Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Professor Mary Renfrew, who is professor emerita at the University of Dundee. I invite you to give us a brief introduction and overview, after which we will go to members' questions.

Professor Mary Renfrew (University of Dundee): Thank you very much for your invitation to talk to you today. I have 10 minutes to speak to you about the report and will then take questions; is that right?

The Chairperson (Mr McGuigan): Yes.

Professor Renfrew: Excellent. It is very good indeed to talk to you about this report, which I was privileged to lead, and to discuss its important implications going forward. I plan to summarise the report briefly and then to consider the next steps. While the report has my name on it, I want to acknowledge that it was the result of work by hundreds of people who participated in various ways, including women and families as well as colleagues from throughout Northern Ireland and beyond.

As I am sure that you know, the report was commissioned as the result of safety concerns, specifically around a free-standing midwifery-led unit and a coroner's report that requested the first two terms of reference of the report, which was looking very specifically at those issues. The third term of reference came from the Department of Health's oversight group, which asked me to look not only at that issue but at the integration of midwifery services more broadly within the wider maternity services. That is why it turned into a bigger brief.

The context of the work is that maternity services do not exist in a vacuum. They are hugely affected by socio-economic conditions — you are much more familiar with those than I am — and specifically, in maternity terms, they are affected by the way in which the whole system works. We tried very hard to look at that. At the outset, we were seeing inequalities in outcomes and experiences, and we were seeing that the rates of perinatal mortality for babies was higher in Northern Ireland than in other jurisdictions in the UK. We were seeing that no maternity strategy had been in place since 2018, and we were seeing the highest intervention rates that we have ever seen for caesarean section and induction of labour. In that, Northern Ireland is similar to the rest of the UK, but the rest of the UK is very different from other similar economic countries. The Republic of Ireland is also very similar to Northern Ireland and the UK, but it is very different from other places. A very different model of care has developed over the past five to 10 years.

Our methods, which I will not go into in detail, were comprehensive, structured, systematic and robust. It was the first report on maternity services in the UK to take a whole-system perspective and to draw on good-quality evidence about what women and babies need in order to inform the solutions and the steps forward. The report looked at strengths as well as failures. We did not just look at what was going wrong; we tried to learn lessons from what was going right, and it is important to acknowledge that. There was input throughout the process from an expert group of colleagues from across the UK, senior colleagues from across Northern Ireland and, very importantly, stakeholder and advocacy groups to provide the service users' views.

The headline findings are that women reported difficult experiences across the whole maternity journey. Often maternity care focuses on the safety discourses around labour and birth. In fact, women told us that there were problems from pregnancy, labour and birth and postnatal care that affected their physical and mental health, their well-being and their relationships with their babies. There were three very difficult points in that, all of which matter.

First, in pregnancy, the care that they received did not enable them to have the information, discussion, care and support that they wanted. Secondly, in late pregnancy, there was a bottleneck as women came in for induction, but the service was not staffed to deal with the numbers coming through for induction of labour, which has really increased in recent years. Thirdly, and possibly most importantly, postnatal care was very difficult for all women. It was very much affected by the caesarean section rates of more than 40% and the low staffing rates on postnatal wards as midwives were called to labour wards. That was possibly the most widespread and biggest difficulty for the women who talked to us.

There was a lack of integration across settings. The community units were working in isolation from the hospital, as was care at home, including home births. It was as if the staffing was working for the buildings and the settings and not for the women and the babies. It was clear that the current model of care, with high intervention rates, which I have described, has developed piecemeal. It is not specifically demonstrating improvement, and it has not been evaluated.

