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Recommendations

Human factors and behaviour

Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level.

Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes.

Workload and workforce challenges

Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population.

This tool should complement the midwifery acuity tools currently implemented nationally.

Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce.

Communication

All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call.

This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.