REVIEW OF MATERNITY SERVICES IN
THE WIRRAL
Review of Maternity Services in the Wirral: PCT Board Meeting 11 September 2007
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Contents
Page number
Introduction
1
Background to the review
Objectives of the review
Review process
Current service provision
4
Overview of local needs
6
PSA Targets and maternity services
7
Executive Summary
8
Meeting needs of vulnerable and disadvantaged women
11
Access
Inequitable service provision
Children’s Centres
Public health interventions
Domestic violence
Women’s views
Community services: access and provision
22
Midwifery care
Routine medical care
Choice
24
Choice of place of place of birth
Facilitating choice
Social enterprise
Antenatal education
Review of Maternity Services in the Wirral: PCT Board 11 September 2007
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Content
Page
Normal birth
31
Culture and environment of care
Domino care
Caesarean section
Breastfeeding
37
Continuity of care
41
Multi-disciplinary and multi-agency working
43
Child Protection
Midwifery & health visiting
Mental Health
Involvement of service users in planning
46
Core recommendations
49
Review of Maternity Services in the Wirral: PCT Board 11 September 2007
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Final version: August 2007
STRATEGIC REVIEW OF MATERNITY SERVICES
Introduction
This document reports on the strategic review of Wirral maternity services and is written by Jill
Crawford, independent consultant for the review (background at page 53). She can be
contacted by email at jill.crawford@tstlc.com.
The report was commissioned in April 2007. It was presented in draft form to Wirral Primary
Care Trust’s Commissioning Co-ordination Group on 31 July 2007. It was circulated to key
stakeholders in August for factual correction. This is the final version of the report. The report
is being presented to the Primary Care Trust Board on 11 September 2007.
Background to the review
The review was commissioned in April 2007 by Wirral Primary Care Trust to enable informed
commissioning of maternity services by Wirral PCT.
In 2004, Standard 11 (Maternity) of the Children’s National Service Framework was published
by the Department of Health. This is to be implemented by the end of 2009. In April 2007, the
Department of Health published Maternity Matters: Choice, access and continuity of care in a
safe service. This outlines the government national maternity choice guarantees to be
available at the end of 2009 and supports the implementation of the NSF.
The Healthcare Commission undertook a national survey of women’s experience over the
summer of 2007. The results of this survey did not form part of the evidence for this report, as
it was not available at the time of review. The Healthcare Commission is expected to maintain
its focus on maternity services. The local results are now available and should form part of the
evidence base for the Primary Care Trust going forward.
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Objectives of the Review
The objectives of the review are:

establish how closely maternity services in the Wirral meet the national objectives and
nationally agreed standards for maternity services;

assess how maternity services contribute to the PCT’s strategic aspirations;

establish how well services meet the needs of local service users.
The national objectives for maternity services, as set out in Standard 11 (Maternity) of the
Children’s National Service Framework and the strategic aspirations of the Primary Care Trust
are detailed in Appendix 1.
The strategic direction for maternity services, informed by these local and national policy
drivers, is towards:
1. Flexible services that are proactive in meeting the needs of vulnerable and
disadvantaged women;
2. Increased provision of and access to services in the community;
3. More choice for women about where they receive care and what care they receive;
4. Services that recognise birth as a normal physiological event and that support normal
birth to improve public health;
5. Services that support breastfeeding to improve public health, with particular focus on
disadvantaged women;
6. Continuity of care;
7. Effective multi-disciplinary working and multi-agency working particularly with regard to
mental health issues, domestic violence and child protection;
8. Involvement of local women in the planning and monitoring of services.
The focus of the review is informed by these themes. The evidence is analysed against each
theme and detailed recommendations made to inform service development, care pathway
planning and future service specification. At the end of the thematic analysis are a number of
core recommendations to Wirral Primary Care Trust (page 49).
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Review process
Maternity service provision in the Wirral has been reviewed using the following evidence:

data on local outcomes;

comprehensive documentation review;

views of key stakeholders, including services users, provider staff and commissioners;

observation of the facilities.
As a significant number of women from the Wirral choose to have their babies in Liverpool
Women’s Hospital and the Countess of Chester, the review also includes information on the
facilities and outcomes of these two units.
During the course of the review, views were solicited from the following professional groups:

Midwives (specialist, team and ward)

Obstetricians

Paediatricians

Anaesthetists

Healthcare assistants

GPs

Health visitors

Social services

Mental health services
Telephone interviews were also undertaken with the Chair of the Maternity Service Liaison
Committee and the Local Supervisory Authority Midwifery Officer.
The primary source of service user views was a series of events at community groups and
meetings throughout the Wirral. Fourteen events were held in Children’s Centres and other
community venues throughout June 2007 and were attended by around 170 women who had
recently used the service. Further information on the process for gathering stakeholder views
is included at Appendix 2.
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CURRENT SERVICE PROVISION
There is one maternity unit in the Wirral, based at Arrowe Park Hospital. Wirral Hospital Trust
is the only trust providing maternity services in the Wirral area. In 2006-7, 3,320 women gave
birth in the Wirral.
Midwives deliver most of the care to women in maternity services. The majority of midwives
are organised into teams of 8 to 12, who work in a particular locality and provide antenatal,
intrapartum and postnatal care to a community. These midwives deliver care at Arrowe Park
Hospital and in GP surgeries. The standard schedule of visits for women antenatally is two
visits at Arrowe Park and eight visits in a GP setting.
There are some midwives who work exclusively on the antenatal and postnatal wards and
some core labour ward staff. There are also a number of midwives who specialise in care of
women who are considered high risk, as well as other specialist midwives.
Women currently access maternity services via their GP. Most GPs involvement in routine
care is limited to the initial contact and referral letter, followed by a postnatal check six weeks
after birth. A small number of GPs with a special interest provide some antenatal care in
conjunction with midwives. GPs provide routine medical care to pregnant women, as the need
arises.
The labour ward has twenty four hour consultant cover. All obstetric consultants are
consultants in both obstetrics and gynaecology. There is a full anaesthetic service, although
women may at times have a wait for an epidural during the night if an emergency section is
being performed.
Currently, there is no midwifery-led birth unit within the hospital although three rooms on
labour ward are currently being converted to provide this. Women will be able to choose to
have their babies in this unit if they are low risk and wish to labour without epidural pain relief.
The midwifery-led unit plans to offer water birth in inflatable pools from October 2007.
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Within Arrowe Park Hospital, there is an Early Pregnancy Unit and a Fetal Medicine Unit.
There is also a new Neonatal Unit, which provides care for sick and premature babies. The
Unit has facilities for one set of parents to stay and plans are in place to expand this provision,
via charitable support.
Postnatal care is provided at hospital and in the woman’s home. On average, women receive
between three and four home visits. Visiting patterns are flexible although midwives report
that visiting on the first, fifth and tenth day after discharge is not uncommon.
Postnatal care from a midwife can extend up to 28 days; if all is well women are often signed
off from midwifery care when the baby is around ten days old. The health visitor visits between
day ten and fourteen and offers drop-in community based clinics thereafter. Health visitors are
going to begin doing targeted antenatal visits for some women.
Wirral Hospital Trust previously had Baby-Friendly Status, the recognised gold standard
indicating good practice in relation to breastfeeding. However, this was recently lost. The Trust
has registered its commitment to regain Baby Friendly Status.
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OVERVIEW OF LOCAL NEED
Maternity services in the Wirral have a particular challenge. The Wirral is made up of to some
of the most deprived and some of the most affluent areas in England. The needs of women
from the contrasting areas in the Wirral, and the choices they wish to make, are likely to be
significantly different. To serve its local population, the PCT must commission services that
are flexible enough to accommodate both groups.
To meet local need, maternity service must deliver on two agendas. The first is reducing
health inequalities and providing services that reach out to women from disadvantaged
groups. The second is the choice agenda, which is likely to be driven by women from less
deprived areas of the Wirral, but will benefit all women.
Health Inequalities
The Confidential Enquiry into Child and Maternal Health showed that women living in families
where both partners were unemployed, many of whom had features of social exclusion, were
up to 20 times more likely to die than women from the more advantaged group (CEMACH
2000-2002).
Babies born in the most deprived areas of the country are up to six times more likely to die in
infancy. The infant mortality rate in Birkenhead is 5.8 per 1000, compared to 4.1 in Bebington
and West Wirral and 5% nationally (Wirral’s Children and Young People’s Plan).
The more deprived wards in the East and North of the borough have higher rates of single
parents and teenage pregnancy. Rates of births to single mothers vary from 14 per 1,000
births in Clatterbridge ward to 388 per 1,000 births in Bidston & St James ward (data from
1999-2003) (Wirral’s Public Health Report). Single mothers are three times more likely to die
than women in stable relationships (CEMACH 2000-2002) and the death rate for babies of
teenage mothers is 60% higher than older mothers.
Maternity services in the Wirral need to be designed to be accessible to these women and to
provide services that meet their needs.
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Women’s Choice
Services and facilities need to be of a high standard and to accommodate women’ s choice to
be able to compete with neighbouring providers. Facilitating choice will make services more
accessible for all women and allow services to meet individual need.
Choice should to be extended to all women, irrespective of socio-economic background.
PUBLIC SERVICE AGREEMENT TARGETS AND MATERNITY SERVICES
Maternity services have a key role to play in contributing to three of the PSA Targets:

PSA Target 2: Reduce health inequalities by 10% by 2010 as measured by infant
mortality and life expectancy at birth;

PSA Target 3: Tackle underlying determinants of ill-health and inequalities by:
o reducing adult smoking rates to < 21% by 2010 & < 26% in routine & manual
groups;
o halting rise in obesity in children under 11 by 2010