There were positive experiences; indeed, there were good examples of services that were very successful and good examples

and genuinely committed staff. However, the positive experiences were not widespread and were not gaining traction across the whole service, and staff are not working in an enabling environment that allows them to do the job that they want to do. There are long-standing staffing issues that are amplified by the model of care that is very resource heavy in the labour ward. Women and staff alike describe working in a culture of fear. Staff and student stress and distress were palpable. In particular, midwifery staff described difficult problems. They felt disempowered, which was resulting in critical safety and quality gaps and was affecting staff retention and sickness absence rates. The findings that I have described were not particularly visible to senior levels of the system, and that, in itself, was quite a challenge and an issue. Indeed, even now, the findings have not necessarily been accepted by all.

There are solutions, and those were identified not only from the evidence but from the women and the staff. We heard all those voices tell us what they want to see happen and what they thought would work. We aligned that input with the evidence. Northern Ireland has a real opportunity to create positive change. In summary, there are three key issues, and that is summarising down the 32 recommendations. Right at the heart is the need for a reconfigured relationship with women to turn them into empowered participants and not passive recipients of care, and for women, families and communities to have a voice in how the maternity service is run at all levels. The second component is an enabling environment for all staff. That includes education and support and a shift in culture away from the culture of fear towards one that is more supportive, more listening to what staff say and more of a voice at higher levels through the system. The third component is reformed and transformed systems for commissioning, governance, accountability and education.

Taken together, those would transform the system and the services for women, babies and families. It will require a real shift in thinking and behaviour and the development of different relationships between disciplines, between hospital and community services and between organisations, including trusts, commissioners and universities, all listening to one another. It will involve better and more accessible data. Above all, it will be a radically different view of women and families.

There are real strengths to build on, and I am very conscious of those. Women and families want to engage. They really want to be part of the solution. There is real staff commitment, and staff also want to engage and be part of the solution. There is a strong undergraduate education programme, good-quality evidence of what should be in place and positive examples of services that work. There are terrific staff who really are role models and shining examples of how to get it right.

Many senior colleagues want this to work, but moving any system is hard, and it involves working across organisations, geography and disciplines. Again, you know much better than I do that, at a time of existing pressure and resource constraints, it is even harder. The recommendations aim to help with that: to free up some of the stasis and to implement transformative actions. As I wrote those recommendations, I had in my mind feasibility and sustainability. We believe that they are feasible, possible and not overly aspirational but with a phenomenal transformative effect, were they to be implemented.

This all matters because maternal and newborn care and services have a short-, medium- and long-term effect on women, babies and families and, ultimately, on everyone. Ultimately, everyone moves through the maternity system, certainly at birth and as part of a family and a community. Everyone is affected. [Inaudible.]

You cannot shift inequalities unless you start at the beginning of life. The way in which we care for women and babies at the start of life is the measure of any society. I believe that Northern Ireland has a fantastic opportunity to get this right, given the phenomenal, positive conversations that I have had with so many people who want to participate.

Thank you for listening to me, and I look forward to discussing this with you.

The Chairperson (Mr McGuigan): Thank you very much for that, Professor Renfrew.

I am going to caveat my comments, as you caveated yours in the report and in your contribution, with the observation that many women had a good experience throughout their pregnancy and interaction. However, in parts, your report is damning. It highlights a disjointed service, inadequate provision, deficits in care, staff not working in good conditions and a lack of staff support. You then go on to talk about things such as the high rates of induced labour and caesarean sections. All of that led to a quality of care that, in some cases — too many cases — led to bad outcomes and experiences for mothers and babies.

In your presentation, you said that some of the inadequacies and deficiencies were not visible to senior staff at the time and that some of the recommendations of your report have not been accepted. That is worrying. I ask you to elaborate on that issue, as it is concerning.

Professor Renfrew: Up to a point, it is not surprising that some of what was happening was not visible to people at senior levels of the system. There has been no large-scale survey of women's views and experiences in Northern Ireland for many years, so there has not been a systematic

women's views and experiences. There has been a reliance on a system that is in place, but it is not appropriate for maternity care. It is called Care Opinion; you may have come across it in other areas of healthcare. The problem with relying on that as a way of gathering views is that it involves women proactively logging on and filling in the form. For reasons that I went into in detail in the report, that does not tend to work in maternity services. After the birth, women literally have their hands full, and it is difficult for them to find the space and time to go in and tell people their views, unless they are specifically approached in sensitive ways. There has been no straightforward mechanism for people at senior levels of the system to know.

