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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