PSA Target 1: Substantially reduce mortality rates by 2010 from suicide and
undetermined injury by at least 20%.
Maternity Matters (2007) highlights that improved maternity services would also support the
sign-off criteria for two of the Local Delivery Plans (LDPs) that contribute to the monitoring of
PSA Target 2, namely delivering a yearly reduction of 1% in pregnant women who smoke and
2% increase in breastfeeding rates in women from disadvantaged groups.
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EXECUTIVE SUMMARY
Wirral Hospital Trust is providing a safe service to women. The stillbirth rate in the Wirral is in
line with the national average, at 5 per 1000 and the percentage of low birth weight babies is
below the national at 5.8% (national average of 7.6%).
The Trust provides a high quality service to women with medical complications.
The service for women with diabetes is compliant with national standards and is an example of
good practice. There is good risk management within the organisation, evidenced by the
achievement by the Trust of Level 2 in the Clinical Negligence Trust Scheme. The neonatal
service is of a high standard, with new facilities and with an effective Neonatal network in
place. It is one of only two units to be designated level 3 by the Neonatal network in the
Cheshire and Merseyside Region.
The majority of women who receive care in the Wirral report satisfaction with their care and
many describe midwives as supportive and friendly. Significant numbers of women choose to
have their babies at either the Countess of Chester or Liverpool Women’s Hospital.
Specialist services for disadvantaged and vulnerable women are good. However, mainstream
services are not designed to be geographically accessible to these women. A high proportion
of care is delivered centrally at Arrowe Park and there is no community provision of key
elements of care, such as booking or scanning.
There is evidence that women from deprived areas of the Wirral are treated differently to
women from other areas. This needs to be addressed as a matter of urgency to ensure that
safety of these women and babies, who are most at risk of a poor outcome, is not
compromised by the attitude of some staff.
Women have little choice about when and where they access care or where they give birth.
Only 15 women of 3,320 had their babies at home. There are low levels of normal birth in the
Wirral. The Women’s Directorate Business Objectives 2007/9 include halting the rise in
caesarean sections and developing an operational midwifery-led unit. However, there is little
evidence that there is significant focus on normal birth at a strategic level.
Breastfeeding rates among disadvantaged women are very low; rates in affluent areas of the
Wirral are high. There are aspects of good practice in relation to breastfeeding and the
achievement of Baby Friendly Status was a significant event. However, there are now
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significant problems at Wirral Hospital Trust relating breastfeeding, which need to be
addressed. Increasing breastfeeding by 2% a year, focusing on disadvantaged women, and
reducing smoking rates by 1% a year are key to achieving PSA target 2 on infant mortality.
Maternity services are key to improving public health in the Wirral. Pregnancy provides a
window of opportunity for social and health interventions that will improve the well being of a
whole family. Currently, there is very little involvement of midwives in Children’s Centres; the
potential for positive intervention should be more effectively exploited by greater integration of
midwifery into children’s services.
Relatively little evidence about health visiting was provided by women during the review.
However, health visitors played an active part in the review and their provision of services in
Children’s Centres is a strength. Communication between health visiting and midwifery
services needs to be improved.
The evidence is mixed about whether women receive continuity of care. Continuity of
care, as explained in Maternity Matters, refers to a known and trusted midwife who is
responsible for providing information, support and on-going care …[an element of
continuity of care is] ensuring that women are aware of the arrangements for ongoing
midwifery support and coordination, should the known midwife be unavailable.”
Some women report receiving high levels of continuity of care whilst others identify lack of
continuity as a weakness. Views of midwives on the issue are also split. What is clear
from the evidence is that continuity of care is not consistently provided.
There is good multi-agency working in relation to child protection and domestic violence.
However, multi-agency working in relation to mental health is very poor, due to a lack of
strategy and service provision. Health professionals often struggle to access appropriate
mental services for women.
Psychiatric illness is the main cause of maternal death in the UK (CEMACH 2000-2002).
Local services do not standards set out in the Children’s NSF; current lack of strategy,
formal network and core service provision poses a serious risk to women from Wirral.
Historically, there has been little involvement of women in the planning of services. There is
an active Maternity Service Liaison Committee, which has a lay chair. This is identified in the
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NSF as an appropriate body for service planning and user involvement. However, the
committee has not had significant influence. To improve its effectiveness, the role of the MSLC
needs to be reviewed and links to disadvantaged women need to be developed. The recent
community events to inform the Kick Start Midwifery initiative provide a wealth of information
on local women’s views and are to be commended.
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1. MEETING NEEDS OF DISADVANTAGED AND VULNERABLE WOMEN
There main cause of disadvantage for women using maternity services in the Wirral is
economic and social deprivation. There are high levels of teenage pregnancy and of
substance misuse in some communities.
There are currently relatively low numbers of women from ethnic minorities, although these
numbers are increasing and are likely to continue to do so. Midwives report that they are
encountering an increasing number of women who have recently arrived in the UK from
Eastern Europe. There is a language line available in the hospital setting and interpreters
can be pre-booked when a woman attends an antenatal appointment. Some midwives
identified a need for additional interpreting services.
There are good specialist midwifery services in the Wirral in relation to teenage pregnancy,
substance abuse, infectious diseases, domestic violence and child protection. The
evidence suggests that women in the Wirral with medical complications, disadvantaged or
otherwise, receive good care. There is a range of specialist clinics and midwives who are
skilled in high risk care look after women with medically complicated pregnancies.
Women who are substance abusers, have infectious diseases such as HIV and Hepatitis
C or are teenage mothers have access to tailored and flexible care from specialist
midwives.
Midwives and consultants report that their services are well used and have significantly
improved the experience and outcomes of these women. This positive evaluation is
supported by the view of teenage parents (Patient Satisfaction Survey – Young Women’s
Antenatal Clinic). Their evaluation suggests generally good levels of care, with the notable
exception care provided at home following the birth of the baby.
Currently, there is not a transitional care facility for women whose babies need more
support and monitoring than can be provided on the postnatal ward but are not so sick as
to necessitate admission to the Neonatal Unit (NNU). In the Wirral, these babies are
currently separated from their mother and admitted to the NNU, which means separating
the babies from the women. This is not in the interests of the mother or the baby.
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There is support from paediatricians for a transitional care facility. This facility would
enable some women with history of substance abuse and some women with diabetes to
remain with their babies.
Recommendations

Need for additional interpreting services to be explored;

Financial feasibility of transitional care facility to be explored.
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Access for disadvantaged and vulnerable women
Although specialist services are strong, mainstream services are not designed to be
accessible to vulnerable and disadvantaged women. There are many vulnerable and
disadvantaged women for whom there are not specialist services (e.g. economically
deprived women who are not teenage mothers, substance abusers etc) and who rely on
mainstream services to meet their needs.
Access to Booking and scanning
Women are all centrally booked in Arrowe Park Hospital. This is often women’s first
contact with maternity services, other than a visit to the GP. This is done because the
computer system is based at the hospital and data can be entered directly. Women are
offered a dating scan at this visit. Women are also required to attend Arrowe Park
Hospital for their anomaly scan at between eighteen and twenty weeks pregnant.
Central booking and scanning creates a practical transport and childcare barrier to
disadvantaged women from socially deprived backgrounds. Nationally, around 16% of all
pregnant women (The Information Centre Hospital Episode Statistics 2004-5), including
many teenagers, delay accessing care until they are at least five months or more
pregnant. These women have worse outcomes than those who access care at an earlier
stage in pregnancy.
Last year nine women were delivered at Arrowe Park Hospital who had not booked into
the system. It is not known how many of these women were not Wirral residents.
Access to non-routine care
A significant amount of care is delivered at Arrowe Park Hospital outside the routine
schedule of visits. This is often where women go if they wish to access care before their
next appointment with a midwife in the GP setting. Reasons for this are explored in
greater depth later in the report.
Provision of key elements of care exclusively at Arrowe Park Hospital disenfranchises
some women from socially deprived backgrounds. This was evidenced by reports from
health professionals of women failing to access care due to practical and financial
difficulties.
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Recommendation

Provide small number of community based midwifery-led clinics to:
o
provide women with choice of community based scanning;
o provide facility for GP/self-referral to midwifery care between appointments.
Choice of direct access to a midwife
Currently, all women access maternity services via a visit to the GP. The need to gain
access to maternity services via a GP may be a barrier to early access to services for
some women. Some teenage women may be reluctant to approach the family GP before
her family know about the pregnancy. Other women, such as asylum seekers, may not
have a GP.
Direct access to a midwife is a key standard with the National Service Framework, on the
grounds of improved access and increased choice. There is clear evidence that this is a
choice that women in the Wirral want to be available to them. Of the 168 women who
commented, over half (90) said that they would like to see a midwife as their first point of
contact with maternity services.
Around 50 women wished to see their GP and others had no preference.
There is some concern locally among GPs about the risk of relevant medical or social
information not being identified without the GP referral letter. Midwives identified
inconsistency in the standard GP referral letters as a problem, with previous medical or
social issues not always being communicated. Steps should be taken to mitigate the risks
posed by both these issues. Consideration should be given to offering women an early
appointment with a midwife in a GP setting to facilitate the access to the woman’s records.
Recommendations

Women are able to choose direct access a midwife in the community;

