Select Committee on Health Written Evidence

Memorandum by the Royal College of Midwives (PS55)



  1.1  Patient safety is of fundamental importance to maternity services. Despite this, damages payments arising from adverse outcomes made in NHS care arise largely from maternity services.

  1.2  There is a popular perception that risk is reduced with greater medical involvement. In maternity services this is true up to a point, but beyond necessary levels of medical intervention, the risk actually begins to increase.

  1.3  The best way to improve safety from where we are now is to investigate what goes wrong and attempt to stop such things happening again. The structures are in place to do this on a systematic and ongoing basis, through such routes as the CEMACH investigations.

  1.4  Good work like this is being done, but the findings are not always implemented. We believe that this is because local services are distracted by the demands of the centre to deliver on politically-important targets. This means that maternity care loses out because there is no sanction for a service which does not implement policies in the area. As babies do not wait, there can be no waiting list for birth.

  1.5  Additionally, maternity services suffer because of the split between acute and community care—much maternity care is delivered in the community and loses out to the demands of the acute sector. To turn this around, we need to see the extra resources, both in terms of midwives and investment.

  1.6  We recommend midwifery representation on Trust Boards so that issues of safety in maternity care can be raised at the highest local level.

  1.7  Finally, we must see vast improvements in the collection of data. The current situation is very patchy. The Committee has raised this before; it should raise it again.


  2.1  The maternity service in the United Kingdom is one of the safest in the world with women enjoying free access to skilled professionals (midwives, obstetricians, paediatricians and others), facilities and resources, a range of care options and technologies. Nevertheless, critical incidents do occur for some women and their newborn. Women with medical conditions provide a particular challenge to the service and some concerns are acknowledged about the quality of care that some women and babies are receiving. In the last decade maternal mortality in the UK has remained stable.

  2.2  It is important to differentiate between "risk" and "safety". Identification of risk allows us to put in place systems of care/resources which enhance safety.

3.  RISK

  3.1  Risk can be defined as the probability that an event will occur encompassing a variety of measures of the probability of a generally unfavourable outcome.

  3.2  In most healthcare areas, the risks associated with medical intervention are simply accepted because there may well be no other way to cure a patient's condition.

  3.3  For the majority, accessing healthcare is about seeking treatment for illness or disease and the risks associated with medical intervention might well be accepted because there is no alternative treatment. For the majority of women pregnancy and birth is straightforward. Although pregnancy is not an illness, women who have medical complications in pregnancy may not have "choice" in the interventions offered. The role of the midwife is about ensuring that women who are well and without complications are kept normal and women who experience problems have access to appropriate care.

  3.4  There is some evidence to suggest that birth is being medicalised beyond the necessary level. A recent consensus statement by the Maternity Care Working Party, a group with a broad membership including the RCM, entitled Making Normal Birth a Reality, suggested that a realistic objective for the proportion of births that are normal would be 60%; in contrast, the median for trusts is around 40%, with a quarter of trusts reporting 32% or less[331].

  3.5  Additionally, it is stated in the latest set of NHS maternity statistics for England[332] that 23.5% of births nationally are now by caesarean section, and there is no established link between a high caesarean section rate and better health outcomes. This compares very unfavourably to the World Health Organisation's recommended rate of just 15%. This may even suggest that maternal risk outcomes may actually be lowered by seeking to reduce levels of medicalisation in areas where it is being used inappropriately, thereby removing the additional risks associated with intervention.

  3.6  Further improvements in safety will come from adequately studying instances when errors or near misses occur, learning the lessons and ensuring that the necessary corrective action is taken. Clinical governance, working with women, Supervisors of Midwives (SoM), individual practitioners and ensuring feedback from lessons learnt are included in strategic and workforce planning.

  3.7  Periodic reviews, like the Confidential Enquiry into Maternal and Child Health (CEMACH) for example, look at maternal mortality and morbidity and make recommendations about how birth can be made safer still. The latest report makes recommendations about the care of migrant women, and highlights the need to assess their overall level of health.


