Memorandum by the Royal College of Midwives
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
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 caremuch
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
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.
3.5 Additionally, it is stated in the latest
set of NHS maternity statistics for England
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.
Safety in maternity is dynamic and involves both physical and
4.2 The safety of UK maternity services
is underlined by the latest CEMACH report.
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
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
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
two or more lives are being cared
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
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
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,
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.
Models of care and systematic data collection also play their
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
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
highlight some implications a woman may experience following a
bladder and ureter injury
needing further surgery
admission to an intensive care unit
developing a blood clot
longer hospital stay and increased
having no more children
placenta praevia in subsequent pregnancies
the placenta covering the entrance to the cervix
tearing of the uterus in a future
intrauterine foetal death before
labour starts in future pregnancies
5.2.4 All intervention therefore must be
appropriate and justified, to avoid unnecessary risk and adverse
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.
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 collectiona persistent
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.
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."
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.
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. HOW SAFETY
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
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
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
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. FURTHER POINTS
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
"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
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.
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
NHS Maternity Statistics, England: 2005-06, published by the Information
Centre, published 26th June 2007 Back
King' Fund (2008) Safe Births: Everybody's Business (p5) King's
Fund London Back
Saving Mothers' Lives-Reviewing maternal deaths to make motherhood
safer 2003-2005 (published December 2007) Back
RCOG (2007) Safer Childbirth Minimum Standards for the Organisation
and Delivery of Care in Labour. RCOG, RCM, RCA, RCPCH Back
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
Caesarean section: Understanding NICE guidance-information for
pregnant women, their partners and the public (published by NICE,
April 2004) Back
NICE (2007) Intrapartum Care: Care of healthy women and their
babies during childbirth. London Back
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
Healthcare Commission (2008) Towards better births: a review of
maternity services in England. London: Healthcare Commission Back
Choice in Maternity Services, the Committee's ninth report of
the 2002/03 session Back
Regional spending was given in answer to a written parliamentary
question, House of Commons Hansard, 2nd April 2008, c1101/02W Back
List provided in answer to a written parliamentary question from
John Baron MP, House of Commons Hansard, 26th March 2008, c210W. Back