Service to be advertised widely.
Inequitable service provision
In addition to the access issues, women from more affluent parts of the Wirral are being
with provided with more care than women from deprived areas and backgrounds.
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There is inequitable antenatal education service provision between parts of the Wirral.
The length of antenatal courses varies widely across the Wirral. Women from Prenton;
Tranmere; Rock Ferry; New Ferry and parts of Birkenhead are offered only one two hour
session; this contrasts with the women cared for by the Greeenwood team (Greasby and
Woodchurch) who are offered six sessions. There is also inequitable access to antenatal
classes that support normal birth (Labour in Motion). The sessions are oversubscribed and
offered at Arrowe Park Hospital and Neston only – making them inaccessible to many
disadvantaged women.
In relation to postnatal care in the community, midwives and health visitors report that
women from affluent areas are most likely to request and receive frequent postnatal visits.
This also contributes to a situation where women who are most in need receive the least
care.
There is concern that some women are discharged from midwifery care without being seen
in the community by midwives if midwives are unable to gain access when they visit
postnatally. Midwives report that increasingly women are unwilling to stay in for a visit from
the midwife at an unspecified time.
It was reported anecdotally that it is more common for midwives to fail to gain entry to
young mothers and concern was expressed about the risks for these women and their
babies. These risks are exacerbated by the fact that there is not routinely a handover of
care from midwife to health visitor.
Postnatal community-based drop-ins and text communication on the day of the
appointment to confirm timings would improve the service to women.
Women who are vulnerable, disadvantaged or have additional needs are soon to be
targeted for an antenatal visit from a health visitor. This will direct resources towards those
women who need them and is to be welcomed.
Recommendation:

Women should have the choice of accessing postnatal care at drop-in clinics (pilot
at Seacombe Children’s Centre underway);
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
Midwives should not discharge any woman without having made contact
postnatally.
Children’s Centres
There has been a significant investment in Children’s Centres in the Wirral. There are
currently ten Children’s Centres (Appendix 6) up and running. Nine others are in
development, with two to open before Christmas and the rest to open by March 2008. In
addition, five satellite centres are being developed.
There will be Children’s Centres in all parts of the Wirral. Every family living in a super
output area (the most deprived areas) will be within buggy pushing distance (half a mile) of
a Children’s Centre by March 2008. Each area of the Wirral will have a Children’s Centre.
Midwifery Teams were realigned at the beginning of 2006 to cover a geographical area
that link into a Children’s Centre.
Children’s Centres provide an integrated service to families with children under 5, with a
focus on good multi-agency working. However, there is very little involvement of midwives
in Children’s Centres (a team of midwives work out of Neston Children’s Centre). This
lack of involvement is a significant weakness in the Children’s Centre and maternity
service provision. The NSF provides clear direction that midwifery services should be
included in Children’s Centres to increase women’s access to service.
One woman in Birkenhead commented:
‘I didn't know or get told about any Children's Centres. I would have found knowing
about Children's Centres a help.’
Some Children’s Centres will be able to offer crèche facilities whilst women access care.
All Children’s Centres would offer women a way to access a range of social, education and
health services in one place.
There is strong support among midwives and health visitors for midwifery services in
Children’s Centres. There is also an enthusiasm for provision of joint services, such as
drop-in clinics. Midwives suggested that midwifery time could be freed up by a
phlebotomist’s inclusion at a clinic at a Children’s Centre.
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There are mixed views amongst GPs about benefits and risks of providing midwifery
services in Children’s Centres. Some GPs want services to remain in a medical setting
and express concern about lack of access to clinical notes in other settings. Others are
generally supportive about midwifery services in Children’s Centres.
Recommendation

Routine midwifery care to be provided in Children’s Centres.
Public Health Interventions
Pregnancy offers an opportunity to reach disadvantaged and disenfranchised
women and improve the well-being of a whole family. Breastfeeding, smoking cessation,
diet and lifestyle advice and support are key to improved public health within
disadvantaged communities.
A key contributor to achieving PSA 2 is a 1% reduction per year in the proportion of
women who continue to smoke throughout pregnancy, especially within smokers from
disadvantaged groups (Maternity Matters, DoH, 2007).
Smoking rates in the Wirral are above the national average. Wirral Hospital Trust figures
indicate that twenty six percent of pregnant women smoke at booking, compared to 20%
nationally. The Children and Young People’s plan identifies widely varying rates across the
Wirral. These figures suggest that 24% of pregnant women from Birkenhead smoke,
compared to 11% in Bebington and West Wirral.
There is a dedicated smoking cessation service in the Wirral, which accepts referrals from
maternity services. Midwives do refer women to the service and all women who are
referred are offered a home visit. However, the role of maternity services within smoking
cessation could be improved.
Some midwifery staff have received smoking cessation training. The smoking cessation
service has stated a desire to provide Level 1 training in Smoking Cessation (Brief
Intervention) to all midwives and healthcare assistants.
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It is reported that this has been resisted due to time restraints on staff. Maternity services
need to play a full role in smoking cessation if PSA Target 2 on reducing health
inequalities, measured by infant mortality, is to be achieved.
There are a number of positive public health initiatives in the Wirral. The proportion of the
population in Birkenhead and Wallasey eating five or more fruit and vegetables a day is
above the national average. However, it is reported that women receive inconsistent
advice from maternity staff regarding diet in pregnancy. Maternity services need to be
involved in strategies relating to food and health.
Support for breastfeeding as a public health initiative is explored in a later section.
Recommendations

Consideration given to training for maternity service staff in smoking cessation;

Smoking cessation advice to be provided in Children’s Centres.
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Domestic Violence
All women are vulnerable to domestic violence. There are similar levels of domestic
violence across all socio-economic groups. Around 1 in 10 women will experience
domestic violence in a year and 1 in 4 women will experience domestic violence at some
point in their lives (Council of Europe, 2002).
Around 30% of domestic violence cases start or escalate during pregnancy (BMA Domestic
Violence: a healthcare issue, 1998) and domestic abuse is responsible for more fetal deaths
than either diabetes or pre-eclampsia (Department of Health Responding to Domestic
Violence 2005).
The Wirral has a strong focus on domestic violence. It has an established Multi Agency Risk
Assessment Committee (MARAC), which is recognised as a model of good practice and
includes midwifery. The MARAC facilitates the risk assessment processes and exists to report
and respond to incidents of high-risk domestic abuse incidents.
Services in the Wirral include specialist midwives and a midwifery secondment into the family
safety unit. The Wirral is the only area to have such a secondment into the family safety unit.
The model is compliant with NSF standards for local networks.
The NSF states that pregnant women should be offered a supportive environment and the
opportunity to disclose domestic violence. The most appropriate time for a woman to
disclose domestic violence is at the booking visit. However, the fact that this is the
woman’s first contact with a midwife and/or that a woman’s pre-school children may be
present are likely to inhibit the disclosing of domestic violence.
Recommendation

Women have an initial visit with a midwife before booking visit;

Where possible, women are given access to childcare at a Children’s Centre for the
booking visit.
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Women’s Views
The data from the community events suggests that women’s experience of maternity
services is different across the Wirral. When asked what was good about their care,
fourteen women identified friendly and helpful midwives. Well over half of these women (9)
are from West Wirral and only two were from Birkenhead. By contrast, over half of the
women who could identify nothing positive about their experience (7 of 13) were from
Birkenhead, one of the most deprived areas in the Wirral, whilst only two were from West
Wirral.
When asked what was not good about their care, 43 women identified poor staff attitude.
Of these women, 24 were from Birkenhead. Their comments include:
‘They spoke down to me because I was young. They didn't listen to me at all’
‘On the ward some of the midwives were snotty and didn’t listen.’
‘Went to see midwife when I had a positive pregnancy test on instruction from GP day
previously. Cold reception and impatient attitude by midwife, felt stupid cos I went’
‘I was given no help or advice. If anything I felt I was being told off and shouted at rather
than being advised as I was a first time mum. I really wanted to breastfeed but I was
handed a bottle and left alone’.
It is also clear from the data that many women from Birkenhead did feel supported by staff.
Women’s comments include: ‘The midwives were nice and helpful’ and
‘Midwife was understanding’.
Whilst the statistical significance of the data is unclear, there is an onus on the provider
Trust to ensure that there is not an underlying attitudinal problem among some staff that
will jeopardise the safety of socially disadvantaged women and babies.
The Confidential Enquiry made it clear that women from disadvantaged backgrounds are
at risk of poor outcomes not only because of their situation but because of the substandard
care they receive (CEMACH 2000-2002).
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It has been established that of women who died during pregnancy, birth and the postnatal
period, 50% received major substandard care where different care may have meant a
different outcome. These women were twenty times more likely to be from the
disadvantaged groups than from an advantaged social group. It is the responsibility of all
providers to ensure that social prejudice does not affect standards of care or women’s
safety.
Recommendation

Women’s satisfaction levels continue to be monitored on a geographical basis;

Action taken to address attitude of some staff towards women from socially
deprived areas.
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2. INCREASED PROVISION OF AND ACCESS TO SERVICES IN THE COMMUNITY
There are a high number of women accessing non-routine care via A&E for admissions
lasting under twelve hours. In the Wirral obstetrics is the single greatest category for
admissions lasting under twelve hours, accounting for 30% of these episodes.
Midwifery care
Some women will need to see a midwife outside the routine schedule of care. Currently
women usually need to wait for the next midwifery clinic at their GP practice or self-refer to
Arrowe Park Hospital. GPs also refer women to the hospital for non-routine care in the
absence of a community-based alternative.
In these circumstances, as outlined earlier, women with the means and motivation are
most likely to access care. These are often not the women most at risk of a poor outcome.
Hospital admissions are costly and divert resources away from other areas. A proportion
of these women will require specialist obstetric care. However, midwives and GPs could
treat others more appropriately in the community. Community provision of care would also
improve access for most women, particularly women who are disadvantaged.
During the review consultation there was support from GPs, obstetricians, midwives and
women for a small number of community-based midwifery clinics with scanning capability.
This model is reported to be well used and valued in Liverpool, where midwifery services
and scanning facilities are available at four midwifery-led centres. The model of antenatal
care used in Liverpool, utilising these centres, is included at Appendix 5.
For the reasons outlined earlier, locating these clinics in Children’s Centres would offer
additional benefits to women.
Recommendation