  4.1  Patient safety can be defined at its simplest as the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare[333]. Safety in maternity is dynamic and involves both physical and emotional wellbeing.

  4.2  The safety of UK maternity services is underlined by the latest CEMACH report[334]. It revealed that between 2003 and 2005, inclusive, 13.95 mothers died for every 100,000 births in the UK. That makes this country one of the safest places in the world for pregnant women to give birth.

  4.3  Although maternal deaths are extremely rare, there is no room for complacency. Indeed, safety cannot be measured simply by mortality. A proportion of women, for instance, experience significant morbidity from physical and psychological problems.

  4.4  The King's Fund, in a report on the safety of England's maternity services, concluded that the overwhelming majority of births in England are safe, some births are less safe than they could and should be, safety is the responsibility of all healthcare professionals and "safe teams" are the key to improving maternity services. Further, it identified features of maternity care most relevant to safety, namely:

    —  unexpected emergencies can develop rapidly

    —  two or more lives are being cared for

    —  maternity care is delivered over a nine-month period

    —  quality of birth experience can have lasting effect on mothers, babies and families

    —  changing demands have impacted on safety in maternity services

    —  the number of births has risen and is expected to continue

    —  an increase in older mothers are having babies, which adds to complexity of care

    —  fertility treatment has led to more multiple births

    —  more obese women leads to greater health risks for pregnancy

    —  more women are surviving serious childhood illness to go on and have their own children, but with a potential consequential increase in health risks during pregnancy

    —  the rising rates of intervention in labour

    —  increasing social and ethnic diversity leading to communication difficulties

  4.5  In the light of audits and reviews, highlighting poor outcomes, the four Royal Colleges have collaborated to produce the report Safer Childbirth[335], which sets out recommended minimum standards for safety.


  5.1  There are several systems issues which contribute to safety in maternity services, as illustrated in the report, An Organisation With a Memory[336]. Models of care and systematic data collection also play their part.

5.2  Models of care

  5.2.1  Popular perceptions of medical risk and how to address them lead people to think that improvements come from additional medicalisation. In the case of maternity care that might be translated into centralisation of care in large obstetric units.

  5.2.2  Appropriate maternity care and services are important in improving outcomes and minimising risk for women and babies. Maternity services need to be flexible in providing different models of care to meet the varied needs of women. Some women need obstetric care however if this is applied to all women there is potential for inappropriate intervention with the likelihood of poorer outcomes.

  5.2.3  For example, NICE[337] highlight some implications a woman may experience following a caesarean section:

    —  abdominal pain

    —  bladder and ureter injury

    —  needing further surgery

    —  hysterectomy

    —  admission to an intensive care unit

    —  developing a blood clot

    —  longer hospital stay and increased readmission

    —  having no more children

    —  placenta praevia in subsequent pregnancies the placenta covering the entrance to the cervix

    —  tearing of the uterus in a future pregnancy

    —  intrauterine foetal death before labour starts in future pregnancies

    —  maternal death

  5.2.4  All intervention therefore must be appropriate and justified, to avoid unnecessary risk and adverse outcomes.

  5.2.5  There is evidence of improved outcomes both physically and psychologically from one-to-one care in labour. Additionally, women in caseload midwifery systems are less likely to receive intervention in labour. In addition, many women prefer this system of care.[338]

  5.2.6  There is currently no evidence to support improved outcomes from the medicalisation of birth. The relative safety of different birth settings is not yet established and this is currently being explored by the National Perinatal Epidemiology Unit's (NPEU) Birthplace study.

5.3  Poor data collection—a persistent problem

  5.3.1  The collection of maternity data informs decisions about patient safety. The importance of good data collection has been highlighted by a number of reports[339]. The problem with this is that there is a very poor record of systematic data collection in maternity services.

