Maternity Services and Multiple Births - Twins Trust · 2019. 9. 22. · Maternity Services and Multiple Births | A Tamba - NCT Joint Report The survey was completed by a total of

Maternity Services andMultiple BirthsA joint report by NCT and the Twins and MultipleBirths Association

Maternity Services and Multiple Births | A Tamba - NCT Joint Report

Multiples make up approximately 1.5% ofpregnancies in UK with numbers risingsignificantly over the past 20 years due tothe increasing use of assisted conceptiontechniques such as IVF. Recent figuresfrom the ONS show that multiplesaccounted for 7.2% of all stillbirths in theUK in 2014, a 13.6% rise from 2013.Stillbirths occurred in 1.07% of all multiplebirths, more than twice the rate forsingletons. Neonatal death rates are alsosignificantly higher at 11.5 / 1000 livebirth in 2013 compared with 2.4 / 1000for singletons. Infant death rates are14.5/1000 compared with 3.4/1000 forsingletons. Multiple births account foraround 10% of all stillbirth maternitylitigation claims in England, which costthe NHS £72m between 2005 and 2014.The risk of preterm birth is alsoconsiderably higher occurring in at least50% of twin pregnancies, with twinsfacing six times the risk of cerebral palsy.

These figures clearly show that outcomesfor multiple pregnancies compare poorlyto singletons. NICE antenatal careguidelines and quality standardsintroduced in 2011 aimed to tackle theseinequalities and improve quality of careand outcomes for multiple pregnancies.

Studies have shown that stillbirth rates,caesarean rates, late admission toneonatal units and patient safety incidentsare all reduced as a result of setting upand delivering services in accordancewith the NICE guidance. UnfortunatelyNICE guidance is still not fully or equallyimplemented across the UK (only fullyimplemented in 10-18% of units) andthere is no specific guidance forintrapartum care for multiples. Thereforeoutcomes for multiple pregnancies andpatient satisfaction with care remain low.Furthermore, reducing still births andneonatal deaths, and health inequalities,are national policy objectives.Unfortunately specific steps to achievethese objectives among multiplepregnancies are consistently absent fromservice reviews, commissioningdocuments, inspection frameworks andmore recently the still birth care bundle.

This report seeks to measure parentexperiences of maternity care and howwell NICE guidelines for multiplepregnancies are being implementedacross the UK. In particular it looks atvariation by region and home nation ofthe UK and variations in compliance overtime.

Background

The Survey

This report describes the findings of theMaternity Services survey distributed byTamba to parents of multiples in the UKbetween April and July 2015. The surveycovered a variety of topics including placeof birth, quality of antenatal and postnatalcare, neonatal care arrangements,feeding support, sleeping arrangementsand input from Tamba and the MultipleBirths Foundation (MBF).

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The survey was completed by a total of1338 respondents. 95.1% were mothersof twins, 3.9% mothers of triplets and0.2% mothers of quads and 2.4% byfathers. 35.5% had given birth within the

last year, 58.5% within the last two yearsand 91.4% within the last six years.73.7% had given birth in England, 14.4%in Scotland, 7.6% in Wales and 4.3% inNorthern Ireland.

The Sample

Gestation

Survey results show that gestation timesfor multiple pregnancies are considerableshorter than the average of 40 weeks forsingleton pregnancies. Average gestationtimes given by the NHS are 37 weeks fortwin pregnancies and 33 weeks fortriplets[1]. The figures shown in the byparents completing the survey are slightlylower at 35.3 weeks for twins and 31.8weeks for triplets.

Distribution of gestation times for twins,triplets and quads are shown in Figure 1below. The graph shows that for twinbirths frequency rises until a peak of 37weeks, when 24.4% of twins are born.Frequency falls sharply after 38 weekswith only 4.8% of twins born after 39

weeks and just 0.4% after 41 weeks. Fortriplet births, frequency rates peak at 33weeks (15.3% of pregnancies) and fallsharply after 35 weeks, with no tripletbirths recorded after 38 weeks ofpregnancy. Numbers for quadruplet birthsare too low to draw accurate data (n=7)but show all births occurring between 32and 38 weeks with an average gestationof 34.8 weeks.

Rates of preterm birth (pre 37 weeks) formultiples are considerable higher than theUK average of 8% [2]. Survey data showsthat 55.2% of twins and 94.9% of tripletswere born pre 37 weeks, with 15% oftwins and 41.9% of triplets born before32 weeks (very preterm).

FIGURE 1

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Gestation times for multiple pregnancies

Perc

enta

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f pre

gnan

cies

Gestation in weeks

0%

5%

10%

15%

20%

25%

30%

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42Gestation in weeks

Figure 1: Gestation times for Multiple Pregnancies

Twins

Triplets

Quads

0%

5%

10%

15%

20%

25%

30%



Twins

Triplets

Quads

Twins

Triplets

Quads

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Due to the high likelihood of prematurebirth and birth complications amongstmultiples, 52.8% of parents completingthe survey had an elective birth, meaningthey were delivered on a pre-planneddate and were either medically induced ordelivered through caesarean section,whilst 47.2% had a spontaneous birth.This compares with national averages forall births of 39.1% elective and 60.9%spontaneous birth in 2013/14 [3].

Rates of caesarean birth are alsoconsiderably higher in multiplepregnancies, estimated at around 60% bythe NHS for twin pregnancies[1] comparedwith the national rate of 26.2% [3]. Thesurvey reported that 68.1% of all birthswere by caesarean and 31.9% werevaginal. For twins these rates were 66.9%caesarean and 33.1% vaginal, whilst fortriplets rates were much higher at 88.1%caesarean and 11.9% vaginal.

Multiple births are also much more likelyto have low birthweight babies (under2.5kg) or very low birth weight babies(under 1.5 kg), particularly for second orsubsequent babies and as the numbersof multiples increase. Nationally low birth

rate babies account for 7% of live births[4].The survey shows that 60.9% of multipleswere born under 2.5kg and 12.8% wereborn under 1.5kg.

Figure 2 below shows that for twins, bothbabies are generally above 1.5kg at birth,with the second twin tending to be slightlysmaller than the first. For triplets the thirdbaby is very unlikely to be over 2.5kg(6.6%) and much more likely to be of verylow birth weight (47.5%). Data forquadruplets seems a little anomalous,though this may be due to the very smallnumbers involved (n=7).

Birth

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FIGURE 2

Perc

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f bab

ies

0%

5%

10%

15%

20%

25%

30%



Twins

Triplets

Quads

Over 2.5kg

1.5-2.5kg

Under 1.5kg

0%

10%

20%

30%

40%

50%

60%

Baby 1 Baby 2 Baby 3 Baby 4

Figure 2: What were your multiples weights?

Over 2.5kg

1.5-2.5kg

Under 1.5kg

Baby 1 Baby 2 Baby 3 Baby 4

Weights of multiples

17.6%

14.4%

11.8%

9.6%8.5%

8.0%

7.6%

5.5%

5.3%

5.2%

4.3%3.9% 2.4%

Figure 3: Region in which parents received their antenatal care

South East

Scotland

Greater London

North West

West Midlands

South West

Wales

Yorkshire & The Humber

East Midlands

East

Northern Ireland

North East

South


Parents received antenatal care in allregions of the UK. Numbers wereunevenly distributed with the South East(17.6%), Scotland (14.4%), GreaterLondon (11.8%) and North West (9.6%)accounting for approximately half of allcare (see Figure 3 below). This is mostlikely due to relative size and populationdensity of the regions.