Small number of community-based midwifery-led clinics with scanning capability
to be established
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Routine medical care
It has been reported that some women access routine medical care at Arrowe Park
Hospital because they can be seen more quickly or conveniently than at their GPs.
Another reported driver behind this high admission rate is a reported reluctance amongst
some GPs to treat routine medical conditions in pregnant women, such as a mild Urinary
Tract Infection. GPs were also said to be referring women with mild wound infection and
perineal breakdown to hospital. Some midwives felt that the latter condition could more
appropriately be dealt with in the community by referral to a tissue viability nurse.
Conversely, it was reported that some women are receiving inappropriate advice from the
GP hours service. An example of this was a woman who was told to stop breastfeeding to
treat mastitis.
A number of stakeholders suggested that a care pathway would facilitate appropriate and
consistent referral, advice and treatment.
Recommendation

A local care pathway for maternity services should be developed and shared with all
stakeholders, including women, GPs, midwives and obstetricians.
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3. CHOICE
The national choice guarantees are that women will have:

Choice of how to access maternity care;

Choice of type of antenatal care;

Choice of place of birth, including home birth, midwifery-led unit or hospital, under
shared care of midwives, consultant obstetricians and anaesthetists.

Choice of place of postnatal care.
Women’s choice in Wirral maternity services is very limited.
Women do not have a choice of how to access care, the majority are not offered a choice
of where to have their baby and there is no choice about place of postnatal care. The
issues relating to lack of choice about where postnatal care and key elements of antenatal
care are accessed have been explored earlier in the report.
Women in the Wirral do have the choice of the type of antenatal care they receive,
choosing between midwifery-led care or shared care (medical and midwifery).
Women do not currently have the choice of giving birth in a midwifery-led unit or of using a
birth pool. Plans are in place to develop a midwifery-led unit with water birth facilities in
Arrowe Park Hospital. This is a positive development. Service user views should be sought
to facilitate a woman-friendly environment and service in the unit.
Choice of place of birth
Around three quarters of women in the Wirral report not being offered a choice of where to
have their baby. One woman reported being told that she could not have her first baby at
home; others report being actively discouraged from homebirth. A number of midwives
openly reported that they do not offer women this choice. Midwives and obstetricians
recognised that this is an area that needs to be addressed.
The North West Local Supervising Authority Audit Report on Statutory
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Supervision of Midwives 2007 identifies that as many babies are born before arrival than
are planned home births. The Hospital Trust identifies a home birth rate of around 0.3%,
compared to the national average of 2%.
Research suggests that many more women would like the opportunity to give birth at
home. Nationally rates vary between less than one percent and 13.9%. Modernising
Maternity Care: a commissioning tool kit (DoH 2006) states that, “The home birth rate is a
useful indicator of service responsiveness to women’s choice.”
At a management level there is a culture of trying to reduce women’s expectations of
choice rather than facilitating home birth. Many midwives stated that they would like to
provide a home birth but are reluctant to do so because they perceive that they are
providing the service on their own time. They report that they are paid £5 to be on call,
receive no additional pay if they are called out and then are often expected to do their
subsequent shift, even if they have been up most of the night at a home birth. Wirral
Hospital Trust states that midwifery terms and conditions of service are as the national pay
scale and meet the Agenda for Change requirements.
It is unclear whether the primary barrier is local arrangements for work patterns and
remuneration or perceptions among midwives that providing a home birth service is not a
core part of their role. Either will need addressing at a management level.
Another reported barrier to home birth is safety fears of midwives in some areas of the
Wirral. Two solutions to safety fears may be:

to arrange for the midwife to be accompanied by a student midwife, health care
assistant or second midwife;

to facilitate case loading for women choosing a home birth, so that the woman and
midwife are known to each other and a risk assessment can be undertaken.
Deprivation of an area is not a valid reason to deny women home births. Deptford, one of
the most deprived areas of London, has a home birth rate of around 40%.
The 15 women who did have their babies at home were required to bring the baby to
hospital for the check of the newborn and midwives report women’s dissatisfaction with
this arrangement.
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Recommendations

Midwives’ work patterns to be reviewed and any attitudinal issues managed to
facilitate home birth;

Policy to be developed to address safety fears;

Arrange home or community-based examinations for babies born at home.
Facilitating choice
Women’s first contact with a midwife is usually their booking visit at Arrowe Park Hospital.
This visit is key to providing appropriate care to a woman as it entails a detailed history
taking and discussion of choices around screening and place of birth.
Women are given information and expected to make decisions about place of birth,
screening and scanning at the same visit. This significantly curtails women’s ability to
make informed and considered choices.
Women’s feedback suggests that many women find the booking process is too long, taking
up to three hours. Midwives also report dissatisfaction with the process. It should be noted
that Wirral Hospital Trust states that the time allocated to a booking appointment is one
hour and that an ultrasound appointment is 15 minutes long.
The NSF states that “maternity service providers should ensure that women are given
enough time between receiving information and making choices to reflect upon the
information, consider their options and seek additional information and advice where they
wish to.”
Recommendations

Women should be given the information at an early visit in the community before
they are required to make choices;

Women should be given a choice of where to do the booking visit.
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Choice of other provider
A significant number of women currently choose to give birth at Liverpool Women’s
Hospital and at the Countess of Chester. Figures provided suggest that between 1 in 6
and 1 in 9 women from Wirral give birth out of area.
Women from affluent areas are more likely to access services elsewhere. Wirral Hospital
Trust figures show 15% of women from Hoylake, West Kirby and Greasby give birth in
Liverpool compared to between 6% and 8% of women from Birkenhead. Liverpool reports
that last year 564 women gave birth at Liverpool Women’s Hospital from the Wirral area.
Wirral Hospital Trust figures state that between 2003 and 2005 an average of 300 women
a year gave birth at Liverpool. Two women from Liverpool gave birth at Arrowe Park
Hospital in 2006/7.
WHT figures indicate that between the same dates around 150 women a year from the
Wirral went to the Countess of Chester, including 25% of women from Bromborough,
Eastham, Neston and Willaston. Last year, 69 women from the Western Cheshire gave
birth at Arrowe Park Hospital.
Liverpool has a midwifery-led unit, water birth and single postnatal rooms. The Countess
offers water birth facilities but does not have a midwife-led unit. Among the reasons
women give for choosing different providers are convenience (proximity to work) and
facilities.
Women from the Wirral who choose to give birth out of area reported hostility to them as a
consequence. This is mirrored by the resentment reported by some midwives at providing
postnatal care to these women.
Women who choose to give birth at another unit are requested to have routine bloods
taken by the other provider. The reason given for this is that there are not reliable systems
for sharing blood test results.
It is also reported that if women are unable to get to their chosen place of delivery, due to
obstetric emergency or speed of labour, staff at Arrowe Park may not have access to
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information about the pregnancy or the woman. Hand held notes address some of these
issues and in the future, electronic records will assist further.
It is clear from observation of the environment at Arrowe Park, in particular the unit
entrance and delivery suite, that some investment is needed in the physical environment to
enable the unit to compete with its neighbours. There is no reception area for the maternity
unit. The environment is dated and unwelcoming and signage is unclear.
Recommendations

Service users to do an audit of the birth environment, using the NCT Better Birth
Environment toolkit and their feedback to be acted upon;

Future reports of poor midwife attitude to informed choice to be dealt with
individually;

Entrance area to be made more welcoming and the viability of a reception area on
the maternity unit explored.
Social Enterprise Organisation
A step change is required to provide women in the Wirral with services that offer flexibility,
support choice and normal birth. To drive change and service improvement, Wirral PCT
should consider inviting tenders from a midwifery social enterprise.
A team of midwives, working within a Social Enterprise organisation, could caseload a
fixed number of women. These midwives could work across deprived communities,
extending choice to women who do not have the means to choose other providers such as
Liverpool and Chester, or throughout the Wirral.
The Albany practice of midwives provides an example of good practice on which the social
enterprise could be modelled. In Deptford, the team of case loading midwives have
breastfeeding rates of 93% and home birth rates of around 40% (study of approximately
200 women).
Interestingly, Albany midwives are self-employed and contracted by Kings Hospital NHS
Trust to provide services to women in that deprived area.
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A Social Enterprise could also provide the small number of midwifery-led clinics in the
deprived communities, with scanning and assessment capability.
Recommendation
 Invite tenders from Social Enterprise organisation for:

small number of midwifery-led clinics in to be established in deprived areas with
scanning capability;

flexible midwifery services via case loading of women in disadvantaged areas.
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Antenatal Education
Antenatal education has a significant role to play in women’s choice. Women, midwives
and health visitors identified a need to review antenatal education provision (parent craft).
Antenatal education can support choice, normal birth and parenting skills.
Many women felt that the antenatal class had not added value and expressed a wish for
them to be improved. Women and health professionals report that content and quality of
sessions varies widely.
The NSF supports practical and emotional preparation for parenthood. Some practical
skills are taught in hospital, such as bathing and nappy changing. Whilst valuable and to
be continued, this does not routinely accommodate fathers or women who give birth at
home. It is also reported staffing levels mean that advice is not consistently offered.
Preparation for parenthood is not routinely included within antenatal education in the
Wirral and women’s feedback identifies a need. Labour in Motion sessions, which give
parents skills for normal birth, are significantly oversubscribed and only provided at Arrowe
Park Hospital and Neston. Antenatal education should be expanded and provided by
multi-disciplinary teams with in Children’s Centres. Plans to provide a six session rolling
programme at Seacombe Children’s Centre with a multi-agency approach are a positive
step.
Recommendations

Preparation programmes should include preparation for birth, breastfeeding and
parenting;

A team should provide the programme, which could include healthcare assistants,
trained parents, antenatal teachers from the voluntary sector (NCT), family support
workers and midwives;

Core content should be agreed, teaching aids and training provided to improve
consistency and quality.