The other reason why it has been difficult is that, because of the way in which senior management works, the most senior midwife in the system, the head of midwifery, does not have a voice through to the board in all trusts, so that voice is carried by the executive director of nursing. None of them, at the moment, I believe, has a particular background in midwifery. They do a fantastic job; please do not hear that as me criticising them. There is a gap, however, between the day-to-day knowledge of what is happening in the service and the discussions at exec and board levels. More than one of the recommendations tries to address that gap and bring those voices directly in to better inform senior management. Until that disjunction is fixed, it will be difficult for people in senior roles to have confidence that they are really getting to grips with what is happening. Does that make sense? Does that answer your question?

The Chairperson (Mr McGuigan): That gives a better picture of it. Thank you.

Ms Flynn: Mary, thank you so much for your report and for being with us today. We spoke at the all-party group on women's health when the report was in draft form. The work that you have done alongside the others whom you mentioned in your introductory remarks is fantastic and probably long overdue. We can see that when we look at some of the recommendations and the gaps and issues that you highlighted in the report.

We have asked the Department and the Minister multiple times about the outdated maternity strategy. While your report was still in process, they noted the number of reports on maternity care and maternity services, and the Department's most recent response about the strategy was that it would await your report, because it would take account of all the reports on these important issues and lay the groundwork for a renewed maternity strategy. I want to get your view on the need for an updated maternity strategy. How important would that be? Should the focus be specifically on the implementation of the recommendations of your report instead? It is about what will make most difference to women and babies, who need consistency in care.

My second question follows up on the Chair's remarks on the gap between service provision and leadership and senior management. You mentioned that your published findings have not been accepted by all. I am not sure how much you can elaborate on that, but it is important for us, as a Health Committee, to know about the response to this report from the leadership, because it will be the leadership of the trusts and the Department that needs to oversee and help with the implementation to make things better. I am not sure whether you can elaborate any further on that remark.

Finally, you mentioned that there have not been many surveys done to get women's opinions or feedback on the care that they received. You will know that the women's health action plan is now a big piece of work that the Minister and Department are undertaking. A survey is live at the moment to get feedback from women. In the work that you carried out on the report and all its recommendations, what interaction have you had with the Department about how to insert it into the delivery of a women's health action plan? Surely, in light of the issues that have been raised, it must be a priority for the overall women's health action plan.

Professor Renfrew: Thank you for those questions. They are all very important. I will take them in turn.

Do you need a maternity strategy? When I talked with the various constituencies and groups at all different levels of seniority, one of the really clear things that I heard was the very diverse view of maternity and newborn services. If I do not keep using the phrase "maternity and newborn", please hear it, because one of the really important things is not to separate women from babies. There is silo working when it comes to women and babies between disciplines and between community and hospital care. There are big gaps. Certainly, there is silo working between senior levels of the system and further down the system.

There are also inconsistencies across trusts and different cultures and philosophies of care happening between disciplines. If you brought into a room any random selection of the various disciplines that all have to work closely together with women — there are multiple disciplines that have to do so — and asked them to tell you what their approach to care was, you would find that they were different between each other. They are not all different from each other. Some have real agreement, but you would get tremendous diversity. The only way to address that is to have an agreed way forward between everybody and an approach to care or model of care that is shared across trusts and disciplines at all levels of the system. You will not get that by accident. It needs to be worked at. That involves a shift of culture and, hugely, conversations between people about what matters and what is right. What are the right ways forward?

