NCT

Who we are

NCT is the UK’s largest charity for parents. Since 1956 we have been a trusted voice and provided essential support for millions of parents.

What we do

We offer services across the UK, from antenatal and parent preparation courses through to day-to-day peer support based in our local branches. We guide people through the transition to parenthood, from pregnancy up to their children’s second birthday. We believe our role is to help parents through what will be one of the most challenging changes in their lives.

Our online support, events and helpline reaches millions of people each year.

How we do it

We help parents both through our own activities and by working externally with health professionals and maternity and family service providers as well as policymakers, opinion formers and employers.

We have 10,000 volunteers on hand to help with local branch support and 1,000 NCT Practitioners to deliver courses. Alongside our traditional classes we also provide antenatal and breastfeeding support through the NHS and Children’s Centres in England as well as providing parent focussed training for health professionals.

NCT Shared Experiences Helpline

Our Shared Experiences Helpline supports parents who are experiencing specific difficulties, problems, worries or other issues during pregnancy, birth and early parenthood by putting them in touch with someone who personally understands.

It is staffed by volunteers who have gone through the same experience and are able to offer understanding and a listening ear. Callers are also given details of other relevant charities or support organisations who may be able to help them.

In the case of a woman or her partner who had experienced the stillbirth of their baby, we would suggest contact with SANDS, the stillbirth and neonatal death charity.

The National Assembly for Wales’ Health and Social Care Committee Inquiry into stillbirths in Wales

We understand that the purpose of this session is to examine the awareness, implementation and effectiveness of current guidance and recommendations across the different sectors with regard to stillbirth prevention, especially in relation to poor fetal growth and reduced fetal movements, and where potential improvements can be made.

We appreciate that, as outlined in the terms of reference for this Inquiry, that stillbirths are more frequent among women:

· with twin or multiple pregnancies

· who are over the age of 35 or under 20

· have specific medical conditions, especially diabetes, hypertension and thrombophilia, or a past obstetric history of complications

· who smoke

· who are obese

· who live in areas of social deprivation

· who are members of certain ethnic minority groups.

There also appears to be some evidence that women pregnant following a previous birth by caesarean section are more likely to experience stillbirth.[1]

We note the point made in the All Wales Perinatal Survey[2] that ‘for 41.7% of stillbirths the cause is unexplained. This represents a large proportion and warrants research into the risk factors and causes of stillbirth’. NCT agrees that such efforts are needed, alongside an assurance of high quality midwifery care, timely referral systems and a network of support and information for parents that both offers helpful messages in advance of the birth of a baby and social support for the family.

NCT services to parents: information

NCT aims to provide information and support to all parents and the charity’s 2010-2020 strategy specifically emphasises increasing our reach to groups who are less well represented among those we are currently in touch with. Our contacts among younger parents, those with lower educational attainment and parents in ethnic minority groups are expanding. In some parts of the UK, NCT also has services specifically for women in prison, those seeking asylum and others in particularly disadvantaged circumstances.

Our web-based ‘info centre’ offers impartial and evidence-based information on a wide range of topics relevant to pregnancy and childbirth, including all those listed above that may affect the wellbeing of mother or baby. The over-arching principle of our information is that pregnancy and childbirth are in general normal, physiological events for women who are in good health, and that medical or surgical interventions are not needed unless illness or serious complications arise. However, there is encouragement for women and their partners to follow healthy lifestyle choices, to learn about the possibility of complications and to obtain advice from a midwife or doctor promptly if there are anxieties or concerns. This includes awareness of fetal movements towards the end of pregnancy.

NCT offers a well-known and widespread service of antenatal preparation courses for expectant parents, many of which are now provided at minimal or zero cost to those attending. NCT antenatal teachers are educated to at least diploma standard with university-accredited qualifications. They are required during the training to follow a module on the subject of ‘loss’, which covers the experiences of late miscarriage, stillbirth and neonatal death. As the ethos of the courses is parent-centred learning, there may be variation as to how much emphasis is put on stillbirth, but those attending will always be asked if they would like to hear more about the risks and frequency of this event.

NCT services to parents: support

NCT was founded on the belief that parents and parents-to-be welcome social contact with people in the same situation as themselves and that making friends with other parents in the neighbourhood is an ideal approach to avoiding isolation, finding appropriate services and forming a network for leisure and learning activities that can last until well into the child’s growing years or longer.

While the majority of such support inevitably takes place in the context of a family with a live and healthy baby, there have been numerous instances when parents bereaved by the stillbirth of their baby have derived comfort in the short or longer term from the other parents they have met during the present or previous pregnancies.

Parents who have experienced a past stillbirth and are expecting a baby again may be in particular need of a friendly group who can offer empathic support and encouragement.