More people should be trained to deliver ‘Labour in Motion’ sessions in the
community;

Antenatal education should be offered in Children’s Centres.
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4. SERVICES THAT SUPPORT NORMAL BIRTH
Normal birth is defined by the Department of Health as birth without surgical intervention,
use of instruments, induction, epidural or general anaesthetic. Normal birth rates have been in
rapid decline in the past ten years.
Normal birth %
Year
Arrowe Park
2003
2004
2005
2006
41
43
43
42
Liverpool
Women’s
47
46
47
46
Countess of
Chester
53
50
51
47
England
47
46.4
48
46.7
www.birthchoiceuk.com using figures from the Hospital Episode Statistics.
Normal birth rates in the Wirral are low. At a strategic level, there is very little focus on
facilitating normal birth. The very low home birth rate and historical absence of a
midwifery-led birth unit or water birth is an indicator of the prevailing medical culture of
maternity services in the Wirral.
It is reported that around 35% of women receive midwifery-led care. However, this figure
includes some women who would not ordinarily be counted as midwifery-led, including
women who use epidural pain relief and who have been induced.
A strong midwifery service is key to supporting normal birth as midwives are experts in
normal birth. Maternity Matters states “There is a need to empower midwives to promote
normal birth”.
There are highly motivated midwives working within the service who seek to support
women to give birth normally. However, there are a number of issues, including resources
allocation, clinical hierarchies and organisational culture that create barriers to this aim.
There is a lack of clinical leadership around normal birth. The Advanced Midwifery
Practitioners, whilst highly valued by midwives and medical staff, are described to be
undertaking the junior doctor role: are trained in the abnormal, such as assisted delivery
and blood sampling. AMPs are reported to promote normality on the delivery suite.
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However, involvement of medical staff without clinical indication and the imbalance in
clinical status is reported to be an ongoing problem.
It is reported by some midwives that the notes of women who are receiving midwifery care
are often marked with the name of a consultant obstetrician. This will have financial
implications in payment under Payment by Results, although services are currently funded
under a block contract. It also undermines a midwife’s autonomy and facilitates the
involvement of medical staff when caring for low risk women.
The North West Local Supervising Authority Audit Report on Statutory
Supervision of Midwives 2007 states “The majority of midwives report that training is not
allocated to the promotion of normality within the unit.”
The development of a midwifery-led unit and provision of water birth should enhance
normal birth. However, training should be provided to increase midwives’ skills in normal
birth across the labour ward. Normal birth is a realistic option for many women who are
deemed high risk and the philosophy of normal birth should not be limited to the midwiferyled unit.
The recent appointment of a maternity inpatient manager may have some impact on
increasing normal birth rates. There are plans to use this post to implement elements of
good practice from the All Wales Normal Labour Pathway to the Wirral. Wirral Hospital
Trust plans to introduce better and systematic screening of women by telephone on labour
ward to reduce unnecessary early admissions to labour ward.
Increasing home birth rates is one way of increasing normal birth. Evidence suggests that
home birth is a safe option for low risk women and that women who plan a home birth are
half as likely to have a caesarean section or assisted delivery (Chamberlain G, et al 1997).
They are also likely to have quicker labours and be more satisfied with their experience.
In Wirral Hospital Trust, midwifery does not have an appropriate voice at a strategic level.
The Modernisation Team, which makes key strategic decisions about maternity service
provision, does not include the Head of Midwifery and the clinical members are medical in
background.
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There is also evidence of ongoing discontentment among frontline midwives, relating to
work patterns and management issues. The Kick Start Midwifery initiative is to be
welcomed and must address these issues successfully to enable midwives to move
forward on normal birth and women’s choice. Midwifery at all levels should be an advocate
of normal birth and choice.
Recommendation

Midwifery to be given a voice at strategic planning level;

Clinical lead/s to be appointed for normal birth;

Home birth rates to be increased.
Culture and environment of care
Currently, the environment in the labour ward is clinical and not woman-centred. It is
noticeable that the language used in relation to provision of care in Arrowe Park Hospital is
medicalised and not user-friendly.
Women who have medical complications are told that the High Risk team is caring for
them. This likely to increase a woman’s anxiety and conveys, appropriately or otherwise, a
likely poor outcome for her or her child.
Women needing further monitoring during the day access the Fetal Medicine Unit. While
the name may be appropriate in some instances, the unit is often not practising invasive
medical procedures on the baby, as the name suggests, but performing monitoring and
assessment. Women access the unit for issues such as reduced movements of the baby
or significantly raised blood pressure. The term Day Assessment Unit is commonly used
for this function. This is a more user-friendly term, which is more accessible to women and
does not convey a sense of medical emergency.
Recommendation

Use of language reviewed to be more user-friendly;

Birth rooms made less clinical in appearance.
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Domino care
One way of increasing women’s choice, the normal birth rate and home birth rate is to offer
women the choice of ‘domino’ style care to women. Under this model, a midwife would
attend the woman at home in early labour to assess progress. If low risk, the woman
decides in labour whether to stay at home or go to hospital. If the woman chooses to go to
hospital, the midwife goes with her. This style of care is a feature of practice in Deptford
and South Devon, both of which have high home birth rates and normal birth rates. In
Milton Keynes, home birth rates went from 2% to 5% in two years by offering the choice of
‘domino’ care.
Recommendation

Choice of domino care for some or all women.
Caesarean section
In the past 15 years, the proportion of caesarean section births has been increasing
steadily in England. In 1989/90, caesarean sections accounted for 12% of all births, while
in 2005/06 the rate had risen to 24%. This increase in operative births has not been
accompanied by a measurable improvement in the outcome for the baby, and has been
shown to carry an increased risk to the mother of morbidity and mortality over normal
delivery (Focus On Caesarean Section: NHS Institute for Innovation and Improvement).
The caesarean section rate in the Wirral is broadly in line with the national average at 24%
in 2006. Focus on: Caesarean Section, a recently published NHS document that aims to
provide practical measures to reduce caesarean section, states that maternity units
applying best practice to the management of pregnancy, labour and delivery will achieve a
caesarean section rate that is consistently below 20% and will have aspirations to reduce
that rate to 15%.
C-section %
Year
Arrowe Park
2001
2002
2003
2004
2005
2006
16
20
20
21
22
24
Liverpool
Women’s
22
23
24
25
24
23
Countess
of Chester
18
20
19
23
24
26
England
21.5
22
22
22.7
22.9
23.5
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www.birthchoiceuk.com using figures from the Hospital Episode Statistics.
One of the measures advocated to reduce caesarean section is one-to-one midwifery care
for all women. The vast majority of women in the Wirral (95%) receive one-to-one
midwifery care in labour. Given that this level of one-to-one care is significantly higher than
the average figure in England (given as 37% at www.drfoster.co.uk ), one would expect
the normal birth rate to be higher.
In the Wirral, the single greatest reason for caesarean section in first time mothers, by a
significant margin, is failure to progress (37% of first time mothers having a c-section). For
women having subsequent babies, the most common reason is previous caesarean
section (27%), followed by fetal distress (25%).
Reducing the number of caesarean sections in first time mothers for failure to progress
must therefore be key to reducing the rate of caesarean section. This should be done by
reviewing whether the policy on when to intervene is evidence-based and by taking steps
to help progress of labour in first time mothers. These steps should include improved
midwifery skills, a better birth environment and a higher rate of home birth.
Obstetricians have recently altered the policy regarding induction of labour for women who
are overdue in an effort to reduce caesarean rates. This is reported to be having an effect
in reducing the caesarean rates.
Recommendations

Multi-disciplinary team focus on use of toolkit within Focus On: Caesarean Section
to reduce caesarean rates;

Increase home birth rate;

Make birth rooms less clinical;

Staff have access to training in normal birth;