Certain hospitals across the UK hadrelatively higher proportions of parentsgiving birth to multiples or receiving theirpostnatal care there. These tended to belocated in large population centres or beregional referral units to which mothers ofmultiples or babies requiring neonatalcare may be referred. Four hospitals(Addenbrookes, Royal Infirmary ofEdinburgh, Royal Victoria Infirmary andUniversity Hospital of Wales) saw over 2%of cases, whilst a further 24 of the 318hospitals listed saw over 1% of cases.

Region

FIGURE 3

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Region in which parents received antenatal care


NICE antenatal care guidelines formultiple pregnancies introduced in 2011list eight quality standards[5] (see below)intended to improve quality of care andoutcomes for multiple pregnancies. Thecurrent survey sought to measure manyof these indicators through questions

about mother’s antenatal care. Figures inthis section show results compiled fromall those completing the survey, whilstsubsequent sections seek to measuredifferences in NICE compliance over timeand by region.

Antenatal Care

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NICE Quality Standards (QS46)Multiple Pregnancy: Twin and Triplet PregnanciesStatement 1Women with a multiple pregnancy havethe chorionicity and amnionicity of theirpregnancy determined using ultrasoundand recorded between 11 weeks 0 daysand 13 weeks 6 days.

Statement 2Women with a multiple pregnancy havetheir foetuses labelled using ultrasoundand recorded between 11 weeks 0 daysand 13 weeks 6 days.

Statement 3Women with a multiple pregnancy arecared for by a multidisciplinary coreteam.

Statement 4Women with a multiple pregnancy have acare plan that specifies the timing ofappointments with the multidisciplinarycore team appropriate for the chorionicityand amnionicity of their pregnancy.

Statement 5Women with a multiple pregnancy are

monitored for foetal complicationsaccording to the chorionicity andamnionicity of their pregnancy.

Statement 6Women with a higher-risk orcomplicated multiple pregnancy havean obstetrician from a tertiary levelfoetal medicine centre involved in theircare.

Statement 7Women with a multiple pregnancy havea discussion by 24 weeks with one ormore members of the multidisciplinarycore team about the risks, signs andsymptoms of preterm labour andpossible outcomes of preterm birth.

Statement 8Women with a multiple pregnancy havea discussion by 32 weeks with one ormore members of the multidisciplinarycore team about the timing of birth andpossible modes of birth so that a birthplan can be agreed.


The NICE guidelines on multiplepregnancy state that all women should beoffered an ultrasound scan by 14 weeksat which the foetuses should be labelledand the chorionicity and amnionicity oftheir pregnancy determined. 92% ofmothers surveyed had been given anultrasound scan by 14 weeks and 81.6%had had the chorionicity and amnionicityof their pregnancy determined (with afurther 4.9% unsure whether this hadbeen done). Of these 27.5% had amonochorionic pregnancy (where bothbabies are dependent on a single sharedplacenta) and 69.1% had a dichorionicpregnancy (where each baby has its ownplacenta). 78.6% of parents had thechorionicity and amnionicity of their babiesexplained to them, most commonly bytheir obstetrician or sonographer.

In the UK hospitals routinely offer womenat least two ultrasound scans during theirpregnancy, the first ‘dating scan’ ataround 12 weeks and a second ‘anomalyscan’ between 18 and 21 weeks, withfurther scans performed where required.Multiple pregnancies are monitored much

more closely, with extra growth scansoffered at regular intervals, dependingupon the chorionicity, complexity of thepregnancy and the number of multiples.The majority of mothers included in thestudy (81.7%) had had at least 6 scansduring their pregnancy, with 39.1%having over 10 and 7.1% of mothershaving more than 20 scans. Thedistribution is shown in Figure 4 below.

Ultrasound

FIGURE 4

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Number of scans during pregnancy

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Perc

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oth

ers

Number of scans during pregnancy

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 >20Number of scans during pregnancy

Figure 4: Number of scans during pregnancy


Pregnant women in the UK (with theexception of Northern Ireland due to theirstrict abortion laws) are routinely offered ascreening test for Downs Syndromebetween 10-14 weeks of pregnancy. Thisgenerally involves an ultrasoundmeasurement of nuchal translucency anda blood test. Mothers receiving a higher-risk result are offered further diagnostictesting. 81.7% of mothers surveyed wereoffered screening for Down’s Syndrome,although some stated they were onlyoffered the ultrasound testing as bloodtesting would give a false positive resultwith multiple pregnancies.

Only 52.1% of mothers who had receiveda high risk result said that the options andimplications of proceeding to a diagnostictest (which can include a possible risk ofmiscarriage) had been discussed withthem, showing a clear need for further

education in this area.

General advice regarding diet, lifestyleand nutritional supplements duringpregnancy is given at the first antenatalappointment and throughout thepregnancy as required. Only 60.6% ofwomen in the study reported being givengeneral advice during pregnancy, thoughit is possible that this advice may havebeen given very briefly or forgotten.

NICE guidelines recommend that fullblood counts are performed at 20-24weeks pregnant and again at 28 weeks toscreen for anaemia and other bloodproblems. 76.4% of women said that theyhad received these blood tests, with afurther 10.9% unsure whether they had.Such blood tests may be particularlyimportant with multiple pregnancieswhere anaemia is more common.

Screening, Testing and Advice

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NICE guidance for twins and tripletsstates that mothers expecting multiplesshould be cared for by a multi-disciplinarycore team with a specialist knowledge ofmultiple pregnancies [5]. This team shouldinclude a specialist obstetrician, specialistmidwife and specialist sonographer,providing continuity of care acrosshospital and community settings andoffering information and support to thosewith multiple pregnancies. The surveyshowed mixed results regarding accessto such care. Roughly two thirds ofmothers (67.7%) had seen an obstetricianwith specialist knowledge of multiplepregnancies, whilst only 20.1% had seena specialist midwife and 28.1% aspecialist sonographer (although 23.7%were unsure if the sonographer had

specialist knowledge). Such statisticsshow that many health authorities areclearly failing to provide the required care,particularly in community settings, andprovision of much of the specialist adviceand knowledge rests with obstetricianobstetricians, meaning that parents maybe missing out on midwife led care andadvice.

NICE guidelines again require thatmembers of the multidisciplinary teamdiscuss the risks, symptoms and signs ofpre-term labour and the potential need forsteroids for foetal lung maturation in amultiple birth. 64.8% of parents haddiscussed these risks, most commonlywith their obstetrician. The multi-disciplinary team are also required todiscuss the likelihood of a caesarean or

Multi-Disciplinary Core Team

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

Ad vice fromob stetric ian to

p rep are ford elivery


p rep are forad m ission ton eon ata l u n it


p rep are forp ostn ata l care


p rep are forcarin g for

b ab ies a fterd isch arg e

F igu re 5: Sa tisfa ctio n w ith o b stetric ia n a d vice

P osit ive

N eg ative


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vaginal birth and timing of birth. 86.6% ofwomen had had the opportunity todiscuss this with one or more members oftheir team, most often the obstetricianand / or midwife, although some felt thatthey had not really been given a choiceand had been pushed into a caesarean orvaginal birth against their wishes.