I will give you one example of that before I move on. Northern Ireland has brought in a policy of supporting continuity of midwifery care. It is a hugely important intervention. It has a whole range of very positive

, almost more than any other intervention in maternity care. It brought that in two or three years ago. It was agreed very widely, but it is not hugely being supported by everybody or resourced at the level where it is going to really make a difference. The midwives are working really hard to put it into place, but the system, by which I mean the board, senior management and interdisciplinary colleagues, is not really wholeheartedly supporting it. That is already a diversity, if you like, or an inconsistency in what one discipline is trying to do versus what others are trying to do at different levels of the system. Women want it: they have made it clear that they want it, and the evidence base for it is very strong.

Without a strategy that is agreed between everybody — all the trusts and the other organisations working in the field — I do not believe that there will be the collaborative strength to move forward and transform the system, if I can put it that way. If you are going to move a system, everybody has to move in the same direction.

Your second question was about whether the gap in service provision is accepted by all. Quite honestly, I do not know the extent to which it is accepted or not accepted. I have had many conversations with colleagues and with women and families across Northern Ireland, but I have not had very many of those conversations since the report was published, because I have not been back very much. I came back for one workshop, at which it was accepted positively. I believe that the Department of Health is wholeheartedly behind this; I have no reason to think otherwise. There are conversations about where best to put the priority and where best to put the resources, but those conversations are about logistics rather than being about the principle. That is what I believe, having spoken with colleagues in different arenas across the Department of Health. Inevitably, understandably and not surprisingly, those conversations are in the trusts, where people are trying day-to-day to do their jobs and to deliver the care. I do not have to tell you how stressed the trusts are day-to-day. The thought of changing what they do while under that level of stress is difficult. Furthermore, because the messages have not been heard clearly from other places — they have been heard from other places, but not clearly — and because of the factors that I mentioned to the Chair about how hard it is for staff at some levels of the trust to hear those messages, I think that there is questioning and pushback from some levels. I think that that is the case, but I cannot quantify that. It would be surprising if there were not pushback. I have run enough implementation projects during my career to know that there is always pushback.

That said, it is important that everyone who is involved in maternity and newborn care and in public health everywhere else in Northern Ireland accepts what is in the report. I have recorded only what I was consistently told to be the case. I am a researcher to my bones: I try to record what I hear. That is what I do. I do not over-egg or prejudice that: I write down what I hear. That which is there in the report, which was scrutinised by many people in the process of its being written — none of it was a surprise to people when it was published — is what we heard, so it needs to be taken on board by all levels including the boards, the execs and right through.

The Chairperson (Mr McGuigan): Órlaithí, you had a third question.

Ms Flynn: Sorry, Professor, I am not sure whether you will have this detail. My question was about the survey for the women's health action plan. Have you had any interaction on how the report will fit into that piece of work?

Professor Renfrew: Thank you for reminding me of the third question. I have not had direct interaction on that. Indirectly, I believe that that survey is being led by Dr Jenny McNeill from Queen's University, who was instrumental in supporting the report, so there is an immediate bridge there. I do not know, however, whether Dr McNeill has the direction in the terms of reference to focus on maternity care in that survey. It is very important that that is done, either as a separate survey or as an integral part of that work.

Ms Flynn: Thank you.

Mr Donnelly: Thank you, Professor, for your presentation and for being with us today. I agree with the Chair's comment that it is damning report. Some of the conclusions are shocking.

You mentioned a shift in culture. What specific key systemic changes are needed to address the concerns that are highlighted in your report?

Professor Renfrew: That is always the most important question because, until the culture shifts, I am not sure that much else will shift. The current culture, as described to me by women as well as by staff — they could feel it; it was palpable — is what they called:

That meant that staff are anxious when they are working. Rather than feeling confident, supported and that they are doing the right thing and that, if something happened, they would be supported, they are making decisions in case something goes wrong — they are assuming that things might go wrong — and, if things go wrong, they feel that they will be blamed. You could also call it a blame culture. That means that a certain type of care is given — it is a just-in-case care. For example, women are being recommended to have an induction of labour at very high levels beyond the NICE guidance that the NHS in Northern Ireland follows. That guidance recommends certain conditions in which women will be offered induction of labour. The number of women having an induction is well beyond that recommended by NICE, and inductions tend to be given just in case. However, without a survey having been done of that, who knows why it is happening? It has not been surveyed. There seems to be an attitude of, "You're getting towards term. We'd better bring you in". I am caricaturing to make a point. That level of 40% of women having an induction of labour is nowhere near NICE guidance, so it needs to be scrutinised to see why it is happening. It is a just-in-case culture.

