SUMMARY

Whilst we know that many recent government documents emphasise that midwives are ‘well placed’ to pass on health messages due to the unique relationship we have with women (DH 1999), many of us are also in a dilemma about how to introduce a core theme of public health into our everyday work. This chapter provides a personal overview of some of the practical aspects and challenges of working in this way. It describes how we have to use the opportunities presented to us to build a maternity service that fits the public health paradigm. It demonstrates to the reader some of the approaches used on a day-to-day basis that help us to promote good health. We discuss our experiences of working with Sure Start programmes and the need to address mainstreaming issues. The chapter also contains examples of how to tackle some key health targets with reference to practical planning and monitoring tools. Finally, we have tried to incorporate some of the learning that took place along the way and take a look at the future.

WIDENING OUR PERSPECTIVE

The new public health model embraces a much wider perspective than many of us were taught as students. There is now a greater understanding of why people make the choices they do, and simply informing them that certain behaviour carries risk is not always enough to produce change. However, trying to work with this approach in mind has not always been highly valued by colleagues or managers in the past, and the time limitations placed upon individual clinicians and services in general are a major factor in this. In a study published by the ENB ‘Research Highlights’ series, the authors acknowledge that public health work is seen as difficult to define and not ‘core’ activity by nurses. The study demonstrated that public health work tended to take second place to that which is more concretely measurable, and these findings are echoed within the experience of many midwives (ENB 2000). Nevertheless, the shift in emphasis towards a population approach to health and ill health means that we need a wider and more innovative approach. That is, we need to work within and with communities to influence changes in policy and environment. This philosophy is at the very heart of the Sure Start programme and even where the opportunity to work within such a programme does not exist, there are still lessons to be learned and transferred over to a mainstream setting.

SURE START LOCAL PROGRAMMES

We have been fortunate as a medium sized maternity unit to have worked with Sure Start since the first trailblazer programmes were being planned in 1998. We took the view early on that Sure Start would give us the opportunity to work differently and we have worked tirelessly and continue to do so in order to reach our goal. It took a little while to grasp, but not too long after we started working with local programmes, we realised our main aim was not to enhance the skills and achievements of any one individual midwife or local programme. Rather, the aim was for all midwives to have a working knowledge of Sure Start and public health and incorporate this into their daily working lives, regardless of whether they were in a Sure Start area or not.

From the beginning, with the first trailblazer programme, we identified that we as midwives were able to deliver services that were key to achieving the targets of the programme, as set out in Box 10.1.

In addition to these targets, each programme will identify specific targets that are of concern to their particular community, for example, a high incidence of domestic violence.

We submitted a bid to the first programme that demonstrated how our services could make a positive contribution to health, and as a result were successful in securing funding for a midwife to join the programme.

Within the next 3 years, the number of programmes established or about to commence within our catchment area had swelled to seven, with funding for midwifery activity built into each one. Each programme had a different lead body and we found ourselves working with many different agencies for the first time, including Early Years and Play services, Education, Primary Care Trusts (PCTs) and Family Support Services. While we welcomed the chance to concentrate extra resources in those areas of greatest need, we had to consider two points. The first was that with so many bedfellows there was a danger of each ‘Sure Start’ midwife going off at a tangent, developing albeit much-needed services within the remit of the local programme area, but in isolation from the core midwifery service itself. The second was the need to ensure that we didn’t view these initiatives as a ‘one-off’ event; rather we would use them as a catalyst to transform core midwifery services in order to take on a Sure Start/public health approach. We knew the funding for the local programmes, although finite, would probably last for up to 10 years. The challenge lay in fitting our plans into this time-frame and across several programmes. We needed to deliver on targets agreed through the service level agreements for each programme, but take a wider view of what we were trying to introduce as a whole service. With this in mind, we undertook a brief review of each programme, identifying the specific traits and targets and how they translated into midwifery services that needed to be established in each area. The review demonstrated that we required strong co-ordination from a midwifery perspective, in order to identify areas of best practice across the programmes, particularly giving direction to the fledgling programmes. The review also demonstrated that some of our existing practice, for example our adapted caseload midwifery model of care, might be a good vehicle for taking some of the Sure Start/public health philosophy forward.