30.5% of hospitals where respondentsgave birth ran multiple-specific parenteducation sessions, most often in theform of a one off session run by a twinspecialist midwife/s. These were mostlikely to be in larger regional hospitalswhich had the resources and numbers ofmultiple pregnancies to make suchsessions viable. n

Satisfaction with Care

Parents were asked about theirsatisfaction with advice and care provided.Table 1 overleaf shows satisfaction withadvice from obstetricians and midwivesand access to screening and prenataleducation.

Figure 5 below shows satisfaction withobstetrician advice, comparing positive(good or very good) ratings with negative(poor or very poor) ratings. Neutral ratingsare not included. The figure shows thatparents are generally satisfied with advicefrom the obstetrician to prepare for birth,with 56.5% of parents rating thispositively. Advice on admission to aneonatal unit is rated fairly equallypositively and negatively, whilst over 40%of parents rated advice from their

obstetrician on preparing for postnatalcare and caring for babies after dischargeas ‘poor’ or ‘very poor’, showing a clearneed for better advice in these areas.Such findings reflect other studies whichshow that mothers often feel underprepared for the postnatal period [13].

Figure 6 shows satisfaction with midwifeadvice, showing that again advice onpreparation for birth was rated the mostpositively, with around a third of mothers(35.5%) rating this as good or very good.All other areas showed higher rates ofnegative satisfaction than positive, withover a third of parents rating midwifeadvice on admission to neonatal units,postnatal care, and care for the babyafter discharge and feeding your babies

FIGURE 5

Satisfaction with obstetrician advice

Advice fromobstetrician to

prepare fordelivery


prepare forneonatal unit

admission


prepare forpostnatal care


prepare forcaring for

babies afterdischarge

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

A d v ic e f r o mo b s t e t r ic ia n t o

p r e p a r e fo rd e liv e r y


p r e p a r e fo ra d m is s io n t on e o n a t a l u n it


p r e p a r e fo rp o s t n a t a l c a r e


p r e p a r e fo rc a r in g fo r

b a b ie s a f t e rd is c h a r g e

F ig u r e 5 : S a t is f a c t io n w it h o b s t e t r ic ia n a d v ic e

P o s it iv e

N e g a t iv e

Positive

Negative


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TABLE 1

Parent satisfaction with advice / care provided

SURVEYRESPONSES

VERYGOOD

GOODREASON-

ABLEPOOR

VERYPOOR

N/A

Advice given by your doctor /obstetrician to prepare youfor birth

30.4% 26.1% 24.9% 11.3% 5.3% 2%

Advice given by your doctor /obstetrician to prepare youfor postnatal care

11.3% 13.5% 27.6% 28.3% 12.7% 6.6%

Advice given by your doctor /obstetrician to prepare youfor neonatal unit admission

15% 16.8% 22.3% 19.2% 13.7% 13.1%

Advice given by your doctor /obstetrician to prepare youfor caring for your babiesafter hospital discharge

8.8% 10.5% 21.3% 29.2% 20.2% 10%

Advice given by your midwifeto prepare you for birth 16.3% 19.2% 25.8% 17.5% 10.3% 10.9%

Advice given by your midwifeto prepare you for postnatalcare

13.2% 16.5% 23% 23.6% 13.1% 10.6%

Advice given by your midwifeto prepare you for admissionto at neonatal unit

9.6% 14.7% 18.1% 22.2% 14.3% 21.2%

Advice given by your midwifeto prepare you for caring foryour babies after hospitaldischarge

11.1% 16.9% 21.7% 22.3% 17.7% 10.4%

Advice given by your midwifeon feeding your babies 13.8% 18.4% 20.8% 20.9% 18.7% 7.4%

Access to screening 20.4% 26.8% 24.1% 10.2% 8.8% 9.8%

Access to parent craft /prenatal sessions 8.8% 14.9% 22.5% 22.3% 22.6% 9%

0%5%

10%15%20%25%30%35%40%45%

Advice frommidwife toprepare for

delivery

Advice frommidwife toprepare foradmission

to neonatalunit

Advice frommidwife toprepare forpost natal

care

Advice frommidwife toprepare forcaring for


Advice frommidwife on

feeding yourbabies

Figure 6: Satisfaction with midwife advice

Positive

Negative


as poor or very poor. Once again thisshows a clear need for further advice andsupport, particularly in the postnatalperiod, and better training for midwiveson supporting parents of multiples.

Satisfaction with access to screening wasrated positively, with 47.2% of parentsrating this as good or very good and just19% as poor or very poor. Parents wereless satisfied with access to parent craft /prenatal sessions, with just 23.7% ratingthis positively, whilst 44.9% rated thisnegatively. Again this was likely to depend

on the area and hospital in which theparents received their care and thefacilities available.

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Conditions During Pregnancy

FIGURE 6

Satisfaction with midwife advice

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %


p r e p a r e fo rd e liv e r y


p r e p a r e fo ra d m is s io n t on e o n a t a l u n it


p r e p a r e fo rp o s t n a t a l c a r e


p r e p a r e fo rc a r in g fo r

b a b ie s a f t e rd is c h a r g e

F ig u r e 5 : S a t is f a c t io n w it h o b s t e t r ic ia n a d v ic e

P o s it iv e

N e g a t iv e

Positive

Negative


delivery


neonatal unitadmission

Advice frommidwife toprepare forpost natal

care

Advice frommidwife toprepare forcaring for


Advice frommidwife onfeeding the

babies

Women with multiple pregnancies may beat higher risk of developing certainconditions during pregnancy such as highblood pressure, pre-eclampsia, diabetesand hyperemesis gravidarum (extrememorning sickness). They are alsosusceptible to conditions which onlydevelop in multiple pregnancies, includingtwin-to-twin transfusion syndrome. 27%of mothers surveyed suffered from highblood pressure during their pregnancy(compared with a national average of

16%[6]), 15.8% developed pre-eclampsia(compared with an average of 2-5%)[6].8% suffered from gestational diabetes,whilst 16.4% suffered from hyperemesisgravidarum, compared with an average ofjust 1% of pregnancies[7]. 9% of mothersreported twin-twin transfusion syndrome.This can only occur in monochorionicpregnancies, which make up under athird (27.5%) of those surveyed, thereforerates are again higher than suggestedprevalence of 10-15%[8].

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Multiple births are far more likely torequire neonatal care than singletons, dueto high levels of prematurity, lowbirthweight and other complications. Thisis reflected in the survey findings withover half (51.5%) of respondents statingthat one of more of their babies requiredsome kind of additional care in a neonatalunit after birth. Of these 42.2% were in aLevel I Special Care Baby Unit (SBCU),25% were in Level II High DependencyUnit and 28.4% were in Level III NeonatalIntensive Care Unit (NICU).