What would shift that? Staff felt very unsupported; they felt that, when things go wrong, they are being blamed and that, when adverse incidents are investigated, there is almost a kind of headhunting going on to find who was responsible rather than learning lessons and moving to what we would call an open learning culture where the lessons, rather than the hunting for blame, become the important thing. That has led staff of all disciplines to feel fearful.

It has a particular impact on midwives. One of the things that has happened across the UK in the past 10 years is that midwives have received a disproportionate level of blame in some of the big maternity reports that have come out in England. The work of midwives when there is a labour — let us look just at labour for a minute and set pregnancy and postnatal care aside — is to offer care, support, confidence, reassurance and skilled care to help women through to birth their babies. Of course, when things go wrong, interdisciplinary care is required, but midwives' confidence in the work that they do has been challenged and undermined to an extent. It is quite hard for them, I believe, to feel really confident that they can carry on with that reassurance and confidence to help women through what might be a challenging labour without taking that just-in-case action. My report recorded caesarean section rates across Northern Ireland at 40%, but, in some trusts, they are over 50%. They are still going up — my point is that they are still going up. They cannot all be life-threatening situations and life-saving decisions. Important as a caesarean section is, half of women

section, it is hard to credit that it will be carried out as a life-saving intervention in every case. There is an act just-in-case thing, which is that culture of fear.

A number of steps in the recommendations would help, but you have to see them as a piece. First, let us step back from the blame culture and put in assistance for staff so that they feel that they are supported in their job and that, if things go wrong, as they do in maternity care, they will not necessarily be blamed; rather, they will be understood and supported, and when the incident is investigated, everybody will learn the lessons.

Another factor is that individual staff often carry the can for the problems of the system. If there are not enough staff, and there frequently are not, and people are running between different jobs and different women at the same time, it is very difficult to always get it right. It is important to say that I do not, and would never, excuse bad care. That is not my point. My point is that it is very difficult for staff to feel confident, supported and enabled in their job right now. In maternity care, that really matters. A sense of anxiety in a labour ward affects the staff and the women, thereby affecting the labour. There is a very direct physiological pathway from anxiety hormones to labour not going well.

I do not think that I am answering your question particularly well. At the heart of the steps that I laid out a minute ago, there has to be a reconfigured relationship with women so that their voices are heard when they talk about what they want and what the services should look like. One could argue that there should also be a reconfigured relationship with staff to hear about what they think is needed. Lots of the staff told me about things that they need, I saw what things are needed and the staff know that they are needed. Systems are also needed to make sure that staff are provided with those things.

Mr Donnelly: Thank you, professor.

Mrs Dodds: Thank you, Professor Renfrew. What you described for us is almost frightening in many ways. It describes a dysfunctional situation. Whether it is senior staff, midwives on the ward or whatever, the situation is very difficult. We have just finished a conversation about the numbers of C-sections and inductions that happen in Northern Ireland. Yesterday, we, as a Committee, visited the new maternity hospital. I asked about the number of C-sections and inductions in Northern Ireland and the reasons for them. I was told very brusquely by the consultant on duty that C-sections are a clinical decision. You have told us today that not all C-sections are clinical decisions, and you told us about the rise in rates of the procedure. I have looked at your report — it is why I asked the question yesterday — which states that they are not all necessary. I would like you to explore that a little further.

