Maternity services inquiry

This project has been completed

What did we do in this project?

We set up an independent inquiry in late 2006 to find out what can be done to make maternity care safer. The focus was on the safety of mothers and babies during birth. The panel members were selected for their expertise in areas related to health care and patient safety.

In 2008, the inquiry published the findings: Safe Births: Everybody's business makes practical recommendations in seven key areas:

  • teamworking
  • staffing
  • training
  • guidance and information relevant to safety
  • the role of trust boards
  • the role of national bodies concerned with safety and maternity services.

The report draws three general conclusions.

  • Most births in England are safe, but some are less safe than they could and should be.
  • Safety is the responsibility of each and every member of the teams involved in delivering or supporting maternity services. This means not just midwives and obstetricians, but anaesthetists, support staff, managers and trust boards.
  • 'Safe teams' are the key to safe maternity services.

Why are we interested in this piece of work?

The overwhelming majority of births in England are safe. Stillbirth and maternal death rates have remained stable in recent years, while infant mortality rates have continued to fall.

But we also know that things can and do go wrong. From June 2006 to May 2007, more than 62,000 maternity-related incidents were reported. Most of these (66 per cent) caused no harm to the mother or baby; but 1.5 per cent caused severe harm.

The media tend to focus on who is to blame when things go wrong. But providing safe care is as much a matter of understanding how to get things right as understanding why things went wrong. The challenge for all those providing maternity services is to find ways to make maternity care as safe as it can be – all of the time, at whatever hospital or unit a woman chooses to give birth.