The majority of parents whose babiesrequired neonatal care (84.2%) were allable to stay together at the samehospital. The survey comments show thatthose parents who were separated fromone or more of their babies often found itvery traumatic and difficult to divide theirtime between the babies, particularly ifthe hospitals were geographically distantor they themselves were still hospitalisedand too ill to travel, making this a priorityfor care wherever possible. In most cases(82.5%) parents reported that the hospitalautomatically offered to keep all theirbabies together, although 3.2% had toargue for places for all of their babies. A

further 6.5% had been told that theywould be spilt up, but luckily placesbecame available at the right time, whilsta further 3.5% had been told they wouldbe spilt up and places did not becomeavailable. For 4.4% clinical needs meantthat all the relevant services andtreatments services could not beprovided at a single hospital. Over half(55%) of parents who had to be in aseparate hospital from one of more oftheir babies were separated for less thanone week and a further 22.5% forbetween one and two weeks. 7.5% ofparents were separated from their one ofmore of their babies for over 8 weeks.21.4% of babies were transferred to asecondary or primary level neonatal unitnearer to home prior to discharge.

60.2% of parents of multiples receivingneonatal care (in a NICU) were able tostay at the hospital or nearby intemporary lodging such as a hotel,Ronald McDonald house or similarovernight accommodation. Many otherparents stated that they were offered thisoption, but chose to stay at home afterthey were discharged from hospital asthey lived nearby.

Neonatal Care

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FIGURE 7

Number of weeks that parents were separatedfrom their babie(s) in neonatal care

0%10%20%30%40%50%60%

Less than1 week

1-2weeks

3-4weeks

4-5weeks

5-6weeks

7-8weeks

Over 8weeks

Figure 7: Length that parents were separated fromtheir babie(s) in neonatal care

Lessthan 1week

1-2weeks

3-4weeks

5-6weeks

7-8weeks

4-5weeks

Morethan 8weeks


Feeding multiples provides additionalchallenges and mothers may find thatthey are unable to feed their babies in theway that they intended. 29.6% of parentssaid they had not been able to feed theirbabies as planned, often due to lack ofbreastfeeding support, pressure tosupplement with formula, difficulties withfeeding premature babies, separationfrom one/more babies, or the sheerdemand of breastfeeding multiples.33.2% were able to breastfeed, whilst27.3% were able to express feed. 21.5%decided to mixed feed, 20.3% to useformula milk and 2.8% to use donor milk.

Babies born at an early gestation areoften unable to breastfeed straightawayand need assisted feeding. 68.7% ofmothers whose babies were unable tofeed said that they had been taught andgiven help with expressing breastmilk.Others said that they had been offered abreast pump, but not shown how to useit adequately, or their babies had beengiven formula milk and they had not beengiven the option. For those whose babieswere able to breastfeed at birth, only 57%were given advice about expressing,sometimes only upon their own request.Some mothers reported beingpressurised to top up with formula milk,

whilst others reported being ‘bullied’ tobreastfeed when they did not want to.Such findings correspond with currentresearch on infant feeding which showsthat women often feel pressure and guiltregarding their feeding decisions[10], whichmay be intensified in the case of multiplesand those with premature or sick babieswho often feel their choice is taken awayfrom them.

Parents were asked whether they weresupported to achieve their feedingpreference, with around a third (35.1%)saying they were not supported in anyway. Around two-thirds (62%) said thatthey had been supported by healthprofessionals, with smaller numberssupported by various voluntaryorganisations including the BreastfeedingNetwork (5.9%), NCT (3.9%), Tamba peersupporters (2.3%), La Leche League(2.2%), Twinline volunteers (1.1%) and theMBF (0.5%). Such figures clearly showscope for further support forbreastfeeding multiples, both from healthprofessionals and voluntary organisations,who may have more expertise and timeavailable to support mothers withestablishing feeding and overcomingdifficulties.

Feeding

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Co-Bedding andSleeping Arrangements

Advice on safe sleeping for multiples issimilar to that for singletons, in that theyshould be placed on their back, feet tothe foot of the crib and share a room withtheir parents for the first six months oftheir lives. However it is also advised that‘co-bedding’ (placing two or more babies

together in the same cot / crib) is safewhile space permits and may help tosoothe the babies and regulate bodytemperatures and sleep cycles[11].

Only 42.1% of parents completing thesurvey had been given advice on safe


sleeping for multiples, showing room forimprovement in this area.

The majority of families had their babiesall discharged from the hospital at thesame time (87.9%), although this was notalways possible where one multiplerequired further medical treatment.

Over half of multiples were co-bedded inthe hospital with 49.5% placed in thesame cot and 4.5% placed in the sameincubator at birth. 22.6% wereundergoing treatment and could not beplaced together, whilst 16.8% wereplaced in different cots in the same wardand 23% were placed in separateincubators in the same ward. Thisseemed to depend upon the preferencesof the parents or those providing thecare, although the small numbers co-bedded in incubators may be due to thelack of availability of suitable facilities.Clear guidance on best practice in thisarea would be useful.

The majority of parents co-bedded theirinfants when they got home, with 57. 7%placing them in the same cot / crib and19.8% placing them in the same Mosesbasket / bassinet. 32.6% placed them inseparate Moses baskets / bassinets and8.2% placed them in separate cots /cribs, with many parents moving between

different forms of sleeping arrangementsas their babies grew, or placing themdifferently during the day / night.

The majority of parents (95%) slept in thesame room as their babies for someperiod of time, most commonly for therecommended 6 months (27.5%). Theamount of time babies spent in theparents room is shown in Figure 8 below,with 8.4% of parents sharing a room withtheir babies for over 12 months.

Only 21% of parents reported that theirbabies had shared a bed with themduring the first 6 months of their lives,with many stating that this was onlyoccasionally when they were havingtrouble sleeping. Such numbers seemlow compared to other studies with Ball(2002) reporting that approximately 50%of UK infants had shared a bed with theirparents at some point during the first 3months of their lives [12]. This may be dueto the self-report nature of the survey(with parents not wishing to be seen to beengaging in ‘unsafe’ sleeping practices),the fact that many multiples are bornpreterm (a risk factor for bed-sharing), orthe additional practical challenges of bedsharing with more than one infant.

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FIGURE 8

Multiples sharing a room with parents

0%

5%

10%

15%

20%

25%

30%

Length of time baby shared a room with parents

Figure 8: Length of time multiples shared a roomwith parents

Length of time babies shared a room with parents

Perc

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f m

ult

iple

s


28.4% of multiples born to parentscompleting the survey were monozygotic(identical), 66.65 were dizygotic (fraternal)and 6.7% did not know the zygosity. Themajority of parents said that they knewthis either from looking at the physicalfeatures of their babies (41.6%) orbecause the team at the hospital hadconfirmed it from the scan as they sharedone placenta (40.4%). A further 6.4% hadthe zygosity confirmed by the hospital

team from a shared placenta in theafterbirth, 5.8% had a DNA testperformed privately, 2.6% had a testduring pregnancy for medical reasons,3.6% had studied the behaviour of theirbabies and 18.4% were unsure how theyknew the zygosity. 3.9% of parents hadbeen told at birth that their multiples wereone type of zygosity, only to be confirmedlater by DNA testing that they were theother.