We do not have a mother-and-baby unit in Northern Ireland for those women who suffer from postpartum psychosis. What is the impact of that in Northern Ireland and on healthcare in Northern Ireland? We have talked a lot — this is the third area that I would like to explore — about the impact on midwives of decisions not being clearly communicated between senior staff and midwives and on the lack of staff on wards etc. There is also another element to that, and that is the impact on mothers and children.

In our papers for this week, we have a letter from one of my constituents that states very clearly what the long-term psychological impact is on the mother and on the child, who now has to receive various therapies etc. Again, I would like to explore that.

Finally, do you think that the Department is serious in addressing the issues? What evidence do you have that it has looked to address the issues thus far?

Professor Renfrew: Thank you, Diane. I am just writing all that down so that I can keep those questions clearly in my mind. Asking whether all caesarean sections are necessary is quite a complicated question to answer. I am not saying that, when it comes to the point of the decision, people are making that decision lightly or unnecessarily; I am saying that the journey through to that decision makes the section much more likely. I raised issues that go across the whole maternity journey, including the limited care and support in pregnancy with information, discussion and working directly with women in pregnancy on the midwifery care that they should get; the high rate of induction of labour, which is associated with higher rates of caesarean section; and the stresses and constraints in the labour ward that we just mentioned. If you add those, you get an environment where the context is making caesarean section more likely. There are psychological and physiological pathways to that, but you can probably follow that simply the workforce pressures, the anxiety and the lack of information and support in pregnancy for women will come together to a point where things in labour will get difficult and stressful. That is one component to put in the picture.

The second component to put in the picture is the fact that about half of those sections are elective and not emergency procedures. They are elective for a number of reasons. Some of those reasons will be based on clinical decisions about the potential for a birth to be difficult, but some are now becoming maternal choice where, from the start, a woman will say, "I want a section". That is a very complicated thing, because, of course, women are responding to what they see and read and what they hear from their friends and family who have been through the system. If you look at studies of women who request caesarean section and listen to the women whom I spoke to, you find that they are anxious and scared and do not want the kinds of experience that they are hearing about, which might be a long and complicated labour and then an emergency section. They want to avoid that. A mix of things is going on.

One of the things that happens in a clinical decision is a risk assessment. Any clinician who is making a clinical decision will do a risk assessment of what is in front of them. When you lay out the risks of caesarean versus physiological birth, you find that there are a lot of considerations that often do not happen. That is also why it is a complicated issue. There are sequelae to having a caesarean section. A caesarean section is a major abdominal operation that is followed by around six weeks of recovery. It has a number of clinical complications in that short-term timescale. It also has serious complications for future fertility and future pregnancies, so the debate about the caesarean section rate has to take those into account. I said in the report not that we should reduce the rate of caesarean section but that we should assess and evaluate the current model of care, including the high induction and caesarean section rates and the way in which care is given, right through the whole maternity journey, from pregnancy, labour and birth to postnatal care, to work out whether it is actually improving outcomes. If you look at the outcomes, you see that they have been getting worse, not better.

At the moment, we have no evidence that the current model of care is working to at least improve survival rates. Women were telling me that the current model of care is affecting their emotional and psychological well-being as well as their physical health postpartum. They did not talk about the future, because they were not thinking about it, but the data and other studies show that their future fertility and complications in future pregnancies can be affected.

I cannot stress enough how complicated postnatal care is. It came out in the report as the top priority. That is because it is not adequately staffed to deal with the current model of care. That is the way that I would put it. Women who are just out of caesarean section find themselves, post major abdominal surgery, with a baby to look after. I also acknowledge the women who have perinatal loss and are struggling in postnatal care. Staffing in postnatal care is not a priority, so midwives are getting pulled away. People are trying to deal with that, but for as long as the current model of care and staffing levels exist, that is what will happen. It is a self-fulfilling prophecy.

