Maternity

Despite a longstanding focus on safety in maternity services, a plethora of standards and guidelines and significant policy interest, there remain some key challenges to delivering safe, women-centred services in the NHS. Even with the government’s commitment to give women and their partners choice of place of birth, the majority of women (97 per cent) still give birth in hospital. Perceived shortages in both midwifery and obstetric posts affect the ability to deliver one-to-one care by a midwife during labour.

Policy development

In 1993, the Department of Health published Changing Childbirth, recommending a wholesale review of maternity. It recognised the need to put women at the centre of services, allowing them to make informed choices. It emphasised ongoing teamwork and communication between obstetricians, midwives and GPs.

By 1995–6, according to the Audit Commission, maternity services were more women-centred. First Class Delivery – improving maternity services in England and Wales also found that many women wanted more and better information about services and about options for care, and felt that information was important in antenatal screening.

In 2001, Secretary of State for Health Alan Milburn announced £100 million for maternity services, intended to ‘ensure that pregnant women have more choice and access to improved maternity services’.

The Health Committee launched an inquiry into maternity services in 2002. Its report on choice re-stated that women should be at the centre of maternity care and able to make informed decisions. It called for a shift towards midwife-led care and recommended that trusts give sufficient priority to maternity issues to reverse ‘the worrying medicalisation of birth’.

In 2007, the government published Maternity matters: choice, access and continuity of care in a safe service. It highlighted the government’s commitment to high-quality, safe and accessible maternity services, introducing a guarantee of choice for women about the care they received.

Standards

The Department of Health published the National Service Framework (NSF) for Children, Young People and Maternity Services in 2004. It looked at how to make maternity services more flexible, accessible and appropriate for all women.

The Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM), Royal College of Anaesthetists and Royal College of Paediatrics and Child Health (RCPCH) produced Standards for Maternity Care in 2008. This summarises in one document 30 individual standards covering the different stages of motherhood.

Safety

The Nursing and Midwifery Council (NMC) is responsible for registering midwives and regulating their practice. All midwives are legally required to be supervised by a named supervisor who provides support, advice and guidance.

In 2008 the Healthcare Commission carried out and published the findings of three investigations at individual trusts where there had been serious failures in care. The Commission’s concerns included:

• below-average staffing levels
• consultant obstetricians not spending the amount of time on labour wards as recommended by the RCOG
• doctors and midwives not consistently attending in-service training
• inadequate continuity of care for women
• women experiencing poor communication, care and support
• too few beds and bathrooms in labour wards.
  

Prompted by these concerns, the Commission launched a national review of maternity services. Towards Better Births: A review of maternity services in England was published in 2008 and found wide variations between trusts in the standard of care provided. In the same year, a report by The King’s Fund highlighted the need for safe teams with clear and shared objectives, effective deployment and the appropriate skill mix. Teams should train together, have clear guidance and protocols, use information effectively, and receive support from their trust boards and national bodies.

Infant and maternal mortality

A system of confidential enquiries, established in 1952 as the Confidential Enquiry into Maternal Deaths (CEMD) was intended to assess the main causes of maternal deaths and to recommend improvements in clinical care and service provision.  

The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) was established in 1992 to improve understanding of the causes of death in late fetal life and infancy, seeking to reduce mortality by identifying poor practice and service provision and making recommendations for improvement.

The Confidential Enquiry into Maternal and Child Health (CEMACH) replaced CESDI and CEMD in 2003, and confidential enquiries are now commissioned by the National Patient Safety Agency from the Centre for Maternal and Child Enquiries (CMACE).

The 2005 CEMACH report considered 295 women who died during 2003–2005. It found that 64 per cent of direct deaths were associated with substandard care, with examples including:

• poor or non-existent team working
• inappropriate or too-short consultations by telephone
• failure to share relevant information
• poor interpersonal skills.

The report’s ‘top 10’ recommendations related to pre-conception care, access to care, migrant women, treatment of systolic hypertension, caesarean section, clinical skills, early warning scoring systems, the need for guidelines on obese pregnant women, sepsis in pregnancy, and pain and bleeding in early pregnancy.

Professionals and workforce

In February 2008 the then Secretary of State for Health Alan Johnson announced that an additional 4,000 midwifes would be recruited into the NHS in the following three years.

Professional bodies have their own recommendations for safe levels of staffing. There is an ambition to provide one-to-one midwifery care for women in labour. There are tools available to the NHS, such as Birthrate Plus, which calculate the number of midwifery staff needed to provide one-to-one care. The average midwife delivered 34 babies in 2007.

The European Working Time Directive has impacted on maternity services, as it restricts junior doctors to working 48 hours a week. There are particular difficulties in paediatric and maternity services because of the need to have specialty-specific clinical skills immediately available 24 hours a day.