Zygosity

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Change Over Time

The report seeks to measure change overtime in terms of compliance with NICEguidelines for multiple pregnancies, whichwere introduced in September 2011. Inorder to do so we compare three timepoints – current 2014/15, data from2013/14 and data from 2010/11 (preNICE guidelines). The measures of NICEimplementation used are shown below:

1. Ultrasound by 14 weeks of pregnancy2. Chorionicity of pregnancy determined

at first ultrasound3. Full blood count taken at 20-24 weeks

and again at 28 weeks4. A multidisciplinary core team with a

specialist knowledge of multiplepregnancya) An obstetrician with a specialist

knowledge of multiple pregnancya) A midwife with a specialist

knowledge of multiple pregnancya) A sonographer with a specialist

knowledge of multiple pregnancy5. Discussion of the risks, symptoms and

signs of pre-term labour and potentialneed for steroids for foetal lungmaturation

6. Discussion of the likelihood ofcaesarean / vaginal birth

The results show that average levels ofcompliance with NICE measures haveincreased from 58.8% in 2010/11, to64.9% in 2013/14 and 69.1% in 2014/15,showing a 10% improvement over thepast four years. Whilst this is a positivestep, rates of improvement are slow andat current levels it could potentially takeanother twelve years to achieve fullcompliance, with associated negativeoutcomes and experiences for parentsand babies during this time.

All measures of NICE implementationhave shown an improvement incompliance over time with the exceptionof ultrasound at 14 weeks, which wasalready at high rates of compliance(92.1%) pre 2011. All other standardshave shown a steady improvement of+10-15% over the four year period thatthe guidelines have been in operation,with smaller improvements over the lastyear, although two standards maintainvery low levels of compliance – theavailability of a midwife with specialistknowledge of multiple pregnancies(23.9%) and the availability of asonographer with specialist knowledge ofmultiple pregnancies (33.1%). Discussion

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ultrasound at14 weeks

Chorionicitydetermined

at ultrasound

Full bloods at20-24 and 28

weeks

Specialistmultiple

obstetrician

Specialistmultiplemidwife

Specialistmultiple

sonographer

Discussionpretermlabour /steroids

Discussionvaginal /

caesareanbirth

Figure 9: Percentage compliance with NICE guidelines 2010/11, 2013/14 and 2014/15

2010/11

2013/14

2014/15

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/152010/11 2013/14 2014/15


of the signs of pre-term labour alsoremains relatively low at 67.3%compliance, whilst the availability of anobstetrician with specialist knowledge ofmultiple pregnancies stands at 72.8%.Ultrasound before 14 weeks pregnancy(93.2%) and discussion of the likelihood

of vaginal / caesarean birth (90%) bothare both above 90%, whilst chorionicitydetermined at first ultrasound (85.5%)and full blood counts at 20-24 and 28weeks (83.9%) show greatly improvedcompliance (see Figure 9 below).

Page 15

FIGURE 9

Percentage compliance with NICE guidelines2010/11, 2013/14 and 2014/15

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/15

Ultrasoundat 14

weeks


atultrasound

Full bloodsat 20-24and 28weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth

Satisfaction with quality of care alsogenerally shows improvement over time(see Figure 10 overleaf), although positiveratings of satisfaction remain below 50%except for obstetrician advice to prepareparents for birth (62.7%) and access toscreening (54.6%), which have both seensignificant improvements in satisfactionover time, most likely linked to theimplementation of NICE guidelines. Allother measures of satisfaction have seensome improvements, with the exceptionof midwife advice on neonatal care, whichhas remained static at around 25.5%.Satisfaction with obstetrician and midwifeadvice in preparation for birth have bothincreased by more than 10% over time,whilst obstetrician and midwife advice onpostnatal care has seen modestimprovements, as has midwife advice onfeeding and access to prenatal education/ parent craft classes. However, overall

levels of positive (good or very good)satisfaction remain relatively low, withmuch further room for improvement,particularly with regard to obstetricianadvice on post-natal and practical babycare and midwife advice on neonatalcare. It is possible that these areas areseen as the domain of the other specialist(midwife / obstetrician) so little advice isprovided.

Levels of negative satisfaction (poor orvery poor ratings) remain relatively high(see Figure 11 overleaf) particularly withregard to obstetrician advice on babycare (47.6%) and access to pre-nataleducation (44.1%). Most areas had seensome small improvements over time,although these tended to be by only afew percentage points and perhapshighlight the areas where NICE standardsare not being met (e.g. lack of midwives

0%

10%

20%

30%

40%

50%

60%

obstetricianadvice

delivery

obstetricianadvice post-natal care

obstetricianadvice

neonatal care

obstetricianadvice baby

care

Midwifeadvice

delivery

Midwifeadvice post-natal care

Midwifeadvice

neonatal care

Midwifeadvice baby

care

Midwifeadvicefeeding

Access toscreening

Access to pre-natal

education

Figure 11: Negative satisfaction with antenatal care, 2010/11, 2013/14, and 2014/15

2010/11

2013/14

2014/15


with specialist knowledge of multiplepregnancies). Such high levels of negativesatisfaction show there is clearly room forfurther improvements in many areas ofantenatal care with only obstetrician /

midwife advice in preparation for birth andaccess to screening scoring below 30%for negative satisfaction (meaning morethan a third of parents are dissatisfiedwith most areas of their care).

Page 16

0%

10%

20%

30%

40%

50%

60%

70%

obstetricianadvice

delivery

obstetricianadvice post-

natal care

obstetricianadvice

neonatal care


care

Midwifeadvice

delivery

Midwifeadvice post-

natal care

Midwifeadvice

neonatal care

Midwifeadvice baby

care

Midwifeadvicefeeding

Access toscreening

Access to pre-natal

education

Figure 10: Positive satisfaction with antenatal care 2010/11, 2013/14 and 2014/15

2010/11

2013/14

2014/15

FIGURE 10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/15

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/152010/11 2013/14 2014/15

Positive satisfaction with antenatal care 2010/11, 2013/14and 2014/15

Obstetricianadviceabout

delivery

Obstetricianadvice

about postnatal care

Obstetricianadvice

about neonatal care

Obstetricianadvice

about careof baby

Midwifeadviceabout

delivery

Midwifeadvice


Midwifeadvice

about neonatal care

Midwifeadvice

about careof baby

Midwifeadviceabout

feeding

Access toscreening

Access topre-nataleducation

n

FIGURE 11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/15

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



at ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth


2010/11

2013/14

2014/152010/11 2013/14 2014/15

Negative satisfaction with antenatal care 2010/11, 2013/14and 2014/15


delivery

Obstetricianadvice


Obstetricianadvice

about neonatal care

Obstetricianadvice

about careof baby

Midwifeadviceabout

delivery

Midwifeadvice


Midwifeadvice

about neonatal care

Midwifeadvice

about careof baby

Midwifeadviceabout

feeding

Access toscreening


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Chorionicitydetermined at

ultrasound


weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland


In addition to variations over time, carecan also vary according to location. Thesix measures of NICE implementationwere measured across the four homenations of the UK (England, Scotland,Wales and Northern Ireland). Overallscores for implementation of NICEstandards were found to be broadlysimilar across England (63.7%), Wales(63.7%) and Northern Ireland (64.1%) andsignificantly higher in Scotland whoscored an average of 70.8% overall.Looking at the NICE recommendationsindividually, scores were broadly similarfor all four nations across five of themeasures, with Northern Ireland scoringhighest for ultrasound by 14 weeks(95.7%), full blood counts at 20-24 and28 weeks (83.3%) and discussion of thesigns and symptoms of preterm labour(74.5%) and England for determiningchorionicity at the first scan (82%) anddiscussion of the likelihood of vaginal /caesarean birth (87.1%). HoweverScotland scored significantly higher on

the measures relating to care by aspecialist multidisciplinary team, with84.9% of Scottish parents seen by anobstetrician with specialist knowledge ofmultiple pregnancies (compared to a lowof 59.6% in Northern Ireland), 37.8 %seen by a specialist midwife (comparedwith 10.4% in Northern Ireland) and35.9% seen by a specialist sonographer(compared with 25.8% in Wales).