Staff are exposed to normal birth during training.
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5. BREASTFEEDING
“Many women intend to sustain breastfeeding but stop before they want to because
of problems or lack of support. The government target is for breastfeeding initiation
is to increase by 2% per year, particularly among disadvantaged groups. Local
target setting should aim to achieve year on year increase in initiation and reduction
in the gap between initiation and reduction in the gap between rates of
breastfeeding at birth and at six weeks. The most effective way to do this is close
adherence to the UNICEF Baby Friendly ten steps and Seven point plan in the
community.”
Modernising Maternity Care: A Commissioning Toolkit for England
Breastfeeding can make a major contribution to public health. It has a significant role to
play in reducing inequality in infant mortality rates and life expectancy at birth (PSA Target
2) and to halting the rise in childhood obesity (PSA Target 3). Breastfeeding initiation rates
in the Wirral are low, at 53% compared to 71% nationally. At six weeks, 38.4% of all
women are still breastfeeding, compared to 43% nationally. Rates vary significantly
across the Wirral. Breastfeeding initiation rates in Birkenhead are reported in the Wirral
Children and Young People’s Plan (2006) as 47% compared to 73.5% in West Wirral.
(Wirral Children and Young People’s Plan 2006-2008)
Targets in the Children’s and Young People’s Plan are 51.2% in Birkenhead and 74.7% in
West Wirral by 2008. The plan recognises the contribution of Baby Friendly Status to this
goal.
There are a number of examples of good practice in relation to breastfeeding in the Wirral.
The breastfeeding support provided in the community by feeding advisors is highly valued
and well used by women and professionals. There is a milk bank on the Wirral.
Breastfeeding support is offered in Children’s Centres and there are a number of peer
support groups in the area.
The achievement of Baby Friendly Status was a major achievement by Wirral Hospital
Trust. The Trust lost Baby Friendly Status in February 2007 due to concerns about a
number of issues including changes in policy and inconsistent advice. It was reported that
the policy changes were made following poor outcomes for some breastfed babies. Wirral
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Hospital Trust has subsequently registered its commitment to regain Baby Friendly status
and has developed a new training programme for staff that has been approved by
UNICEF.
Around two thirds of women report feeling supported in their choice of feeding and some
women reported feeling very supported to breastfeed. One woman from West Wirral states
“lots of support for breastfeeding even someone to call and would come to house when
needed” and another comments “Breastfeeding support fantastic”.
A small number (5 of 148) report feeling pressured to breastfeed. Twenty eight comments
(around 1 in 5) related to a lack of support and many of the comments related to failure to
support breastfeeding. The evidence suggests that there are women from all areas of the
Wirral, including deprived areas, that wanted to breastfeed but did not receive the
appropriate support. Comments include:
“I never got a choice in breast feeding or bottle feeding they automatically took the baby
and gave him to his dad to bottle feed.”
“Breastfeed not shown properly as staff shortages and didn't have time”.
“Not supported at all I really really wanted to breast feed but was given a bottle and left on
my own”
All the women quoted are from Birkenhead, an area with particularly low breastfeeding
rates. Failure to support these women is a missed opportunity to make a significant
contribution to the health of that community.
There is a significant problem in the Wirral Hospital Trust in relation to breastfeeding.
There has been a serious backlash amongst some senior staff against the promotion and
support for breastfeeding following the adverse incidents relating to breastfed babies. It is
reported that the measures put in place subsequently resulted in the lost of Baby Friendly
Status.
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There is a perception amongst some staff that Baby Friendly policy is not always in the
best interests of the mother or the baby and there is open hostility from some staff to the
promotion of Baby Friendly practice.
Women are advised to stay in for three days if they wish to breastfeed to ensure feeding is
established. This is on the basis that staffing levels on the postnatal ward do not allow for
a woman to be observed feeding her baby for 45 minutes if women are discharged in
under three days (Maternity Advisory Committee minutes, March 2006). It is unclear
whether a lack of breastfeeding support in the community is also behind this
recommendation.
Informing women antenatally that they should stay in hospital for three days if they wish to
breastfeed is likely to discourage many women from breastfeeding. It also has huge
resource implications. Nationally 71% of women leave hospital by the end of the day after
they gave birth (www.ic.nhs.uk). Wirral Hospital Trust reports that the average length of
stay for all women, including all modes of delivery, is 2.5 days.
It is reported that, as a result of the poor outcomes, there is a focus on medical monitoring
of babies rather than on providing support to mothers to breastfeed effectively. Many
breastfed babies on the ward are on a protocol that involves regular checking of blood
sugar via a pinprick to the baby. Staff reported that this was distressing to mothers,
undermined women’s confidence in breastfeeding and consumed a great deal of staff time
which could otherwise be used to support women to feed. They also reported that they felt
the procedure is over-used.
The best way of avoiding poor outcomes in the future must be to provide women with the
help they need to successfully establish breastfeeding.
Women and staff report that the level of staffing on the postnatal ward is not adequate.
Women report long waits for pain relief and other elements of basic care. The evidence
suggests that midwives and healthcare assistants are significantly over-stretched. At the
same time, it is reported by some staff that there is an overprovision of healthcare
assistants on the antenatal clinics.
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There is also overprovision of midwifery appointments in the antenatal period (by two
appointments) for some women, according to the NICE guidelines for antenatal care. This
is due to failure to differentiate between women having first and subsequent babies.
There is a strong case for redirecting resources to facilitate earlier discharge via additional
support on the postnatal ward and in the community. There is confusion among staff
about the role of the specialist breastfeeding midwives. Some staff see the role as
providing direct breastfeeding support to women, other staff viewed these roles as training
and policy focused. The role of these midwives should be clarified to enable staff to
understand their own responsibilities and the resources available to women.
Community services in the Wirral (e.g. health visiting) and Wirral Hospital Trust are
working towards Baby Friendly Status independently. Collaborative working would
improve services and consistency of advice.
The NSF states that antenatal education should be provided about breastfeeding and
should include partners.
Recommendations

Stop recommendation that breastfeeding women remain in hospital for three days;

Additional support to be provided on the ward;

Additional breastfeeding support to be provided in the community;

Review current practice and policy of monitoring of breastfed babies;

Staff attitudes to be addressed where required;

Role of breastfeeding midwives clarified to staff;

Baby Friendly Status to be regained.

Antenatal education on breastfeeding to be offered, including partners;
6. CONTINUITY OF CARE
Maternity Matters seeks to ensure that service users experience good continuity of care
throughout pregnancy. This means that women should be supported by a midwife they
know and trust before and after the birth. Women and their partners should know all
members of the team and know how to contact them. (Maternity Matters 2007).
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The aim of team midwifery in the Wirral was to provide continuity of care throughout
pregnancy, birth and postnatally.
Continuity of care is provided to some women and is valued by them. Asked what was
good about their care, 15 comments out of 176 identify continuity of care. When asked
what was not good, 13 comments identified lack of continuity. There is no clear
geographical pattern among either group. Interviews suggest that women having children
in quick succession were, understandably, more likely to know their midwives.
Views vary among midwives on whether the model delivers continuity of care. Midwives
and women report that the size of teams has been increased since the pilot and that as a
result continuity is not provided consistently. However, figures from Dr. Foster suggest
that many more women in the Wirral know the midwife that attends them in labour than is
standard nationally (72% compared to 22%).
The focus of national standards is for continuity in the antenatal and postnatal period, with
less focus on care from a known midwife in labour. It is unclear from the data whether it is
important to local women that they know the midwife caring for them in labour.
The team model is currently under review due to discontentment among midwives with the
current application of the model.
A view was expressed from obstetrics that women would be better served by midwives
who specialised in intrapartum care. If this model is introduced, it will be important to
ensure the majority of those midwives are expert in normal birth.
Recommendations

Future midwifery model developed by Wirral Hospital Trust to deliver antenatal and
postnatal continuity to women;

Care pathway developed which is shared with women and provides contact details
for all relevant team members;

Women made aware of how to change midwife if relationship of trust is not
established.
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7. EFFECTIVE MULTI-DISCIPLINARY AND MULTI-AGENCY WORKING
Child Protection
Child Protection has been considerable advanced and multi-agency working facilitated by
the Child Concern Model. The child protection midwife is highly valued by medical and
midwifery staff and provides a valuable resource in an area with a high level of child
protection.
Links between maternity services and Wirral social services are good as a result of the
specialist midwife. However, there is scope for improvement.
Social services would welcome more informal contact from midwives for advice. Social
services report some in difficulty in contacting individual midwives in a timely manner;
paediatrics report difficulty in accessing social service team leaders. This has the effect of
delaying the discharge of some babies.
A concern was expressed that teenage parents-to-be often found themselves indirectly
discouraged from maintaining attendance at school. An example of this is pregnant girls
being told not to come to school in uniform.
Recommendations

Paediatrics to be supplied with up-to-date numbers of team leaders in social
services;

Midwives to be provided with numbers of area social service teams to access
advice;

Social services access to individual midwives to be facilitated.
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Midwifery and Health visiting
Communication between health visitors and midwives is poor. Joint meetings are poorly
attended and there is no hand over care from midwife to health visitor. Health visitors
report difficulty in timely access to a named midwife. There is no co-location of midwives
and health visitors.
Health visitors reported that when co-location was in place for a short time, communication
and interprofessional working improved dramatically.
Recommendations

Consideration is given to some co-location of midwives and health visitors;

A mechanism for handover of care is developed.
Mental Health Services
Mental Health services emerged as a major gap in services for women using maternity
services. Midwives, obstetricians and health visitors repeatedly identified major under
provision of services and lack of co-ordination. Over one in ten women will suffer from a
depressive illness after birth. Psychiatric illness is the main cause of maternal death in the
UK (CEMACH 2000-2002)
Currently, there is no overarching strategy or network for perinatal mental health as
required by the NSF. Wirral Hospital Trust has a care pathway for antenatal mental health
and it is reported that Cheshire and Wirral Partnership NHS Trust is developing a perinatal
mental health pathway for severely mentally ill women. Midwives report that relevant
mental health issues are not consistently identified in GP referral letters and that standards
of care provided by GP vary.
There is a Clinical Nurse Specialist (Liaison Psychiatry, Cheshire and Wirral Partnership
NHS Trust) who provides one clinical session a week at Arrowe Park Hospital for women
with antenatal mental health issues. However, long delays are reported in accessing this
service. It is reported that there is a dearth of service provision for women with mild to
moderate depression.
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The nearest mother and baby psychiatric unit is in Manchester. Staff reported real
difficulty in accessing care for severely mentally ill women. The lack of resources and coordination pose a high level of risk to women in the Wirral.
The National Institute of Clinical Excellence issued guidance for Antenatal and Postnatal
Mental Health in February 2007. Health care providers, including Wirral Hospital Trust,
Wirral PCT and Cheshire and Wirral NHS Partnership Trust) need to work together at a
strategic level to increase service provision and implement the guidance as a matter of
urgency.
Teenage women are three times more likely to be affected than other women, with 40%
likely to be affected (Social Exclusion Unit, Teenage Pregnancy 1999). The midwife with
responsibility for teenage pregnancy is not able to refer women to Children and Adolescent
Mental Health Service.
Consequently when a client requires mental health services, the midwife must ask the
woman to go via her GP. The teenage woman may choose not to access care rather than
open up to another health professional, where the same level of trust may not exist. This
can prove a significant barrier to appropriate care.
There is also a need for a counselling resource for pregnant teenage women. The need is
often short term and relates to disclosing to family. It has been available on a voluntary
basis previously. The responsible midwife suggested that an arrangement could be
sought with the local counselling training organisation for placements of near qualifying
students to provide a resource at little cost.
Recommendations