You will get diverse views. Any obstetrician will tell you, "We do sections only when they are needed". At that point in time, they are often right, and I would not want to argue with them. I am saying that the journey to get to that point is what is needed for care, attention and better support of women through pregnancy and labour to tackle that culture of fear and anxiety, high induction rates and everything else. I am sorry; I am repeating myself now.

Did that answer your question, Diane? It is a complicated question.

Mrs Dodds: I think that it did. Thank you for that. It is something that we need to think about.

The Chairperson (Mr McGuigan): Professor, I must alert you to the fact that we have the Minister coming in at 3.00 pm, so this session has to end at 2.58 pm, regardless of where we are in the proceedings, unfortunately, because it is such an important issue.

Professor Renfrew: OK.

The Chairperson (Mr McGuigan): We have Nuala left to ask questions.

Miss McAllister: Thank you, Professor. I apologise for being late; I was at another Committee that was running over time. I have a few questions, and they are relatively quick.

I noticed in the report that the number of VBACs seems to be more encouraging in Northern Ireland compared with the other regions. However, I am not an expert, so I wanted your thoughts on whether that number is encouraging. Also, are you encouraged by the breastfeeding rates in Northern Ireland?

I had two births that were polar opposites: one scary and one absolutely amazing. One of the key elements in that was choice. Does choice come into induction often enough? There are women who would choose and want to choose an induction for their own reasons, which are often medical or for mental health, and they have had a long and laborious journey.

Whilst induction is not always done for strictly physical medical reasons, the number who have it is wide-ranging. I agree that it is concerning that the number of inductions is so high, but choice is also important. I have just those three questions. Thank you.

Professor Renfrew: Thanks, Nuala. I will try to answer them briefly. On your first question about VBAC, were you asking about the Northern Ireland rate versus the rate in other jurisdictions?

Miss McAllister: Yes. Are those numbers encouraging? I think that, when I compared the numbers in the report, we were not too low down on the list of percentages. Oh, maybe we were; I have read it wrong. A lower percentage is bad; a higher percentage is better.

Professor Renfrew: A higher percentage of VBAC is good.

Miss McAllister: Yes.

Professor Renfrew: VBAC stands for vaginal birth after caesarean section. They happen so that caesarean section does not become a self-fulfilling prophecy; you get one and then you get another one for any subsequent baby. The VBAC rates are very low in Northern Ireland. They are almost vanishingly non-existent, which means that anybody who gets a section will get another one in the future. That is why you will keep seeing the rates going up. A lot of those caesarean sections are for first-time mums.

Miss McAllister: OK, so we need more education on VBAC and awareness for women.

Professor Renfrew: We need more VBAC. More VBAC is good.

On your second question, I am very encouraged by the breastfeeding rates in Northern Ireland. The proactive Northern Ireland policy on breastfeeding has raised the rates in a way that has also happened in Scotland but not in the other countries, so well done. The rates are being held back by all the factors that we are talking about, but other factors are supportive. That is helpful. It would be good to look at how that has happened because it is a good example from which to learn.

You talked about choice. Of course, if women want an intervention, they should have that choice. That is not in question. My comment is to ask why they want it and whether they are being fully enabled, supported and confidently reassured that they will get really good care either way and that, if they want to go forward in another way by having an induction or not having an induction, they will get the best care. At the moment, women who are going through induction are not getting the best-quality care because of the high numbers who are having inductions and because staffing models are not meeting the demand. There are the other factors that we were talking about just now. Actually, where choice and induction are concerned, women told us that induction is now so common that they are not even being asked for consent. There is an incredibly important choice argument in both directions.

Miss McAllister: Thank you very much.

The Chairperson (Mr McGuigan): Professor, we really appreciate that. It has been really informative and timely after our visit yesterday. I know that a couple of members could have asked a lot more questions. Unfortunately, as I said, we have a busy meeting ahead of us today. We really appreciate you giving us your time and answering our questions. Thank you very much.

Professor Renfrew: Thank you very much indeed. Bye-bye.