MAINSTREAMING

Tackling Health Inequalities (DH 2003b) specifically looks at the recommendations of the Acheson Report (DH 1998), how we are progressing and how we plan to achieve the recommendations by 2010. One of the key messages contained within the Report is the importance of integrating public health interventions into the mainstream of service delivery with a focus on disadvantaged areas and groups. The document specifically mentions ‘mainstreaming Sure Start’.

Fortunately, as we arrived at the conclusion of our Sure Start local programme review, the Department for Education and Skills invited bids to pilot ways of addressing some of the mainstreaming issues that would inevitably arise from the local programmes, particularly as funding is withdrawn. We were invited by colleagues from Early Years and Play, on behalf of Manchester City Council with whom we had worked closely in Sure Start, to contribute to a larger joint bid. Our part of the bid included funding for a midwifery ‘mainstreaming’ co-ordinator and the pump-priming extension of our adapted caseload midwifery service to become a vehicle for delivering midwifery care with a public health/Sure Start philosophy. In January 2002 we learned our bid had been successful.

THE ROLE OF THE MAINSTREAMING CO-ORDINATOR

The remit of the Midwifery Mainstreaming Co-ordinator has been to work closely with Sure Start in order for the midwifery work within the local programmes to be co-ordinated, best practice and effective interventions to be identified and then carried over to other programmes and non-Sure Start areas. The role also included providing midwifery representation on each local programme board, which in turn helped to identify and resolve potential or existing problems. Other aspects of the role include raising awareness of Sure Start and public health issues for midwives; identifying ways of mainstreaming some of the lessons learned in the local programmes, for example improving multi-agency working; liaison with the La Leche League Peer Counsellor Training team; organisation of this training and supporting the midwives in different areas until their initiatives became established; establishing a data collection system, promoting multi-agency partnerships and helping all midwives to have high-quality information and contacts for available local services.

In order to establish some of the best practice and new ways of working, it was necessary for the Co-ordinator also to secure funding from non-Sure Start sources for those areas that do not have a local programme.

INTEGRATED APPROACH

Extending the adapted caseload midwifery model was the second part of our mainstreaming bid. It was already established in two of our local catchment areas. This model of care helps midwives to provide care in the antenatal and postnatal period and some intrapartum care (30%) to women within their caseload. The model consists of a small group of midwives working together in a defined area. The group approach to care has allowed midwives to support each other in developing extra services for women in their locality, for example parent education. We felt that if we could extend this model to three other areas, the group midwifery approach would allow us to include public health interventions in each area, including breastfeeding support groups, parent education and improved smoking cessation services.

A key element in utilising the adapted caseload model was the consideration of how midwives funded by Sure Start could remain close to the provision of the core service, while at the same time helping existing midwives in the area to be exposed to the Sure Start way of working. We made a decision that where an adapted caseload group was established in a Sure Start local programme area, the midwife funded by the programme could be integrated into the midwifery group. This integrated approach had been tried in the first local programme, an area with traditional midwifery. The existing community midwife and the midwife funded by Sure Start worked in close partnership, with a great deal of success. Extending this integrated approach to the adapted caseload meant that a greater number of core midwives would have the opportunity to work with a Sure Start programme. They would do this by sharing a collective responsibility to reach the local programme targets whilst continuing to provide clinical care. Their colleague funded by Sure Start working within the group would assist them. The long-term aim is that eventually there will be little difference in the way core and Sure Start midwives work. This will enhance the possibility of the roles being absorbed into the mainstream and remaining where they have greatest effect. Other benefits of this approach include being able to continue the input into the local programme in times of absence of the Sure Start funded midwife. The funded midwife is still the official ‘link’ to the programme and she retains responsibility for monitoring.

COLLABORATION

We realised we cannot change from a management perspective alone, and those at grass roots level cannot change without management support. Regular communication and a shared vision are crucial to this. Our learning is that this doesn’t happen overnight. One cannot assume a vision is shared or accepted in one or two presentations, discussions or debates. It is an ongoing process and is often achieved incrementally over a long period of time. Small areas of conflict need to be resolved, or at least articulated. When a vision or aim conflicts, it is important to articulate both parties’ opinions. Agreement is a welcome outcome, but we should recognise that this is not always the case. People may still have different views, but what is important is that they have been able to articulate their concerns and from doing this, they each come to understand and respect one another’s position. Acknowledgement and acceptance is often enough for people to agree to move on and to try to work differently. Much of the success of the changes is down to the core midwives being flexible and willing to become involved in Sure Start and share the work with their colleagues. However, we have found that not all midwives like to work in this way. This issue has to be addressed and individuals need to be supported.