  5.3.2  The Health Care Commission's (HCC) Trust-by-Trust assessments of maternity services contain a large amount of data, but this was collected after a gargantuan one-off exercise. In their final report, the HCC noted that "Good information is crucial to effective management. A number of trusts lack systems that can provide all the data that we requested for our top-level assessment. Only 60% had a system that complied with the requirements of Connecting for Health and 17% reported having no system for maternity care at all."[340]

  5.3.3  Every year, maternity statistics are published by the NHS, but they are not comprehensive. This is because the right questions are not asked or because the data is not collected. The report for 2005/06 did not include information on a quarter of hospital births and 85% of home births. The failure to make Maternity HES mandatory and the lack of data for 25% of NHS Trusts is a long standing matter for concern. The failure to adjust for response bias may render the data unreliable.

  5.3.4  This lack of data is nothing new. The Health Committee itself published a report on maternity services more than five years ago that demanded action on the collection of maternity data[341]. Despite that warning, little has changed.

  5.3.5  The burden of data collection must be minimised, so we would recommend that in addition to seeking to improve the comprehensiveness of data collection, due attention is also given to the dataset itself, perhaps through establishing a minimum dataset.

  5.3.6  Progress is being made currently on the use of the Maternity Dashboard. This promises to offer the ability to view all the major indicators relating to maternity care in one place. This development has promise, although only in maternity units, and must focus on all aspects of care, not just the medical indicators.


  6.1  Governance is a key element in enhancing safety and reducing risk. Robust governance structures of obstetric and midwifery services (with the remit to develop policies and evidence-based guidelines) to assure safety and to promote safe practice and learn lessons are advocated by both the reports from the King's Fund and Safer Childbirth.

  6.2  Early access to antenatal care from a midwife has been demonstrated to lead to improved health outcomes for women and babies. Early access enables midwives to communicate public health messages to women and their families. Examples would include working with women to reduce smoking and drinking to excess in pregnancy, promoting a healthier diet, preparing a woman for breastfeeding, reassuring her about the birth itself, and even pointing her in the right direction if she needs better housing. Antenatal care from a midwife, which addresses the woman's physical, psychological and social assessment of health determinants, can enable a therapeutic relationship with the woman. Women in good health experience better pregnancy outcomes.

  6.3  Good communication and teamwork are also essential. Maternity services are provided by groups of professionals all with their own areas of expertise but all of whom must work together in the interests of safety. Clear pathways of care, routes of referral and systems of transfer must be established.

  6.4  Work is ongoing on making maternity care safer still. The HCC investigates local services when alarm bells ring, plus it has also conducted a nationwide investigation of maternity care provision. CEMACH regularly identifies how practice can and should minimise risk and enables professional organisations to work together to improve standards. Local investigations also help to improve care. What are needed are the resources to turn all this good work into practice.

  6.5  Adequate resources are a prerequisite to safety and part of the answer is appropriate midwifery staffing. England is short of around 5,000 full-time NHS midwives. This is calculated using the latest births figures from the Office for National Statistics, and the latest NHS midwifery workforce figures, and using estimates of the proportion of births that take place in hospital, midwifery units and at home, and then applying recommendations on minimum midwifery workforce ratios developed by Birthrate Plus and Safer Childbirth.

  6.6  A midwifery staffing shortage of that magnitude inevitably affects safety. As already stated, UK maternity services are relatively safe, but with appropriately increased midwifery staffing levels the service could be safer.

  6.7  Maternity services also need adequate financial resources[342]. The number of live births in each of the 10 English regions rose in 2007, but in six of those regions, spending on NHS maternity care was reduced. The deepest cuts came in London, where the fall was £46.5 million, and the South West, where £27.5 million was lost; those were colossal 15% and 18% reductions, respectively.

  6.8  The case for additional financial resources can be made on purely financial grounds. As demonstrated below, the litigation costs when adverse outcomes occur are huge. Improvements in the safety of maternity care therefore have the potential to cut that bill significantly. Cutting back on maternity services is a false economy if adverse outcomes continue to result in damages payments.


  7.1  Even with low level of maternal mortality and poor outcomes the cost of litigation is high. Of the 100 largest damages payments relating to NHS care made in the last five years, 48 relate to maternity care and the total cost was over £261 million[343]. This highlights that whilst there are few incidents the financial cost is high.