Parent satisfaction with care /advice alsovaried across the UK, with Scotland andNorthern Ireland scoring consistentlyhigher on all measures of satisfaction(except access to screening in NorthernIreland) and Wales scoring consistentlythe lowest. The highest satisfactionscores were for obstetrician advice toprepare parents for parents for birth inScotland (61.6%), Northern Ireland(58.4%) and England (56.4%), whilstsatisfaction in Wales was only 48.9%.Access to screening also scored highly inScotland (55.1%) and England (49%).

Variation Across the UK

Page 17

FIGURE 12

Implementation of NICE guidelines for multiplepregnancies across the UK

Ultrasoundat 14

weeks


atultrasound

Full bloodsat 20-24and 28weeks

Specialistmultiple

obstetrician


Specialistmultiple

sonographer


Discussionvaginal /

caesareanbirth

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Chorionicitydeterm ined at

ultrasound


weeks

Specialistm ultiple

obstetrician

Specialistm ultiplem idwife

Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

England Scotland Wales Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



ultrasound


weeks

Specialistm ultiple

obstetrician


Specialistm ultiple

sonographer


Discussionvaginal /

caesareanbirth

England

Scotland

Wales

Northern Ireland



Lowest levels of satisfaction were withobstetrician advice on practical babycare, midwife advice on neonatal careand access to prenatal education, withlowest levels of satisfaction all occurringin Wales. The exception to this wassatisfaction with access to screening inNorthern Ireland which scored only20.5%. This is likely due to strict abortion

laws, which prevent abortion for foetalabnormalities, therefore screening forDown’s syndrome was only offered to21.3% of parents compared with 81.7%across the UK.

Negative satisfaction with care / adviceshowed a similar pattern, with higherlevels of negative satisfaction occurring in

Page 18

FIGURE 13

Positive satisfaction with care and advice across the UK


delivery

Obstetricianadvice


Obstetricianadvice

about neonatal care

Obstetricianadvice

about careof baby

Midwifeadviceabout

delivery

Midwifeadvice


Midwifeadvice

about neonatal care

Midwifeadvice

about careof baby

Midwifeadviceabout

feeding

Access toscreening


FIGURE 14

Negative satisfaction with care and advice across the UK


delivery

Obstetricianadvice


Obstetricianadvice

about neonatal care

Obstetricianadvice

about careof baby

Midwifeadviceabout

delivery

Midwifeadvice


Midwifeadvice

about neonatal care

Midwifeadvice

about careof baby

Midwifeadviceabout

feeding

Access toscreening


0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

7 0 %

o b s t e t r ic ia na d v ic e

d e liv e r y

o b s t e t r ic ia na d v ic e p o s t -

n a t a l c a r e

o b s t e t r ic ia na d v ic e

n e o n a t a lc a r e

o b s t e t r ic ia na d v ic e b a b y

c a r e

M id w ifea d v ic e

d e liv e r y

M id w ifea d v ic e p o s t -

n a t a l c a r e


n e o n a t a lc a r e

M id w ifea d v ic e b a b y

c a r e


fe e d in g

A c c e s s t os c r e e n in g

A c c e s s t op r e -n a t a l

e d u c a t io n

F ig u r e 1 3 : P o s it iv e s a t is fa c t io n w it h c a r e / a d v ic e a c r o s s t h e fo u r h o m e n a t io n s

E n g la n d

S c o t la n d

W a le s

N o r t h e r n Ir e la n d

0%

10%

20%

30%

40%

50%

60%

obstetricianadvice delivery

obstetricianadvice post-

natal care

obstetricianadvice

neonatal care


care

M idwifeadvice delivery

M idwifeadvice post-

natal care

M idwifeadvice

neonatal care

M idwifeadvice baby

care

M idwifeadvice feeding

Access toscreening

Access to pre-natal

education

Figure 14: Negative satisfaction with care / advice across the UK

England

Scotland

Wales

Northern Ireland


Wales (and to a lesser extent England)across almost all indicators (with theexception of access to screening inNorthern Ireland). Satisfaction scores canpartly be explained by higher overall ratesof NICE compliance in Scotland, althoughit is unclear why Northern Ireland showsmuch higher rates of satisfaction thanEngland / Wales and why Wales has thelowest rates of satisfaction overall,showing a need for further investigation inthis area.

Page 19

Variation by English Region

In addition to variation across the UK,rates of NICE compliance and parentsatisfaction also vary across the regionsof England, showing a ‘postcode lottery’in access to care. The North East is thehighest performing regions with overall71.5% compliance, whilst the South Eastand West Midlands are the lowest bothwith 61.1% (see Table 2 overleaf), adifference of ten percentage points. Areasof overall lowest compliance wereavailability of a specialist multiple midwife(seen just 7.8% of parents in the EastMidlands compared with 47.9% in theNorth East) and a specialist multiplesonographer (seen by just 21.3% ofparents in the South West compared with51.1% in the North East). Discussion ofthe signs and symptoms of pre-termlabour and possible need for steroids forfoetal lung maturation also scoredrelatively lowly across the board.

Examples of particularly good or badpractice can be seen at individual trust level:

The Newcastle upon Tyne HospitalTrust is performing particularly wellacross all markers. With one of thehighest amounts of multiples births in2014 (152), they only had a small numberof multiple birth related patient safetyincidents (22). The NICE compliance wasalso at the top end with an overallaverage of 84.7%, with three being over90%. Ultrasound by 14 weeks gestation

93.3%, full bloods at 20-24 weeks andagain at 28 weeks gestation, 93.33%,and discussion of the risks, symptomsand signs of preterm labour and the needfor steroids for foetal lung maturation93.8%. This third marker is typically oneof the lowest scored NICE guidelinesacross the board so such a highcompliance is doubly commendable.Patient satisfaction scores were alsodominated by a much larger positive thannegative feedback on all 6 measures.

Leeds Teaching Hospital Trust isalso performing very well. With a highmultiple birth rate of 180 in 2014, therewas only 36 multiple pregnancy relatedpatient safety incidents. NICE compliancewas an overall 84.4%, with five at 90% orabove, two of these at 100% (ultrasoundby 14 weeks gestation and full bloods at20-24 weeks and again at 28 weeksgestation). An impressive 60% evenreported having a specialist multiplessonographer, one of the highest scoresfor this NICE guideline. Patientsatisfaction was also high, with a fargreater level of positive feedback thannegative feedback across all 6 measures,and 0% negative feedback forobstetrician at birth.