SUCCESSFUL TRANSITION

Mainstreaming to us meant a successful transition from ‘Sure Start initiative’ to core service component. It would have been impossible to recreate the work of Sure Start in its entirety, so we agreed that we would initially identify a small number of alternative practices that had worked well in the local programmes and set about breaking them down into key components. We would then be able to transfer these over to other areas with support until the practice became well established. Some of the key areas that we felt could be developed and taken into mainstream services in the long term were:

The evidence for focusing on these is well established (DH 1998, DH 2003a, Protheroe et al 2003) and applying this evidence to our practice means working in a more creative manner in order to improve health outcomes. We have had varying degrees of success, not surprisingly those where we have spent the most time and effort being the most successful.

BREASTFEEDING SUPPORT

One such initiative is the roll-out of the La Leche League (LLL) Breastfeeding Peer Counsellor Programme. It is recognised that increasing the number of women who choose to breastfeed and encouraging them to breastfeed for longer is an important public health issue. Within the Sure Start programme, giving guidance on breastfeeding is part of a larger health target that includes reducing the number of infants admitted to hospital with gastro-enteritis and respiratory infection. There is evidence to suggest that by increasing breastfeeding rates, the incidence of these infections will fall (Howie et al 1990, Kramer et al 2001, La Leche League 2003).

This approach to encouraging breastfeeding was ideal for our core service as it is also a health target for the PCTs and is highlighted within the ‘Priorities and Planning Framework’ 2003-2006 targets (DH 2002).

As we began to look at this area, our first reaction was that we had always encouraged women to breastfeed – Sure Start wasn’t telling us anything ‘new’. However, Sure Start required baseline statistics at a local, rather than unit, level. This exercise demonstrated how ineffective we had been in certain areas. Many of the rates were well below 10% and some areas had no reliable methods of data collection at all.

It is clearly documented that breastfeeding rates tend to be well below the national average within disadvantaged communities (Dunkerley 2000, Jamieson & Long 2001, Protheroe et al 2003). In order to change a culture within a community it is important to empower those living there to make healthier choices in their lives (Dunkerley 2000). Training local women to become breastfeeding peer counsellors is one way of trying to change the culture around breastfeeding and empower local women. Evidence within the recent HDA report (HDA 2003) suggests that women are more likely to choose to breastfeed if they see other women breastfeeding, rather than reading or talking about it, and that peer support for breastfeeding is the way forward in increasing rates within deprived areas (Protheroe et al 2003). There are different organisations that provide training programmes for local women to become breastfeeding peer counsellors and these include the Breast Feeding Network, the National Childbirth Trust and the La Leche League, which is an international organization. There are also some well-established individual Trust-based training workshops.

Having met with and been inspired by some of the LLL trainers and women who were working as peer counsellors at a conference in London 2001, we decided to implement the LLL programme within one local area if we could manage to meet the not inconsiderable £6,000 cost. Fortunately, the area was one of the Sure Start trailblazers with a breastfeeding rate of 20% and we successfully secured funding to try this innovative approach.

WHAT DOES THE TRAINING ENTAIL?

The LLL training package has a two-pronged cascade approach, training 10 ‘workers’ (not necessarily health professionals) who then train 10 local women. We decided to make this training multi-agency and included senior crèche workers, health visitors, midwives, the Sure Start centre manager and the special care community midwife. This was to ensure that there was a cross-section of workers within each area that would be giving a consistent message to local women about breastfeeding. The training (Box 10.2) consisted of 5 full days split over 3 weeks for the ‘workers’ and 10 weekly 2-hour sessions for the mothers.

The training for the 10 local women uses the same curriculum format. The topics are delivered in 2-hourly sessions over 10 weeks with crèche facilities available. It is important to try to have a cross-section of women who are breastfeeding at different stages. For example, newly delivered mothers, mothers with older babies and even toddlers. It is also important to have a lead professional, preferably two, for example a midwife and a health visitor, who will oversee the training and be able to offer support to the peer counsellors. This also gives a message to the women that midwives and health visitors work together to provide a seamless service in supporting women to breastfeed.

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