The overwhelming majority of births in England are safe, despite growing pressures on maternity services, a major independent inquiry concludes today, in our report, Safe Births: Everbody's Business. However, it warns that the lack of a systematic approach to ensuring safety across maternity services is creating unnecessary risks, and calls for a range of practical improvements.
The inquiry, commissioned by The King's Fund, found that stillbirths, infant mortality rates and maternal deaths directly related to pregnancy or birth have fallen or remained stable over the past ten years, while birth rates and the complexity of some pregnancies has risen.
But this is despite there being insufficient focus on maternity services and safety by trust boards; staff being overburdened with too many separate and complex guidelines; tension between obstetricians and midwives leading to problems with team working and communication; and, often, inadequate numbers of staff with the right skills on duty.
The inquiry identifies the key factors in improving safety as: stronger governance at board level, better team and multidisciplinary working, more training in safety, including training on the labour ward, and good management of staffing levels and skill mix.
Overall, the chair of the inquiry, Professor Onora O'Neill, President of the British Academy, made it clear that the message was a reassuring one:
'Despite concerns about the safety of maternity services, maternal and perinatal death rates have remained low in the face of growing pressures and a rising birth rate. This is something to build on, so that all births are as safe as possible.
'Maternity services are fortunate to have a dedicated workforce, but I believe they could work in ways that are less burdensome for them and would, on balance, be safer for mothers and babies. All maternity units need to have a reliable safety culture in place. Good team working is key, and this means strong collaboration between different professionals; consistent ways of doing shift handovers; and more 'on the job' training, such as 'skills and drills' training for dealing with emergencies.
'Safe teams do the basic things well – they are clear about who their leaders are, what their objectives are, and also about who has responsibility for what and how they are going to communicate with each other if difficulties arise. These are simple things, but we believe many maternity services could do them better.
'Beyond the maternity unit, managers can do more to ensure the right numbers of staff and, even more crucially, use and deploy staff more effectively, while the boards that run NHS hospitals must give more priority to the safety of maternity services.'
The inquiry focused specifically on the safety of maternity services rather than their quality or efficiency, and concentrated on the safety of mothers and babies during birth. It follows a review of maternity units by the Healthcare Commission last month that found significant variations in the quality of care across the country.
The King's Fund inquiry was informed by oral and written submissions from a broad range of organisations and professionals; visits to selected maternity units in England; research into the views of women with recent experience of childbirth; as well as the wider literature on safety in general and maternity services in particular.
It identifies a number of challenges that threaten the safety of maternity services, including:
- Low priority– some NHS trust boards are not giving high enough priority to patient safety or to maternity services. They need to do so in order to meet their responsibility for safeguarding the patients for whom their staff provide care.
- Administrative overload – maternity staff are issued with too many standards by a range of national organisations; this places considerable burdens on staff without delivering commensurate safety improvements. Also, in some units, guidelines are not always used or followed.
- Poor team working – tensions between the two principal professions responsible for delivering maternity care sometimes result in a breakdown in trust, respect and understanding between midwives and obstetricians. This can lead to poor team working that puts patient safety at risk.
- Leadership and communication – maternity teams are not always clear about leadership and are not well managed, while communication between clinicians, particularly at crunch points such as referrals between health professionals, shift changes and in emergencies, is not always effective.
- Staffing – although it is widely accepted that all women should have one-to-one midwife care during labour, this is not always available. Midwives are sometimes diverted to tasks that could more appropriately be done by maternity support workers, theatre support staff, nurses or cleaners. Some maternity units do not meet the recommended level of consultant cover, and changes to obstetric training as a result of the European Working Time Directive mean that specialist registrars are likely to be less experienced on completion of training than in the past.
The King's Fund chief executive Niall Dickson said:
'This report should provide some reassurance to prospective mothers and their families, but it also clear there is much still to be done to make maternity care in England as safe as it could and should be. This report should be regarded as a call for action. In short, we could do better for mothers and their babies.'
The inquiry panel makes a series of recommendations that it believes are most crucial to assuring patient safety in maternity services. These include:
- Role of trust boards – boards must strengthen accountability for maternity safety by prioritising safety, communicating that priority to staff and patients and making data on the safety of their maternity services publicly available. This safety information should be regularly presented and examined at board meetings.
- Improving guidance – standards for the safety of maternity services should be set and monitored by a single body – the Healthcare Commission (in future the Care Quality Commission) on the advice of other relevant bodies. National guidelines should be adapted to produce short summaries and one-page protocols that can be used easily by staff for both training and practice.
- Team working – maternity teams need shared objectives and clear roles; effective leadership; and clear and agreed procedures for communication. Placing safety at the heart of maternity services requires the royal colleges to support the development of effective teamwork and provide national leadership for culture change.
- Training – maternity teams that work together should also train together, with regular training taking place on the labour ward rather than on 'away days' and being seen as a core activity rather than an extra that is difficult to fit in. Simulation training, which assesses clinical, communication and team skills within a single exercise, should be offered to all maternity staff, ideally within their own units. Safety awareness training should be introduced into mainstream professional education
- Staffing – maternity units need to review demand and capacity regularly, ensure that they employ enough staff with the right mix of skills, and deploy them effectively across peak and other times.
The King's Fund has agreed to help take the findings and recommendations of the inquiry forward and will be looking to explore and test out these ideas with maternity units interested in driving up safety standards.
Notes to editors:
- For further information or interviews, please contact the King’s Fund media and public relations office on 020 7307 2585, 020 7307 2632 or 020 7307 2581. An ISDN line is available for interviews on 020 7637 0185.
- Download Safe Births: Everybody’s business: Independent inquiry into the safety of maternity services in England from The King's Fund website.
- The inquiry was led by Professor Onora O’Neill, a senior figure in medical ethics and President of the British Academy. She was assisted by a number of panel members and expert advisers, selected for their expertise in areas related to health and patient safety. Further biographical details of the inquiry team are available.
- Please contact the King’s Fund press office if you would like recommended case studies of maternity units.
- The King’s Fund is grateful to the Edgar E Lawley Foundation and the Donald Forrester Trust for financial contributions towards the inquiry.
- The King’s Fund is an independent charitable foundation working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through funding. We are a major resource to people working in health and social care, offering leadership development programmes; seminars and workshops; publications; information and library services; and conference and meeting facilities.