St Georges Hospital NHS Trust has ahigh overall NICE compliance 89.9%, with100% compliance for ultrasound at 14 weeksand discussion of the likelihood of vaginal

n


Page 20

TABLE 2

Compliance with NICE standards by English region

NORTHEAST

LONDONNORTHWEST

EASTMIDLANDS

YORKSHIREAND

HUMBEREAST

SOUTHWEST

WESTMIDLANDS

SOUTHEAST


95.5% 89.9% 93.4% 98.3% 88.1% 93% 85.6% 91.9% 93.7%

Chorionicitydetermined atultrasound

75.6% 83.6% 88% 83.3% 81.2% 79% 78.3% 78.1% 83.4%

Full bloods at 20-24 and 28 weeks

87.5% 70.4% 75.9% 84.1% 77.4% 76.3% 77.2% 70.6% 74.5%

Specialistobstetrician formultiples

64.6% 72.1% 63.3% 67.7% 73% 57.6% 72.8% 60.8% 55.1%

Specialist midwifefor multiples

47.9% 25.2% 25% 7.8% 18.5% 10.2% 8.6% 19% 12.8%

Specialistsonographer formultiples

51.1% 36.5% 27.8% 22.6% 30.2% 29.1% 21.3% 24.5% 17.7%

Discussionpreterm labour /steroids

66.7% 67.2% 67% 57.8% 60.1% 71.2% 61.7% 59.4% 63.8%

Discussionvaginal /caeserean birth

83.3% 94.9% 82.9% 90.5% 78.5% 87.7% 88% 84.2% 87.7%

Overall NICEcompliance 71.5% 67.5% 65.4% 64% 63.4% 63% 61.7% 61.1% 61.1%


Page 21

/ caesarean birth and 92% discussingpreterm labour and steroids for foetal lungmaturation. The trust recently introduceda specialist antenatal clinic for multiplebirths and integrated care pathwaysdelivered by a core interdisciplinary teamwith specialist knowledge of multiplepregnancies and multiple antenataleducation sessions. This is reflected inthe high numbers of women seeing aspecialist obstetrician (84.6%), aspecialist midwife (92.3%) and specialistsonographer (77.8%) and high levels ofpatient satisfaction. An audit pre and postimplementation [14] showed that stillbirthrates for multiples had fallen dramaticallyfrom 10/1000 twins to 3/1000 twins, alevel comparable with that for singletonsand rates of caesarean section had alsofallen below 50% for twins, significantlylower than other equivalent services.

In contrast to these positive accounts,there are some trusts who areunfortunately performing significantlyworse. One trust in particular had 34multiple births in 2014, and 32 multiplerelated patient safety incidents. Theoverall NICE compliance scores were alsoone of the lowest at only 37.5%, mostnotably with 0% compliance to any of thethree markers for a specialistmultidisciplinary team. None of therespondents reported having anobstetrician, midwife or sonographer with

specialist knowledge of multiplepregnancy and birth. Continuing with thistrend, the patient satisfaction data showsno aspects where positive feedback isgreater than negative, with most being a50% split and one being more negativefeedback than positive. Neonatal deathrates were at the higher end of thespectrum at 6.02 per thousand births.

Another trust has one of the highest ratesof negative feedback rates (71.43%)regarding satisfaction with obstetriciancare and advice given upon admission toa neo-natal unit. This trust also scoredpoorly on several of the other satisfactionof care situations; midwife postnatal(71.4% negative), midwife after dischargeand returning home (85.71% negative)and midwife feeding (85.7% negative).NICE compliance from this trust tells aninteresting story with only 51.7% totalcompliance and severe deficits in all threeof the ‘professionals with specialistknowledge of multiple pregnancies’(obstetrician 33.3%, midwife 0% andsonographer 0%). In addition the NICEguideline surrounding the ‘discussion ofrisks, signs and symptoms of pretermlabour and potential need for steroid usefor foetal lung maturation’ was alsocritically low at 12.5%. There were 31multiple births in this foundation in 2014,and 15 patient safety incidents. n


The report shows that parents ofmultiples still face additional challenges inpreparation for labour and birth, antenataland postnatal care. Multiples make up3% of pregnancies in UK, 7% of stillbirths,and 14% of neonatal deaths. Theyaccount for around 10% of all stillbirthmaternity litigation claims in Englandwhich cost the NHS £72m between 2005and 2014. The risk of preterm birth is alsoconsiderably higher, occurring in at least50% of twin pregnancies, with twinsfacing six times the risk of cerebral palsy.These outcomes compare poorly tosingleton births and the discrepancy hasexisted for decades.

Rates of preterm birth are considerablyhigher for multiples, with the surveyshowing average gestation times of 35.3weeks for twins and 31.8 weeks fortriplets. Multiples are more likely to beborn by elective birth (52.8% comparedwith 39.1% nationally) and caesareansection (68.1% compared with 26.25nationally) and parents may feel they aregiven little choice over their birthexperience. Multiples are also more likelyto be born at low birthweight (73.7%compared with just 7% nationally) and torequire some form of additional neonatalcare (51.5% of babies in this survey).Parents may also be more likely toexperience problems with feeding theirbabies due to difficulties of prematurity,illness, separation, lack of feedingsupport, or the sheer demands of feedingmultiples, with 29.6% of parents sayingthey were unable to feed their babies asplanned.

Such additional challenges have beenrecognised in the NICE guidelines formultiple pregnancies introduced inSeptember 2011, which aim to provideparents with a level of care suitable forthe complexity of their pregnancy,including additional monitoring, adviceand care by a multidisciplinary core team

with specialist knowledge of multiplepregnancies. However parentexperiences of antenatal care remainmixed and unevenly distributed acrossthe UK, with variable implementation ofNICE guidelines.

Parent satisfaction with access toantenatal screening is generally good,with 47.2% of parents rating this as‘good’ or ‘very good’. 92% of parentsnationally had received an ultrasound by14 weeks of pregnancy and 81.6% hadthe chorionicity and amnionicity of theirpregnancies determined at the firstultrasound. Multiple pregnancies aremonitored much more closely thansingletons, with 81.7% of parents havingat least six scans and 7.1% having morethan twenty. 81.7% were offeredscreening for Downs Syndrome and76.4% were offered full blood tests at 20-24 and 28 weeks pregnancy.

Access to care by a specialist multi-disciplinary core team is much morelimited, with approximately two-thirds(67.7%) of mothers seeing an obstetricianwith a specialist knowledge of multiplepregnancy, but just 20.1% a specialistmidwife and 28.1% a specialistsonographer. Such statistics show thatmany health authorities are clearly failingto provide the required level of care, andidentify a clear need for further availabilityand training of suitable staff.

Parent satisfaction with advice providedby the healthcare team is also generallylow. Advice from both obstetricians andmidwives in preparation for birth is ratedpositively, with 64.8% of parentsreporting that they discussed the risks,signs and symptoms of pre-term labourand 86.6% that they had the opportunityto discuss the timing of birth andlikelihood of vaginal / caesarean birth.However advice on postnatal issuesincluding preparation for admission to a

Conclusions

Page 22


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neonatal unit, post-natal care, caring forthe babies after discharge and advice onfeeding the babies were all ratednegatively, reflecting previous studieswhich show that parents often feelunprepared for the realities of the earlypost-natal period and abandoned byhealth professionals at this time[13].

