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Landmark maternity audit reveals 'extreme' variation in NHS care

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Midwives should make “every effort possible” to ensure mothers and babies have skin-to-skin contact within one hour of birth, according to a major new report on maternity care that shows not all are experiencing this important bonding process.

Early skin-to-skin contact has been shown to improve breastfeeding rates and can help bring babies’ heart rate, blood pressure and breathing back to normal after birth.

“There is extremely wide variation in the proportion of babies receiving skin-to-skin contact within the first hour after birth”

National Maternity and Perinatal Audit report

However, the first report from the National Maternity and Perinatal Audit (NMPA) found “substantial variation” in rates of timely skin-to-skin contact across England.

The report, published today, also revealed major variations in other key clinical processes and outcomes in UK maternity care, including rates of haemorrhage in women who have just given birth and severe tears that can increase the risk of incontinence.

While some of the differences between services may be down to factors such as the variation in the number of high or low risk women seen in different units, or the quality of data, services have been urged to compare their results to identify possible improvements.

The report includes data from 149 trusts and boards that provide maternity care in England, Scotland and Wales and is based on records of nearly 700,000 births between April 2015 and March 2016.

While increasing access to midwife-led care is a national priority, it found only about 13% of women gave birth in a midwife-led setting.

“These initial results, however, identify opportunities for sharing good practice, as well as highlight increasing pressures on the service”

Mandy Forrester

The NMPA, which is a collaboration including the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists, found that in England more than one in five newborn babies and their mums do not have skin-to-skin contact within one hour of birth. 

Scotland and Wales do not record this information so there was no equivalent data in for them in the audit by the NMPA, which also includes the Royal College of Paediatrics and Child Health, and the London School of Hygiene and Tropical Medicine.

“Although some services achieve high rates, there is extremely wide variation in the proportion of babies receiving skin-to-skin contact within the first hour after birth, which has been shown to improve the rates of women starting and continuing to breastfeed, and in the proportion of babies receiving breast milk for their first feed,” said the report.

While the variation may be down to reporting, results were “also likely to reflect difference in practice between sites,” it added.

“Clinicians should make every effort possible for all babies to have skin-to-skin contact with their mothers within one hour of birth, where the condition of mother and baby allows,” said one of the key recommendations in the report.

“This comprehensive assessment of performance will act as an important resource and benchmark for maternity services in England”

Dr Matthew Jolly

The report shows 79.8% of babies did get skin-to-skin contact and this was more likely for those born slightly later.

The rate of contact was 81.3% among babies born between 37 and 42 weeks but went down to 55% among those born between 34 and 36 weeks.

There were big variations in rates of obstetric haemorrhage, with some units seeing this occur as often as one in 15 – compared overall rate being one in 40 women, according to the audit.

Third and fourth degree tears – also known as obstetric anal sphincter injuries – happened in around one in 30 vaginal births, but in some units this was reported in up to one in 15 vaginal deliveries.

Meanwhile some hospitals said about one in 80 babies needed additional support in the minutes following birth as indicated by a low Apgar score – a measure of a baby’s breathing and circulation – while others units said that occurred as often as one in 30.

There was also “extremely wide variation in the proportion of women who quit smoking during pregnancy, which is not related to the number of births in a site or trust”, said the report.

Of those women whose smoking status was recorded at their first antenatal appointment, 14% in England were smoking, 16% in Scotland and 18% in Wales.

The report shows less than half of pregnant women had a body mass index within the normal range and one in five were obese.

Royal College of Midwives

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Mandy Forrester

More than half of births were to women aged 30 or over and one in seven were to women aged 35 and over.

Mandy Forrester, head of quality and standards at the Royal College of Midwives, said maternity services were under pressure and called for more investment in staffing, which would also help improve the quality of data collected.

“Every day, midwives enter a large amount of electronic information about the women they care for. This report is the first to make use of this data source on a national scale,” she said.

“More investment in our maternity services, and crucially an investment in more midwives and resources is needed to improve data quality.

“These initial results, however, identify opportunities for sharing good practice, as well as highlight increasing pressures on the service from demographic changes,” she added.

Dr Matthew Jolly, NHS England’s national clinical director for reviewing maternity and women’s health, said the report would help services share best practice.

“This comprehensive assessment of performance will act as an important resource and benchmark for maternity services in England as we continue to make services safer and more personal,” he said.

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