Maternity services in England - Public Accounts Committee Contents

2  Women's experience of maternity care

14. For the vast majority of women NHS maternity services provide good outcomes. In addition, most women rate the care they receive—during pregnancy, during labour and birth, and after the birth—as excellent or very good.[20]

15. However, when maternity care goes wrong the consequences can be devastating. Maternity cases account for a third of total clinical negligence payments and maternity clinical negligence claims have risen by 80% over the last five years. Nearly a fifth of trusts' spending on maternity services (some £480 million in total, equivalent to £700 per birth) is for clinical negligence cover. The NHS Litigation Authority has recently produced helpful research on the causes of maternity claims, looking at data from the last ten years. The most common reasons for maternity claims have been mistakes in the management of labour and relating to caesarean sections, and errors resulting in cerebral palsy.[21]

16. The Department told us that it was seeking to reduce the legal costs associated with clinical negligence claims. The Department admitted that there had been no financial penalties for trusts that had higher litigation costs as the amount trusts paid for maternity clinical negligence cover had been based on an assessment of their maternity care processes, rather than their outcomes. However, in future the amount individual trusts pay for maternity clinical negligence cover would be linked to their litigation costs.[22]

17. In 2011, 5,183 babies were stillborn or died within seven days of birth in England, equivalent to 1 in 133, a rate that was higher than in the other UK nations and some European countries. The Department and NHS England referred to work in the West Midlands to detect babies at risk of being growth-restricted, which form one of the greatest proportions of stillborn babies. The stillbirth rate in the West Midlands had come down to below the national average in the past three years, although there was still wide variation between the rates for the region's individual clinical commissioning groups. There is also wide variation between individual trusts in the quality of care provided, as indicated by rates of complication (such as rates of emergency readmission for mothers and babies) and medical intervention (such as emergency caesarean section rates).[23]

18. We questioned the Department about the persistent inequalities in the reported experience and levels of care received by different groups of women. The latest available data, from 2010, show that black and minority ethnic women were less positive about the care they received during labour and birth. They were also significantly more likely to report shortfalls in choice and continuity of care and were less likely to see a midwife as often as they wanted after birth. NHS England recognised that this was a problem noting that the women concerned were often in more deprived communities and that sometimes there were also language or cultural barriers. The Department told us it intended to address inequalities through improved early access to maternity care, but data from the National Audit Office show regional and demographic inequalities in the proportion of women receiving an antenatal appointment within 12 weeks of conception.[24]

19. We also asked about the inequalities in the quality of care women receive at weekends compared with weekdays. Rates of maternal infection, infection to the baby and injury to the baby are all higher at the weekend. Although there have been substantial improvements in levels of consultant presence on labour wards in recent years, over half of obstetric units were still not meeting the levels recommended by the Royal College of Obstetricians and Gynaecologists at September 2012. The Department acknowledged that a proper 24/7 service was needed across all parts of the NHS, and that it needed to work out how to achieve this in terms of employment contracts and affordability.[25]

20. The witnesses highlighted the important role maternity networks can play in improving the quality of care by spreading good practice and reducing variation. To achieve the best possible outcomes for women and babies, the Department intended to bring together commissioners, providers and other stakeholders (including users of maternity services) in a local area to form maternity networks. Despite recommending the creation of maternity networks in its 2007 strategy, the Department has not made it compulsory for commissioners and providers to create them and a quarter of trusts are still not part of a network. In contrast, nearly all trusts are part of a neonatal network. Less than 40% of trusts are part of a maternity network with a paid coordinator, compared with 90% for neonatal networks.[26]

21. Choice is central to the Department's strategy for improving maternity services. Women who have a low-risk pregnancy should be able to choose where to give birth, in terms of setting (that is obstetric unit, midwifery-led unit or home birth) and provider. Women may need to be transferred to an obstetric unit if complications occur. However, the Department and NHS England seemed unaware of recent joint research by the National Federation of Women's Institutes and the NCT which shows that there is a significant disparity between what women want and what women receive in terms of choice of place of birth. According to this research, only a quarter of women want to give birth in a hospital obstetric unit, with care led by consultants, but 87% of women still gave birth in this setting in 2012.[27] Not only are women not able to exercise choice as to where their baby is born, but stakeholders considered the costs to the NHS are much higher for births that take place in a hospital setting.

22. The Department pointed to the significant increase in the number of midwifery-led units, which has risen from 87 in 2007 to 152 in 2013. The research by the National Federation of Women's Institutes and the NCT found that more than half of women want to give birth in a midwifery-led unit, where midwives take primary responsibility for care, yet currently only 11% of women do so.[28]

23. The level of choice available to women in practice is restricted when maternity units have to be closed for short periods to safeguard the quality and safety of care when demand might outstrip capacity. Over a quarter of maternity units had to close to admissions for half a day or more between April and September 2012. The main reported reason for these closures was a lack of either physical capacity or midwives.[29]

20   C&AG's Report, para 27 Back

21   Qq 79, 81, 85, 95, C&AG's Report, para 14, 1.15 Back

22   Qq 79, 97-100 Back

23   Qq 69, 151-154, C&AG's Report, paras 14, 1.9 Back

24   C&AG's Report, paras 1.5-1.6  Back

25   Qq 37, 124, 132-133 Back

26   Qq 15, 17, 118-120, C&AG's Report, para 2.18 and Figure 11 Back

27   Qq 175-180, 215, The National Federation of Women's Institutes and the NCT, Support overdue: women's experience of maternity services, May 2013 Back

28   Qq 175, 180, 215, C&AG's Report, paras 9, 1.42 Back

29   Q 162, C&AG's Report, paras 1.46 &1.47 Back

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Prepared 31 January 2014