Such findings show a clear need forfurther advice and preparation forpotential postnatal complications (whichare more common in multiplepregnancies) and general postnataladvice and support. Over a third ofparents (35.1%) said that they were notsupported in any way to achieve theirfeeding preference and 57.9% had notreceived advice on safe sleeping formultiples. Such figures show a need forfurther postnatal input from healthprofessionals, but also a possible role forvoluntary organisations such as Tambawho may have more time and expertiseto dedicate to such issues. The surveyshows that health professionals are poorat signposting to such organisations, withover half (55.4%) of parents not informedabout Tamba or the MBF’s services andjust 24.5% attending their parenteducation sessions. Feeding support isanother area where voluntaryorganisations may play a key role, withonly a minority of parents (15.9%)currently accessing support in this way.

The report shows some positiveimprovements in access and satisfactionwith services over time. Overallmeasurements of NICE implementationhave increased from 58.8% in 2010/11 to69.1% in 2014/15, showing a 10%improvement over the past 4 years.However progress is slow and at currentrates of improvement it could beestimated to take a further 12 years toachieve full compliance, with associatedrisks of continued negative outcomes formultiple births and patient safetyincidents. Access to a specialist midwife(23.9%) and sonographer (33.1%) remainparticularly low, showing clear needs forfurther improvements. Rates ofsatisfaction with care / advice have alsoshown some improvement over time,

although satisfaction with post-nataladvice and access to pre-natal educationremain particularly low.

The report also shows variations inaccess to care across the four nations ofthe UK. Scotland has considerably higheroverall scores for NICE implementation(70.8%) than the rest of the UK, withEngland (63.7%), Wales (63.7%) andNorthern Ireland (64.1%) all broadlysimilar. Scotland also shows highestlevels of satisfaction with care / advice,followed closely by Northern Ireland, withWales scoring consistently lowest onsatisfaction, despite similar levels ofcompliance. Parents in Northern Irelandwere particularly dissatisfied with theiraccess to screening, whilst scoring highlyin all other areas, due to their strictabortion laws.

The study also shows variations NICEcompliance and parent satisfactionacross the regions of England, revealing a‘postcode lottery’ in access to care. TheNorth East is the highest performingregion with overall 71.5% compliance,whilst the South East and West Midlandsare the lowest with 61.1%. Examples ofparticularly good practice can be seen incertain healthcare trusts, including theNewcastle upon Tyne Hospital Trust, theLeeds Teaching Hospital Trust and StGeorges Healthcare NHS Trust.

Overall the report shows thatimplementation of NICE guidelines isslowly beginning to address theinequalities of care experienced byparents of multiples and recognise theiradditional needs, however much furtherprogress is required. Parents generallyhave good access to screening andadvice in preparation for birth, but havefurther needs in terms of post-nataladvice and support and access to amulti-disciplinary team with specialistknowledge of multiple pregnancy.

Access to an appropriately trained teamduring both pregnancy and birth wouldimprove quality of care, patient safety andoutcomes for multiple pregnancies andensure that all families were able to


access the range of options available tothem. Studies have shown that, whereservices are implemented in compliancewith NICE guidance stillbirth rates,caesarean rates and patient safetyincidents are reduced. A recent Australianstudy[15] showed that after theimplementation of a specialist twin clinic,caesarean rates, late preterm births (34-37 weeks) and maternal inpatient staywere all reduced.

We would therefore call for more full andrapid implementation of NICE guidance todrive improvement for multiples and theirfamilies. This involves acknowledging thatmultiples (along with other distinct groupse.g. women from some ethnic

backgrounds) have specific needs thatare easily overlooked, which can result inpoorer outcomes and should be explicitlyaddressed through national, regional andlocal policy initiatives.

Planned extension of NICE guidelines tocover the intrapartum period would alsohelp to ensure continuity of care andimprove outcomes for babies and parentsduring this time, when the majority ofclinical negligence claims occur. Clearguidelines for the postnatal period wouldhelp to ensure best practice in postnataland neonatal care and provide familieswith the additional support they require incaring for their multiples.

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n

This summary report was prepared by Rebekah Fox (Senior Research and Evaluation Officer, NCT),Keith Reed (CEO, Tamba) and Sarah McMullen (Head of Research, NCT) with background supplied

by Hazel Windmill (Windmill Research).

We would like to thank all the parents who took part in the survey.

For further enquiries about the research, or any other enquiries about NCT / Tamba research andpolicy, please contact [email protected] or [email protected] .


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1. NHS Choices. Giving birth to twins or more. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/giving-birth-to-twins.aspx#close

2. NHS Choices. Premature Labour and Birth. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/premature-early-labour.aspx#close

3. Health and Social Care Information Centre (HSCIC). NHS Maternity Statistics – England, 2013-14. Availableat: http://www.hscic.gov.uk/catalogue/PUB16725

4. Office for National Statistics. Characteristics of Birth 1, England and Wales 2013. Available at:http://www.ons.gov.uk/ons/rel/vsob1/characteristics-of-birth-1--england-and-wales/2013/index.html

5. National Institute for Health and Care Excellence (NICE) Multiple Pregnancies: twin and triplet pregnancies.Quality Standard (QS46) available from: https://www.nice.org.uk/guidance/qs46/chapter/List-of-quality-statements

6. NHS Choices. High blood pressure (Hypertension) and pregnancy. Available at:http://www.nhs.uk/conditions/pregnancy-and-baby/pages/hypertension-blood-pressure-pregnant.aspx#close

7. NHS Choices. Severe vomiting in pregnancy. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/severe-vomiting-in-pregnancy-hyperemesis-gravidarum.aspx

8. NHS Choices. Antenatal care with twins. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/antenatal-care-twins.aspx#TTTS

9. McAndrew, F, Thompson, J, Fellows, L, Large, A, Speed, M & Renfrew, M (2012) Infant Feeding Survey2010: Summary. Available at: http://www.hscic.gov.uk/catalogue/PUB08694/ifs-uk-2010-sum.pdf

10. Fox, R, McMullen, S & Newburn, M (2015) UK women’s experiences of breastfeeding and additionalbreastfeeding support: a qualitative study of Baby Café services. BMC Pregnancy and Childbirth.15:147. doi:10.1186/s12884-015-0581-5

11. NHS Choices. Twins and sleep. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/multiples-and-sleep.aspx#close

12. Ball, H (2002) Reasons to bed-share: why parents sleep with their infants. Journal of Infant and ReproductivePsychology. 20 (4).

13. Bhavnani, V 7 Newburn, M (2010) Left to your own devices: The postnatal care experiences of 1260 first-timemothers. London NCT

14. National Institute for Health and Care Excellence (NICE) (2013) Multiple pregnancy service, St George'sHospital: influencing stakeholders to implement NICE guidance Available at:https://www.nice.org.uk/sharedlearning/multiple-pregnancy-service-st-george-s-hospital-influencing-stakeholders-to-implement-nice-guidance

15. Henry, A, Lees, N, Bein, K, Hall, B, Lim, V, Chen, K, Welsh, A, Hui, L & Shand, A (2015) Pregnancy outcomesbefore and after institution of a specialised twins clinic: a retrospective cohort study. BMC Pregnancy andChildbirth 15:217 DOI 10.1186/s12884-015-0654-5

References

Maternity Services and Multiple Births

R Fox, K Reed, S McMullen and H Windmill

NCT and Tamba

©2015

Documents

Maternity Services and Multiple Births - Twins Trust · 2019. 9. 22. · Maternity Services and Multiple Births | A Tamba - NCT Joint Report The survey was completed by a total of