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'Distressingly' wide variation in quality of maternity services

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An independent review of maternity care in England has uncovered what has been labelled a “distressingly wide variation” in the quality of services.

Under-reporting of safety incidents is “widespread” and there are big differences in approaches to learning from them, according to the review team in its report published today, called Better Births: Improving outcomes of maternity services in England.

“When talking to maternity teams during visits, there were clear differences in approaches [to safety incident learning] between high and low reporting units”

NHS maternity review of England

While official figures on maternal and stillbirth or neonatal deaths show the country has improved – with the latter falling by 20% in a decade – these fail to show underlying problems in certain areas, said the report.

The report was commissioned last year by NHS England, partly in response to an investigation into maternity and neonatal services at University Hospitals Morecambe Bay Foundation Trust.

The Morecambe Bay investigation was led by Dr Bill Kirkup, who was subsequently asked to assess the quality of care in maternity services across the country for the national review – by looking at data and visiting some units.

National maternity review

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Julia Cumberlege

Almost half of all Care Quality Commission inspections of maternity services result in either an “inadequate” or “requires improvement” rating, the report noted. Data from trusts showed the numbers of incidents reported varied greatly.

“This degree of variation is impossible to reconcile with differences in the underlying occurrence of adverse events, and it is clear that under-reporting of safety incidents is widespread,” said the report.

“When talking to maternity teams during visits, there were clear differences in approach between high and low reporting units,” it added. “Those from higher-reporting units described a strong learning culture with good team working. Elsewhere, opportunities for learning and improvement were being ignored.”

Safety was “inconsistent” and there was scope for “significant improvement” in many maternity services, it added.

At a briefing yesterday to launch the report, NHS England chief executive Simon Stevens, noted although maternity care was now safer than it had ever been, there were still problems in different parts of the country.

“There are still distressingly wide variations in the quality of care across different parts of England”

Simon Stevens

“The good news is that maternity care is now safer than it has ever been and there have been remarkable improvements in the quality of care over the last decade and beyond…[But] as the report makes clear there are still distressingly wide variations in the quality of care across different parts of England.”

The report makes a series of recommendations for the NHS, government and other bodies such as regulators, based on seven themes.

These are to ensure personalised care for the mother, to provide continuity of care, safer care, better postnatal and perinatal mental health services, improved multi-professional working, more commissioning of services across boundaries, and reforms of payment systems for maternity services.

It called for improvements to models of maternity services and “radical” approaches to the way staffing is organised.

Too few women are being offered choice in their place of birth, with 87% of births happening in hospitals, when only 25% wanted to be there, said the report.

More community “hubs” should be considered in local areas – where women can access different maternity care at one site, such as midwife-led units and smoking cessation services – to act as a “one-stop shop” and ensure faster referral to more specialised services if needed.

“Women have told us they want to be given genuine choices and have the same person looking after them throughout their care”

Julia Cumberlege

Meanwhile, greater continuity of care should be achieved by ensuring every woman is allocated a midwife within a small team of four to six midwives, who then continue to look after her across settings.

This would ensure midwives are better equipped to recognise changes to risk factors, said the report.

Other recommendations include a national standardised investigation process for when safety incidents occur, a rapid “redress and resolution” scheme to speed up learning and help families, and the development of a nationally agreed set of indicators to benchmark local maternity services.

Improved multi-professional training for undergraduates and staff to improve collaboration, and a new payment system – called personal maternity care budgets – to ensure women’s choices drive funding for services, were also called for.

Review chair baroness Julia Cumberlege said: “Women have told us they want to be given genuine choices and have the same person looking after them throughout their care.

“We must ensure that all care is as safe as the best ad we need to break down boundaries and work together to reduce variation in the quality of services and provide a good experience for all women.”

Seven themes to improve maternity services:

  • Personalised care, centred on the woman, her baby and her family, based around their needs and their decisions, where they have genuine choice informed by unbiased information
  • Continuity of carer, to ensure safe care based on relationship of mutual trust and respect in line with woman’s decisions
  • Safer care, with professionals working together across boundaries to ensure rapid referral and access to the right care in the right place. Leadership for a safety culture within and across organisations and investigation, honesty and learning when things go wrong
  • Better postnatal and perinatal mental healthcare, to address the historic underfunding and provision in these two vital areas which can have a significant impact on the life changes and wellbeing of the woman, baby and family
  • Multi professional working, breaking down barriers between midwives obstetricians and other professionals to deliver safe and personalised care for women and babies
  • Working across boundaries to provide and commission maternity services to support personalisation , safety and choice, with access to specialist care whenever needed.
  • A payment system that fairly and efficiently compensates providers for delivering high quality care to all women , whilst supporting commissioners to commission for personalisation, safety and choice.


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