Achieving safer maternity care in the UKBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n45 (Published 12 January 2021) Cite this as: BMJ 2021;372:n45
- Marian Knight, professor of maternal and child population health1,
- Charlotte Bevan, bereaved parent2
- 1National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- 2Warminster, Wiltshire, UK
- Correspondence to: M Knight
The publication of the first recommendations from the independent review of maternity services at Shrewsbury and Telford NHS Trust1 raises the question of why safety is still a concern in UK maternity services. It is more than five years since a previous investigation at Morecambe Bay trust,2 and there have been similar concerns at Cwm Taf University Health Board, East Kent hospitals, and Crosshouse Hospital.
To women and their families, this latest report can only raise more anxiety about the care they will receive during pregnancy and childbirth, wherever they plan to give birth in the UK. To those families who have tirelessly campaigned for improved maternity safety since well before this latest review was commissioned, the findings will feel depressingly familiar. The review highlights again a need for the voices of women and families to be heard, for enhancements to multidisciplinary care, and better local learning from serious incidents. The report also recommends new senior roles to ensure best practice in fetal monitoring.
To place this report in perspective, national confidential inquiries have led to substantial falls in the numbers of maternal and perinatal deaths in the UK.34 The combined rate of stillbirths and neonatal deaths has decreased by 15% over five years5 and rates of death of women during or after pregnancy have fallen or remained static over the past decade.6
This decline is set against the background of a more complex maternity population— women giving birth are now older, more likely to be overweight or obese, and more likely to have pre-existing physical or mental health conditions.7 Here, perhaps, lies a partial explanation of why safety remains an issue. The perception that pregnancy and childbirth are largely free of complications remains widespread. We continue to think in silos of high and low risk pregnancies—descriptors which do not help women or their babies.
Bias against complexity
Reported tensions around the care of women in pregnancy and childbirth often focus on this dichotomisation of risk—broadly reflecting a need for obstetrician led or midwife led care—when in reality women’s care needs cannot be fixed and will change throughout pregnancy, labour, and the postpartum period.
Many women will need specialist multidisciplinary care to ensure the best outcomes for them and their baby.6 Yet our healthcare structures are biased against complexity and are not set up to deliver seamless multidisciplinary care. Too often, care pathways do not allow for women’s changing needs for input from multiple professionals. This increases the scope for women to “fall between the gaps” through failures in communication, and encourages siloed thinking by the professionals caring for them. When women raise the alarm, their concerns are not heard and their symptoms not taken seriously89—another professional bias towards the normalisation of pregnancy—with potentially catastrophic consequences.
Failures of fetal heart rate monitoring are often reported when babies die or sustain life changing injuries. What is rarely recognised is that fetal heart rate monitoring is an imperfect screening tool for identifying a compromised baby in utero.1011 This narrow focus on fetal monitoring results in cognitive biases that influence recommendations to improve care. As an example, more training in interpreting fetal monitoring is commonly recommended after an unexpected death occurs, despite little evidence of effectiveness.12 Local reviews often call for actions targeted only at individuals, or relatively weak systems changes.13
Any discussion of maternity safety cannot be complete without a discussion of the quality of local reviews of care. These have either been non-existent or poorly conducted. Families are rarely engaged in the process.314 By the time families’ voices are heard and lengthy legal processes or independent inquiries concluded, years have passed, during which the opportunity to learn lessons locally and nationally has been lost. Kate Stanton Davies, the baby whose death was a catalyst for the Shrewsbury and Telford review, died in 2009. By 2020, the care of a further 1861 women and babies demanded scrutiny, the largest number of clinical reviews in a single service in NHS history.
Is there any light at the end of the tunnel for women and families? Only with sustained and substantial increases in resources for maternity services, including for local reviews. Robust local reviews of the care of women or babies who have died would provide greater local ownership of safety improvement measures, but they take time, training, and resources.13 To carry objectivity and weight, reviews also require an external perspective. How this is achieved has yet to be established. Reviews conducted in England by the Healthcare Safety Investigation Branch have limitations15 and increase the length of time it takes for affected families to receive answers.
For every mother or baby who dies, there are many more near misses. Deaths are avoidable only through individualised care for every woman, starting with a detailed assessment of needs, ideally before pregnancy but as a minimum at the first antenatal visit, followed by continuity of care from an expert team of midwives and doctors throughout pregnancy, birth, and the postpartum period. This will require additional staff with extra skills. The Royal College of Midwives estimates there is a shortage of 3000 midwives in England alone,16 but additional specialist skills training will also be needed. In today’s maternity, there is no place for “one size fits all.”
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: MK is an NIHR senior investigator and declares grants from the NIHR and Healthcare Quality Improvement Partnership in relation to maternity outcomes review and research programmes. CB is employed part-time by Sands, the stillbirth and neonatal death charity. The views expressed in this article are those of the authors.
Provenance and peer review: Commissioned; not externally peer reviewed.