Ensure development of perinatal mental health strategy - implement NICE
guidance;

Ensure establishment of perinatal mental health network;

The teenage midwife should be facilitated to refer directly to CAMS;

Arrangements should be sought with the local counselling training organisation for
placements to provide short-term services to teenage women.
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8. INVOLVEMENT OF LOCAL WOMEN IN THE PLANNING AND MONITORING OF
SERVICES
Key to the involvement of service users in service planning is the Maternity Service Liaison
Committee (MSLC). The NSF recognises the role of MSLCs in bringing together
commissioners, service users and providers to plan and monitor services. North West SHA
endorses the role of the MSLC in the implementation of Maternity Matters.
There is an existing Maternity Service Liaison Committee in the Wirral, which has a lay
chair and is well attended by a range of healthcare professionals. Service user
representation on the committee is limited and below the recommended minimum of one
third.
It is reported that the primary function of the MSLC currently is for providers and
commissioners to share information between professionals. Service planning is not
achieved at the forum. Those issues of policy that are shared at the MSLC are for
information rather than discussion.
Decisions relating to maternity services in the Wirral are made at the Maternity Advisory
Committee and the Modernisation Team at Wirral Hospital Trust. The Maternity Advisory
Committee makes decisions on clinical policy matters. Appropriately, it is populated by
clinicians and is a proactive and useful forum.
However, views of commissioners and service users, via the MSLC, should be sought on
some policies and service issues. A good example of the kind of issue that requires this
input is the recommendation from the Maternity Advisory Committee that women should
be encouraged to stay in hospital for longer than 48 hours if they are breastfeeding (March
2006). The rationale behind this is that it is unrealistic to observe a woman for 45 minutes
before discharge on day two due to staffing restrictions.
However, this is likely to create a barrier to breastfeeding, is not woman-centred and may
well be an inappropriate use of resources.
Commissioners and women are likely to be of the view that resources would be better
targeted towards providing adequate breastfeeding support on the ward and in the
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community. Views of commissioners and service users need to be included in these
discussions and the MSLC should provide the forum for this.
Service redesign currently happens within the Modernisation Team at Wirral Hospital
Trust. There is no link between the Maternity Service Liaison Committee and the
Modernisation Team.
The Modernisation Team covers the whole of obstetrics and gynaecology. To implement
Maternity Matters, a Team to Support Improvements and Commissioning (TIC) needs to
be identified. The proposal from the Cheshire and Merseyside Maternity Perinatal Network
is that the MSLC is the appropriate vehicle for this.
To be fit for purpose, the membership and function of Wirral MSLC will need to be
reviewed and include relevant members of the Modernisation Team. The MSLC
should be of a size and structure to facilitate effective decision-making. Another forum or
method should be found for sharing of information between professionals groups.
To function effectively, the lay members of the TIC and the MSLC should be appropriately
funded and supported. This will enable wider and better participation. Channels should be
developed to give access to the views of service users, particularly those from deprived
areas and who are vulnerable and disadvantaged.
The recent community events to collect service user feedback for the Kick Start Midwifery
initiative and for this review are an example of good practice. The events were facilitated
by non-NHS staff and held in the community for existing groups. There is a wealth of
information that can be used to tailor services to meet women’s needs.
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There is evidence that there is resistance to listening to the views of women within
midwifery. The most recent North West Local Supervising Authority Audit Report on Statutory
Supervision of Midwives indicates that service user feedback was met with hostility from a
small number of supervisors of midwives. This is concerning and needs to be addressed.
Soliciting and acting on service user feedback will be key to service improvement in the
Wirral.
Recommendations

Terms of reference and membership of MSLC are reviewed;

Maternity Advisory Committee to make recommendations for consideration by the
MSLC on key service issues;

Midwifery to be given a voice at a strategic level of service planning;

Culture of inviting and acting upon women’s feedback to be developed;

Team to Support Improvements and Commissioning (TIC) for Maternity Matters to
include members of the Modernisation Team and service user representation (TIC
to be MSLC or MSLC related steering group);

Project to be funded to develop links with women from disadvantaged groups and
areas and views to be included on MSLC.
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CORE RECOMMENDATIONS
RECOMMENDATION 1
Commission routine midwifery care in Children’s Centres, providing:

routine antenatal care;

drop-in postnatal care;

joint midwifery/health visiting clinics;

additional breastfeeding support.
Rationale
 NSF compliant
 Women gain access to range of health, education and social services in one location
 Improved multi-disciplinary working
RECOMMENDATION 2
Commission a small number of community based midwifery-led units to provide:

Scanning facilities;

Facility for GP referral for non-routine midwifery care;

Facility for women to self-refer for non-routine care;
Rationale
 NSF compliant
 Improve access to disadvantaged women
 Reduce hospital admissions
 Increase women’s choice
RECOMMENDATION 3
Invite tenders from Social Enterprise organisation and others for flexible
community-based midwifery services for:

small number of midwifery-led clinics in to be established in deprived areas with
scanning capability as outlined under recommendation 2;

case-loading of women in disadvantaged areas.
Rationale
 Increase normal birth rates;
 Increase home birth rates;
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 Increase choice among disadvantaged women;
 Increase continuity of care;
 Provide local competition.
RECOMMENDATION 4
Oversee the development of an evidence-based local care pathway for maternity care
which:

includes direct access to a midwife;

offers a community visit providing information before booking choices are made;

reduces the number of routine antenatal visits for women having their second and
subsequent child;

sign-posts community based midwifery clinics.
Rationale
 NSF compliant
 Reduce unnecessary hospital admissions
 Increase women’s choice by knowledge of pathway options
 Enable appropriate allocation of resources
RECOMMENDATION 5
Commission services that support normal birth by:

Providing midwifery with a voice at a strategic service planning level;

Ensuring clinical lead/s for normal birth (Advanced Midwifery Practitioners or a
consultant midwife);

Commissioning a domino style care package;

Commissioning a fully functioning home birth service.
Rationale
 Increase normal birth in the Wirral;
 Increase women’s choice;
 Improve service provision.
RECOMMENDATION 6
Commission high quality antenatal education that:

Offers ‘Labour in motion’ sessions to all women;

Includes parenting preparation;
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
Supports informed choice;

Is provided in Children’s Centres;

Is equitable and of a consistently high quality.
Rationale
 Increase normal birth;
 Support choice;
 Improve parenting skills;
 Improve access to disadvantaged women.
RECOMMENDATION 7
Commission services that redistribute resources towards postnatal support, including:

Additional staffing on the wards, with resource for providing breastfeeding support to
women;

Choice of postnatal drop-in or home visits, including breastfeeding support;

Transitional care facilities.
Rationale
 Increase choice;
 Increase breastfeeding rates;
 Improved services.
RECOMMENDATION 8
Ensure that the model emerging from Kick Start Midwifery initiative offers women
continuity of care in the antenatal and postnatal period
Rationale
 NSF compliance;
 Improve outcomes for women and babies;
 Meet women’s wishes.
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RECOMMENDATION 9
Address deficit in mental health services for women using maternity services by:

establishing a strategy for perinatal mental health to implement NICE guidance;

establishing a perinatal mental health network.
Rationale
 Mitigate significant risk to women and babies
 NSF compliance
RECOMMENDATION 10
Strengthen involvement of service users, commissioners and midwifery leads in
service planning and monitoring by:

Reviewing the terms of reference and membership of MSLC;

Formalising relationship between Maternity Advisory Committee and MSLC, with
MAC to make recommendations on service issues to MSLC for decision;

Implementation team for Maternity Matters (Team to Support Improvements and
Commissioning or TIC) to include members of the Modernisation Team and service
user representation (TIC to be either MSLC or MSLC related steering group);

Project to be funded to develop links with women from disadvantaged groups and
areas and facilitate influence on service.
Rationale
 Meet PCT objective of service user involvement
 NSF compliant
 Achieve value for money for commissioners
RECOMMENDATION 11
Develop commissioning arrangements that:

Incentivise normal birth;

Incentivise breastfeeding rates and Baby Friendly Status;

Incentivise compliance with NICE guidance.
Rationale
 Drive service improvements via commissioning structures.
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NOTES ON THE AUTHOR
Jill Crawford is an independent consultant with expertise in maternity service provision. She
has significant experience of maternity service review as well as extensive background in
maternity services and expertise in facilitating involvement of disadvantaged maternity
service users in service redesign.
As a lay reviewer, she conducted Local Supervisory Authority Audits for Yorkshire Strategic
Health Authority (2002 - 2004). In 2005, she trained service users to audit services for
Thames Valley Strategic Health Authority.
In 2005 and 2007, on behalf of the Nursing and Midwifery Council, she reviewed maternity
services at Northwick Park Hospital to assess its suitability as a placement for student
midwives in the light of the maternal deaths at the hospital. Also in 2005, she undertook the
review into the role of the London Local Supervisory Authority in the run up to the
introduction of Special Measures by the Secretary of State.
Maternity service background
In 2001, Jill was appointed as a founding lay Council Member of the Nursing and Midwifery
Council (NMC) by the Privy Council. She was reappointed in 2006 and is Vice Chair of its
statutory Midwifery Committee, which sets national midwifery standards.
In 2006, she chaired Milton Keynes Maternity Service Liaison Committee, where she
reviewed service provision against the National Service Framework and facilitated the
involvement of teenage parents in service planning. Between 2000 and 2003, she chaired
Bradford and Airedale Maternity Service Liaison Committee, where she steered a project to
involve of service users from ethnic minorities and economically deprived communities in
service design.
She was involved in developing the maternity standard of the Children’s National Service
Framework, contributing to the standards for care in labour and service user involvement
(2004). She also contributed at a national level to the development of the choice agenda
across the NHS.
Between 2002 and 2007, she chaired Fitness to Practise hearings at the Nursing and
Midwifery Council. She is currently a lay panellist for the General Medical Council, where
she assesses the fitness to practise of medical practitioners.
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APPENDIX 1
The national objectives for maternity services, as set out in the Children’s National Service
Framework, are:

Flexible individualised services designed to fit around the woman and her baby’s
journey through pregnancy and motherhood, with emphasis on the needs of
vulnerable and disadvantaged women.

