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Healthcare Commission Maternity Review

This page provides a briefing on the findings of the Healthcare Commission’s 2007 review of maternity services in England.

Towards better births: A review of maternity services in England

The Healthcare Commission (HCC) review of maternity services in England was undertaken in 2007 and included 148 trusts providing obstetric maternity services and four trusts which provided midwifery-led units only. The review focussed on the entire maternity pathway from the start of pregnancy through to postnatal transfer of care by a midwife to the health visiting services.

The key concerns of the HCC that have arisen from the findings are that in some trusts:

  • Levels of staffing were well below the average, indicating that they may have been inadequate.
  • Consultant obstetricians did not spend the time recommended by their professional body on labour wards. It has been noted by the HCC and the RCOG that this may be due to other programmed activities such as gynaecological care, which means consultants are unable to do more labour ward work. An important measure can be found in Safer Childbirth which recommends appropriate consultant presence on the labour ward, and is cited within the report.
  • Doctors and midwives did not attend in-service training courses consistently across trusts.
  • There was not adequate continuity of care for women.
  • Recommendations were not adequately adhered to for antenatal care, particularly for those women whose pregnancies were likely to be more risky.
  • Women experienced poor communication, care and support after their babies were born.
  • There were too few beds and bathrooms, particularly in labour wards.
  • Inadequate computer and data systems prevented efficient management of the maternity service, even among some of the larger and well-respected trusts.

The report makes seven main recommendations:

  • Trusts should monitor the pathway of care from first contact with the maternity services to the time of transfer to the health visiting service, and ensure that care complies with guidance for antenatal, intrapartum, mental health and postnatal care from the National Institute for Health and Clinical Excellence (NICE).
  • Trusts should ensure that there are sufficient numbers of appropriately qualified staff available to provide a high level of care.
  • Trusts and those commissioning services should ensure that there are regular and effective mechanisms for gathering and acting on the views of women using their services, and should ensure that they are represented in the process for planning and monitoring the quality and safety of service provided.
  • Trusts should encourage and support all maternity staff in working effectively in multidisciplinary teams with agreed shared objectives.
  • Trusts should ensure that all staff are appropriately trained, up-to-date and confident in practising the essential skills needed for a safe and high quality maternity service; where appropriate, this training should be multidisciplinary.
  • Trusts must ensure that maternity units are equipped with appropriate IT systems that comply with Connecting for Health, enabling completion of mandated national data sets and the provision of accurate and systematic data on outcomes and management information on which to plan, commission and manage the resources required for maternity care.
  • SHAs and Monitor (the performance monitoring bodies) should ensure that trusts and those bodies charged with commissioning services address effectively the requirements of women and their babies who are from higher risk groups during pregnancy and afterwards, identified by the Confidential Enquiry into Maternal and Child Health. This includes ensuring that the process of planning and setting of priorities identifies them and appropriate clinics and visits are provided to support them.

Key findings of the report

Antenatal

  • Many women make a ‘booking’ for maternity care late, particularly in London.
  • Some women receive fewer antenatal appointments than recommended.
  • Some women do not receive an early ultrasound scan to establish the expected date of birth.
  • Nearly all women receive a fetal anomaly scan.
  • Many trusts are not following the latest guidance for screening for Down’s syndrome.
  • Not all trusts provide antenatal classes to women who want them.
  • Many trusts do not have access to a specialist perinatal mental health service.

Although some trusts achieved over 90% of women booked by the end of week 12, a quarter stated that their figure was 74% or less. The report found that ethnicity played a role in late bookings, only five per cent of white British women were booked after 12 weeks, but up to 15% of some ethnic groups were booked after this time, particularly Black African and Bangladeshi groups. It is suggested that commissioners with diverse communities look at why women are presenting late and work with communities to increase contact with a health professional early in pregnancy.

The report found that although most trusts provide substantial specialist care for conditions that increase risk in pregnancy, there are variations across the country. Sixty-three percent of doctors and sixty-four percent of midwives reported that specialist services were not always available for women.

In a quarter of trusts 86% of women (or less) received an initial dating scan. There were a number of reasons that women did not have the scan, including late presentation and some trusts being non-compliant with the NICE recommendations. There was a higher uptake on the second scan between 18 and 20 weeks, the proportion rated between 88% and 100% across all but one trust. NICE guidance recommends that 11 attributes are checked as part of this scan, of which two are optional. Only 62% of trusts reported including all 11 attributes.

Care during labour and birth

  • Most, but not all, women are offered a choice of location for the birth, but many did not feel that they were given sufficient information to make a choice.
  • Choice is limited by lack of availability of midwife-led units.
  • Too few women experience a birth without medical intervention.
  • Some women did not get the pain relief they wanted.
  • Some women were left alone when it worried them.
  • Most women were not cared for by the same midwife throughout their labour.
  • Rates of caesarean section are variable across trusts but nearly always higher than the recommended level.

Forty per cent of obstetric units reported that they had closed to new admissions at some time during the year, with the maximum being 12 days. A third of free standing midwifery units and 36% of co-located midwifery units been closed during the year, with some units reporting being closed for more than 55 days.

Although the majority of women reported getting the pain relief they required in labour, in a quarter of trusts up to 25% of women felt they did not get the pain relief they needed.

One in five women reported that they were left alone at some point during labour when it worried them and 11% reported the same thing after giving birth.

Postnatal care

  • Postnatal care is least favourably reported on by women.
  • Some women would have liked more contact with midwives after going home.
  • Rates of breastfeeding need to be increased.

Staffing and training

  • Variation in levels of staffing indicate that some units may be understaffed.
  • Poor attendance at training courses in some trusts.
  • Variation in supervision of midwives.
  • Insufficient presence of consultants on labour wards.
  • Doctors and midwives do not always feel they share the same goals.

Improved consultant presence on the labour ward is an important and practical measure to improve safety, care and reduce interventions. The report cites Safer Childbirth and states that it recommends consultant presence should be 40 hours per week unless the unit has over 5000 births per annum, in which case it should be 60 hours per week.

The report found that it was difficult to judge how much time was being spent separately on obstetrics once gynaecology duties were removed. Variation in the data presented by trusts on consultants ‘programmed activities’ (PAs) per week also concerned the HCC. Thirteen per cent of obstetrics units did not report on their consultants PAs and the subsequent 87% varied between 30 PAs per week to 0 for every 1,000 births per annum.

The report also found that inter-professional working needed improvement, with a number of staff responding that they did not feel obstetricians and midwives shared the same goals, were clear about their role in the organisation, or felt valued as a member of a multidisciplinary team.

Better communication between staff, particularly at hand-over was also required.

The report found that there was wide variation when it came to training courses for staff. Some reported almost universal attendance and for others attendance was poor. There was little difference between doctor and midwife attendance.

Facilities

  • All obstetric units have access to general emergency facilities, but some trusts do not have access to interventional radiology.
  • Some trusts are short of delivery beds.
  • Many trusts are short of baths or showers.
  • Very few women use a birthing pool.
  • Many women reported that toilets and bathrooms were not clean.

Information systems

  • A number of trusts lack information systems that can provide the necessary information on their maternity activity and as a result they could not provide data that HCC requested. Only 60% of Trusts had a system that was compliant with the requirements of Connecting for Health and 17% reported having no maternity system at all. Coverage of antenatal and postnatal care is particularly weak.

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