  7.2  The litigation impact of damage to the newborn at birth, through no fault or multifactoral aspects, can have lifelong consequences. For these reasons, safety in maternity care must rank amongst the most important of all healthcare areas.

  7.3  Adequate numbers of appropriately skilled staff is essential to maternity service safety.


8.1  Good work is being carried out

  8.1.1  Work is going on to improve safety. CEMACH reports, referred to, play an important role. The HCC investigates Trusts where concerns are raised, such as Ashford and St Peters Hospitals, New Cross Hospital, and Northwick Park Hospital. The HCC and the King's Fund have both conducted excellent studies, and produced authoritative reports as a result.

  8.1.2  Collaboration also takes place between the professional organisations, as evidenced by the Safer Childbirth report which includes recommendations, implementation of which will be audited in 2009.

  8.1.3  The National Patient Safety Agency is working on problems with giving sets and locking systems to reduce the incidence of drug errors, as recently highlighted by the Coroner for Wiltshire & Swindon in the Mayra Cabrera case.

8.2  Local implementation is a problem

  8.2.1  Implementation of this work is hampered at local level. We find that action to improve maternity services is sidelined as Trusts strive to implement national targets. An example would be the 18-week maximum wait for inpatient treatment.

  Local services often have to choose between recruiting more midwives and buying diagnostic equipment to cut the average wait.

  8.2.2  There is evidence of a lack of consideration of safety in maternity services from Trust Boards. This is a key finding from the King's Fund report which found Trust Boards seriously lacking:

    "Trust boards pay relatively little attention to| patient safety"

    "Executives focus on financial health and national targets"

    "Trust boards have a fundamental duty to safeguard patients|[they] should demand rigorous routine information on safety"

  8.2.3  The RCM supports the report's assertion that Boards should prioritise safety, educate themselves better about the issues, ratchet up their involvement in safety and strengthen governance arrangements regarding safety. We also believe that maternity services should be a regular agenda item for Trust Boards.

  8.2.4  The RCM would also make the specific recommendation that the position of heads of midwifery must be strengthened and there should be direct representation of maternity services on Trust Boards by a midwife. There needs to be evidence of midwifery leadership and investment in developing future leaders. This will increase the status of the service and so effect improvements.

September 2008

331   Statistics taken from the Healthcare Commission's trust-by-trust assessment of NHS maternity services in England, conducted during 2007 and published earlier this year Back

332   NHS Maternity Statistics, England: 2005-06, published by the Information Centre, published 26th June 2007 Back

333   King' Fund (2008) Safe Births: Everybody's Business (p5) King's Fund London Back

334   Saving Mothers' Lives-Reviewing maternal deaths to make motherhood safer 2003-2005 (published December 2007) Back

335   RCOG (2007) Safer Childbirth Minimum Standards for the Organisation and Delivery of Care in Labour. RCOG, RCM, RCA, RCPCH Back

336   Department of Health (2000) An Organisation With a Memory: Report of an expert advisory group on learning from adverse events in the NHS. London Back

337   Caesarean section: Understanding NICE guidance-information for pregnant women, their partners and the public (published by NICE, April 2004) Back

338   NICE (2007) Intrapartum Care: Care of healthy women and their babies during childbirth. London Back

339   RCOG (2007) Safer Childbirth Minimum Standards for the Organisation and Delivery of Care in Labour. RCOG, RCM, RCA, RCPCH; King' Fund (2008) Safe Births: Everybody's Business (p5) King's Fund London Back

340   Healthcare Commission (2008) Towards better births: a review of maternity services in England. London: Healthcare Commission Back

341   Choice in Maternity Services, the Committee's ninth report of the 2002/03 session Back

342   Regional spending was given in answer to a written parliamentary question, House of Commons Hansard, 2nd April 2008, c1101/02W Back

343   List provided in answer to a written parliamentary question from John Baron MP, House of Commons Hansard, 26th March 2008, c210W. Back

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