Supporting women to have as normal a pregnancy and birth as possible, with
medical interventions recommended to them only if they are of benefit to the woman
or her baby (NSF)

Midwifery and obstetric care being based on good clinical and psychological
outcomes for the woman and baby, while putting equal emphasis on helping new
parents to prepare for parenthood.
The strategic aspirations for Wirral PCT are:

To develop a new focus on patient and public involvement and develop systems
which give real time feedback to influence planning and commissioning;

To target resources to reduce health inequalities and narrow the gap in life
expectancy and infant mortality between different areas in Wirral

To develop primary and community services, to reduce avoidable admissions to
hospital and provide more community based alternatives to hospital care;

To develop an agreed vision for the unique and important role of Wirral Hospital
Trust in providing healthcare on Wirral;

To become a high performance high reputation organisation.
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APPENDIX 2
GATHERING VIEWS OF STAKEHOLDERS
Gathering Professional Views
During the course of the review, views were collected from the following professional
groups:

Midwives (specialist, team and ward)

Obstetricians

Paediatricians

Anaesthetists

Healthcare assistants

GPs

Health visitors

Social services
Views were gathered during a series of structured group interviews, using a list of questions
developed from the content of Maternity Matters (Appendix 3). Each group was made up
of a single professional group. Each session addressed a subset of questions from the list,
selected according to relevance to individual professional groups. All individuals were
offered the opportunity to respond to the full set of questions in writing after the group
interviews.
The list of questions was also circulated in survey form and a number of responses from
groups of health professionals have been received.
A response is awaited from mental health services.
GP views
The GP meeting was rescheduled due to poor availability for the initial date. In addition,
following the structured meeting with GPs, a briefing note outlining the views and
suggestions of those GPs in attendance was circulated to all GPs, requesting responses to
this and to the survey.
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Views of Midwives
Wirral Hospital Trust held a one-day event in April 2007 for midwives. The event, entitled
Kick Start Midwifery, was well attended and solicited views of midwives on the strengths
and weaknesses of the existing midwifery services. The data produced at this event has
been used to inform this review.
Gathering Service User Views
Fourteen events were held in Children’s Centres and other community venues throughout
June 2007 and were attended by around 200 women who had recently used the service.
The women were asked a series of questions (Appendix 4) and were provided with post-its
or questionnaires (2 groups of the 12 to record their comments. The sessions were
facilitated by Health Care Co-ordinators employed by the Local Health Authority
Events took place in:

Birkenhead and Tranmere Children's Centre Area

Rock Ferry Children's Centre

Leasowe Children's Centre

Bromborough Children's Centre

Upton Children's Centre

Claughton Children's Centre

Wirral Toy Library and Resource Centre - Prenton

Teddy Bears Group - Claughton

Family Group - Civic Medical Centre - Bebington

Postnatal Group - West Kirby Concourse

Bidston and St James Children's Centre Are

Seacombe Children's Centre
Six women on the postnatal ward at Arrowe Park Hospital were also interviewed, using the
same structured approach.
Service user views from previous surveys and complaints data was also accessed.
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APPENDIX 3
WIRRAL MATERNITY SERVICE REVIEW
SURVEY
Introduction
This survey forms part of an independent review of maternity services in the Wirral. The aim
of the review is to enable the Primary Care Trust to commission services that meet the
needs of local women and their babies and reduce health inequalities in the area.
Not all questions will be relevant to all professional groups. Please feel free only to answer
those questions that are relevant to your role. If you need more space than is provided,
please attach additional sheets and indicate by number and letter which question you are
answering.
Confidentiality of respondents will be maintained. Any comments will not be attributed to
individuals but may be attributed to professional role.
1. General
a) What are the strengths of Wirral maternity services?
b) What needs to be improved or changed to meet the needs of women and babies
more effectively?
c) Are there elements of care that are routinely provided which are not evidence-based
or are unnecessary?
d) Are there any primary and/or community services that could be developed to reduce
avoidable admissions to hospital and provide more community based alternatives to
hospital care?
2. Reducing Health Inequalities
a) Who are the vulnerable and disadvantaged women and babies in the Wirral? e.g. social
group, area, condition.
b) What could be done to make services more accessible to them?
c) How could services better meet their needs?
d) Is there any thing else that could be done to reduce the health inequalities between
maternity service users living in the different areas of the Wirral?
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3. Choice
a) What choices do women have currently?
b) Is there anything that women want to choose that it currently not available or is difficult
to choose?
c) What issues do women want to exercise choice over?
d) What could be done to make services more flexible and tailored to the woman and her
baby’s individual needs?
4. Normal birth
a) How well do maternity services in the Wirral support normal birth?
b) What is currently being done to increase normal birth rates?
c) What else could to be done to increase normal birth?
5. Breastfeeding
a) How well is breastfeeding is supported in the Wirral?
b) What is currently being done to increase breastfeeding rates, particularly among
disadvantaged women?
c) What else could be done – generally and among disadvantaged women?
6. Parenting
a)
Do parents currently receive any preparation for new parenthood?
b)
What else could be done to better prepare new parents for parenthood?
7. Multi-disciplinary and multi-agency working
a) How easy is it for you to refer women and babies to sources of support outside your
area of expertise? e.g. mental health services, housing, domestic violence.
b) Are there barriers to good multi-agency and multi-disciplinary working? If so, please
state.
c) Are there gaps in the support available? If so, please state.
Please indicate your professional identity/role here e.g. health visitor, midwife.
Is this a response from an individual or on behalf of a group? If a group, please
indicate the number of people represented
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APPENDIX 4
QUESTIONS – SERVICE USERS KICK START EVENT
1. What do you think was good about your care?
2. What did you not like about your care?
3. What would you like to be offered that is not currently available?
4. Was there any part of your care that you felt was unnecessary or did not add value?
5. Which professional would you like to be your first point of contact when you think
you are pregnant?
6. What do you feel about the current booking system? (Your 1st visit to the hospital).
7. Were you asked about where you would like to have your baby?
8. What do you understand by midwifery led care?
9. Did you feel you received enough information during your antenatal period at a time
when you wanted it?
10. What did you understand of the role of your G.P. during your pregnancy and
postnatal period?
11. What did you feel about the communication systems in place to help you in planning
your care?
12. Would you like to comment on you experience of Team Midwifery?
13. If you needed any specialist service was this available to you?
14. Was information available in the local area to prepare you for parenthood?
15. Did you feel that your birth experience was promoted as a normal event?
16. Was a midwife available to be with you throughout your labour?
17. What was good about you postnatal care in hospital/community?
18. What could we have done better during your postnatal care in hospital/community?
19. Did you feel adequately supported in your choice of feeding?
20. What are your comments about where your care was delivered?
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APPENDIX 5
LIVERPOOL MODEL OF ANTENATAL CARE
Reproduced from Liverpool’s plans for midwifery led care, with thanks to Grace Edwards, Consultant Midwife at
Liverpool Women’s Hospital
Pregnancy confirmed by GP/midwife
Early pregnancy problems
Early Pregnancy Unit
Health assessment by midwife/GP
Not pregnant
Referred for booking
Low Risk Pregnancy
Guidelines determine risk factors
High risk pregnancy
Community based care
Midwife led
care
Consultant & specialist
midwife care
GP/Midwife
led care
Risk factors develop transfer care
according to guidelines
Day assessment unit
In patient
Consultant Clinic
Obstetric assessment
Centre
Fetal assessment Centre
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APPENDIX 6 Location of Children's Centres (www.wirral.gov.uk)

St James’ Centre,
334 Laird Street,
Birkenhead,
Wirral
CH41 7AL

St Werburgh’s Catholic Primary School,
Park Grove,
Birkenhead,
Wirral
CH41 2TD.

Leasowe Primary School,
Twickenham Drive,
Moreton,
Wirral
CH46 2QF

Ganney’s Meadow Early Years Centre,
New Hey Road,
Woodchurch
CH49 8HB.

Mount Primary School,
Mount Pleasant Road,
Wallasey.
CH45 5HX.

Liscard Primary School,
Withens Lane,
Wallasey,
CH45 7NQ.

Rock Ferry Primary School,
Ionic Street,
Rock Ferry,
CH42 2BL.

Seacombe Family Centre,
St Paul’s Road,
Seacombe,
Wallasey,
CH44 7AN

Bromborough Children’s Centre,
Gratrix Road,
Bromborough.
A further 10 Centres will open over the next four years. For further information on your nearest Children’s
Centre, call the Children’s Information Service on 0800 0858 743.
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