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National report reveals key factors impacting safe maternity care

Work demands in maternity services are forcing midwives to make “a trade-off between efficiency and thoroughness”, a new report has warned.

A report published today by the Care Quality Commission (CQC) Maternity and Newborn Safety Investigations (MNSI) programme has identified workload and staff capacity as some of the key factors affecting the delivery of safe maternity care in hospitals.

“Learning lessons from both failed and successful maternity services is crucial to ensure mistakes are not repeated and good practice is shared”

Birte Harlev-Lam

The report is based on a thematic analysis of 92 maternity investigation reports conducted as part of the MNSI programme, where the investigation resulted in making safety recommendations to midwife-led units in NHS hospital trusts in England.

The investigations were complete on or before 14 June 2022 and were carried out by the Healthcare Safety Investigation Branch (HSIB), which previously ran the MNSI programme.

MNSI director, Sandy Lewis, said: “Today’s report shares important safety observations from our investigations in midwifery units and aims to help trusts do all they can to ensure the safest possible care is provided.

“Our investigations have demonstrated very clearly how supporting staff through appropriate training, ensuring consistent and robust triage processes are in place, and implementing an effective fetal heart monitoring approach are all critically important.”

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Ms Lewis added that, while the report draws on analysis of incidents specifically involving midwife-led units, “all maternity services must prioritise actions to mitigate safety risks”.

The report identified four common themes as the main issues affecting maternity safety.

Work demands and capacity to respond

The MNSI analysis of maternity investigation reports found evidence of the negative impact that inadequate staffing and high workload can have on the safety of patients.

Work demands exceeding capacity was identified as a factor in 40 (43%) of the maternity investigation reports.

When this happens, staff may be required “to make a trade-off between efficiency and thoroughness”, warned the report.

This can result in delays in monitoring pregnant women and their babies, or meeting other care needs, it added.

The analysis identified that the delivery of safe care in midwifery units was not only impacted by the unit’s own capacity challenges, but also by the capacity challenges experienced in other areas, like obstetric units and ambulance trusts.

Reports showed that women were sometimes directed to midwifery units for care, or remained under the care of a midwifery unit, even when they needed care additional to that which the midwifery unit could provide.

While the MNSI acknowledged that additional investment had been made into maternity and neonatal care in England, it said the experiences shared in this thematic analysis “provide further evidence of the need to address midwifery staffing”.

Intermittent auscultation

Intermittent auscultation is the recommended method of monitoring a baby’s heart rate in labour in pregnancies where there are no anticipated complications. It involves listening at regular intervals and is usually the method used when care is being provided in a midwifery unit.

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The thematic analysis revealed that intermittent auscultation was not carried out in line with national guidance in almost half (49%) of the maternity investigations analysed. This finding was often associated with “high workload”.

Evidence from the reports suggest that carrying out intermittent auscultation in line with the guidance was “difficult to achieve in practice”.

The MNSI noted that research was underway to understand reasons for this and to develop a toolkit to improve the way intermittent auscultation is carried out in practice.

Organisational preparedness for predictable safety-critical scenarios

Of the investigation reports analysed, 40 (43%) were about predictable safety-critical scenarios and described circumstances where work systems and processes had not functioned as intended and had hindered the response of staff.

For example, the reports showed that the process of urgent transfer of a pregnant woman or their baby to an acute hospital “often did not go smoothly”, resulting in a delay in care or treatment.

The MNSI noted that national reports, including the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust, also highlighted problems with the process of transfer, confirming the need for greater organisation preparedness.

Meanwhile, the report found examples where the environment, access to equipment and inadequate staff training and preparation had hindered the ability of maternity staff to respond effectively to a baby who may need resuscitation.

As such, it called for further training and rehearsal of situations to ‘stress test’ whether existing systems and processes work as they should.

The MNSI noted that simulation was a useful way to rehearse safety-critical scenarios, in order to identify and address issues and safety risks in current ways of working.

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Telephone triage

Telephone triage is when a pregnant woman phones for advice in the first instance when labour begins, rather than visiting a midwifery unit or hospital obstetric unit in person.

This enables midwives to capture and interpret information about the pregnant women’s condition and the wellbeing of their baby, which will then inform decisions about their care.

However, the MNSI’s analysis found that there was variation in the advice and information given to pregnant women during telephone triage and how information about these calls is recorded.

This was most evident if the pregnant women had spoken to different members of staff, who were using different information systems (paper and electronic) and in different geographical locations.

Responding to the report, the Royal College of Midwives (RCM) executive director midwife, Birte Harlev-Lam, said: “Learning lessons from both failed and successful maternity services is crucial to ensure mistakes are not repeated and good practice is shared, so the RCM really welcomes this report.

“Sadly, it underlines what the RCM and our members have been long saying: that staffing shortages drastically impacts safety and quality of care that can be delivered.”

Ms Harlev-Lam noted that, given the rise in more complex pregnancies, “having the right skill mix of staff on shift is key”.

She added: “Poor organisational culture has been identified as a key factor in recent investigations and reports on maternity safety and there is a growing body of evidence clearly linking culture with safety.

“Improving the culture and working environment in maternity services must be a shared endeavour between all members of the maternity team.

“Safety needs to be everyone’s business.”

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