National Institute for Health and Clinical Excellence, London.

33 This report can be referenced as Wray J, Waterhouse C, Lythgoe J (2010) Evaluation of Salford New Deal for Communities Enhanced Midwifery Service Project Final Report University of Salford ISBN: Contact the Salford Centre for Nursing & Midwifery Research: Jill Potter (Research Support Officer) Tel: +44 (0) j.potter@salford.ac.uk University of Salford