NCT maternity policies

The charity has since its inception had a role in lobbying and influencing both government and other health bodies around policies in maternity and family services. Its successes in ensuring that services are more parent-centred (for both mothers and fathers) and avoid routine, non-evidence-based interventions are well documented (http://www.nct.org.uk/about-nct/our-history).

Last year, NCT responded to the consultation held by the Welsh Assembly Government on their Strategic Vision for Maternity Services in Wales. We wrote: “We wholeheartedly support the philosophy, aspirations and values enshrined in the strategic vision, and believe the development of a new strategy provides a welcome opportunity to dismantle barriers to effective delivery. We particularly endorse the emphasis on pregnancy and birth as events ‘of social and emotional significance’ and the explicit statement that a safe, healthy and satisfying experience of birth is important for new parents to feel ‘confident, capable and well supported in giving their child a secure start in life’”.

We recommended, in addition, that the Government ‘working through a Maternity and Early Years Board, seeks to enable strong co-ordinated leadership for local services, centred around the mother and her family rather than professional divisions, as well as multidisciplinary training and working’.

It was noted that the Strategic Vision had a strong emphasis on public health with maternity episodes seen as an opportunity for good health and lifestyle messages to be conveyed, and the arrival of a baby welcomed as an opportunity for the family to be motivated to improve healthy habits and reduce activities such as smoking and poor dietary intake which can affect the chances of stillbirth or other adverse outcomes of pregnancy. NCT supported this principle but was aware that a major burden can rest on midwives who may be expected to implement the programme at a time of staff shortage, unit closures, rising birth rate and greater social and medical complexities of pregnancy.[3]

Later in the response, we noted that in Wales ‘caesarean section rates increased from 12% in 1990 to 24% in 2008 with no improvement in outcomes’: we feel this is a significant fact to bear in mind for the current Inquiry, as it serves to confirm our view that the answer to reducing the number of births with an adverse outcome is not increased medicalisation of care nor more births taking place in hospital, but an improvement in the quality of care throughout pregnancy, labour and the postnatal period.

NCT and midwifery services

NCT was represented by the charity’s CEO on the UK Programme Board of Midwifery 2020.[4] This unique collaborative project across the four countries of the UK was a key piece of work in bringing up to date the elements of the midwife’s role in a changing context of birth. Here too was a strong focus on the midwifery role in public health and in particular addressing inequalities. As set out above, women who are in circumstances of social deprivation are more likely to experience stillbirth, and these groups often overlap with very young pregnant women and also women from some ethnic minority backgrounds.

A further key message from Midwifery 2020 was that ‘midwives should have a visible place in a community setting’ and this flags up the immense importance of midwives making their services available in the community including attendance at births in freestanding midwifery units (FMUs) and in the family home. The recent major study Birthplace in England[5], while not specifically covering units in Wales, confirmed that – in comparison to an obstetric unit setting - for all low-risk women planning a birth in an FMU is safe and for all women expecting a second or subsequent baby planning a birth at home is safe. When considering if changes are needed to the maternity services to help reduce the rate of stillbirths, it should be remembered that the very large and well-conducted Birthplace study did not show any advantage for obstetric unit births in terms of poor outcomes, so long as the women was in a low risk category and not expecting her first baby.

In further support of women receiving midwife-led care, the Cochrane Collaboration has published a review[6] showing multiple benefits of this style of care, including women receiving midwife-led care being ‘less likely to experience fetal loss before 24 weeks’ gestation’, although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks.

The elements of midwife-led care that appear to offer the numerous benefits evidenced in both safety and quality of the woman’s experience are:

· continuity of care during pregnancy that helps to build a trusting relationship between the midwife and the woman and her partner – this can enable the successful conveying of healthy lifestyle messages that are useful both in pregnancy and beyond

· continuance of this relationship during late pregnancy when the midwife may be able to observe fetal growth restriction, if occurring, and it is essential that each woman feels she can contact her midwife at any time if she is concerned about reduced fetal movements[7]

· Continuous one-to-one midwifery care during established labour which has been shown not only to improve outcomes generally in reducing unnecessary intervention, but also to enable detection of deviations from the norm that could lead to antepartum stillbirth.

NCT strongly supports the present calls for an adequately-staffed midwifery service that ensures women receive quality care, as above, through a trusting relationship with their midwife, and if necessary timely referral to a multi-disciplinary team.

[1] Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003; 362: 1779-84.

[2] All Wales Perinatal Survey. Annual Report 2010. http://www.cf.ac.uk/medic/awps/

[3] Royal College of Midwives. State of Maternity Services report 2011. www.rcm.org.uk

[4] Midwifery 2020 Delivering expectations.http://www.midwifery2020.org

[5] Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400

[6] Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models

of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

[7] Royal College of Obstetricians and Gynaecologists. Reduced Fetal Movements. Green-top Guideline 57 February 2011.