National learning report – Factors affecting the delivery of safe care in midwifery units

Maternity and Newborn Safety Investigations programme – May 2024

This report is intended for healthcare organisations, policymakers and the public. It is based on a thematic analysis (a process that looks for common themes) of 92 maternity investigation reports, where the safety incident under investigation included care provided in a midwifery unit.

Midwifery units are staffed by midwives and support staff. Typically, pregnant women who choose to give birth in a midwifery unit have been assessed as having a low chance of complications during labour and birth. Sometimes a pregnant woman or baby may need to be transferred from a midwifery unit to an obstetric unit (a hospital unit where specialist doctors are primarily responsible for their care) to receive additional care and treatment.

The thematic analysis identified 4 main themes and findings, which include issues relating to:

1. Work demands and capacity to respond – the number of tasks needed to be done and whether there are enough (and suitable) staff, and appropriate physical space, to do them.
2. Intermittent auscultation – a method used to assess a baby’s heart rate as an indicator of their wellbeing.
3. How prepared an organisation is for predictable safety-critical scenarios, and the role played by in situ simulation (a training method that involves staff rehearsing scenarios in the workplace).
4. Telephone triage – the assessment a midwife carries out when a pregnant woman telephones because they have gone into labour or have a concern about their pregnancy.

Read the report – National learning report – Factors affecting the delivery of safe care in midwifery units

Review of North Central London’s Start Well maternity and neonatal care

Nuffield Trust – Published: 15/03/2024

The Mayor of London has developed six tests to apply to major health care reconfiguration programmes in the capital, designed to ensure that major changes are in the best interests of all Londoners. The Nuffield Trust has been involved in supporting the development of these tests, and the Mayor commissioned the Nuffield Trust to undertake a review of proposals by North Central London Integrated Care Board to consolidate maternity and neonatal care services within its geographic area. This report sets out our assessment of those proposals against the first four of the Mayor’s tests.

Read the report – Review of North Central London’s Start Well maternity and neonatal care

Maternity survey 2023 – CQC

CQC – February 2024

This survey looked at the experiences of women and other pregnant people who had a live birth in early 2023.

Women and other pregnant people who gave birth between 1 and 28 February 2023 (and January if a trust did not have a minimum of 300 eligible births in February) were invited to take part in the survey. Trusts with sample sizes meeting this minimum were asked to additionally sample ethnic minority groups from January and March to enable statistical analyses at regional and ICS levels. Fieldwork took place between April and August 2023. Responses were received from 25,515 women and people who had recently given birth. This was a response rate of 41%.

Read the report – Maternity survey 2023

WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage

WHO – December 2023

In 2023, the World Health Organization (WHO) convened a Guideline Development Group to update an existing recommendation on assessing postpartum haemorrhage (PPH) and consider using a care bundle to treat PPH. This decision was based on new evidence on the subject that had become available. This document issues an updated recommendation on the assessment of PPH and a new recommendation on the use of a treatment bundle for the management of PPH.

WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage

The Sands Listening Project – learning from the experiences of Black and Asian bereaved parents

Sands December 2023

In the report you can find out more about pregnancy loss and baby deaths among Black and Asian babies in the UK, ​our findings, real-life experiences and case studies, plus what needs to change.

These findings have been shared alongside a national enquiry to provide powerful evidence for improvement.

Read the Report –learning from the experiences of Black and Asian bereaved parents

Further reading – MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK

MBRRACE-UK Comparison of the care of Asian and White women who have experienced a stillbirth or neonatal death

HQIP – 14th December 2023

The Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal confidential enquiry report on a comparison of the care of Asian and White women who have experienced a stillbirth or neonatal death. It is based on deaths reviewed in England, Wales, Scotland and Northern Ireland, for the period between 1 July 2019 and December 2019.

The overall findings of this enquiry were based on the consensus opinion of panel members concerning the quality of care provided for 34 Asian and 35 White mothers and their babies. This enquiry was developed to try and identify any differences in the quality of care provided to women of Asian ethnicity compared with their White counterparts, and forms the main focus of this report. As such, the recommendations are targeted at trying to ensure equity for the quality of care provision for both Asian and White mothers and their babies.

Read the Report – MBRRACE-UK Comparison of the care of Asian and White women who have experienced a stillbirth or neonatal death

MBRRACE-UK Comparison of the care of Black and White women who have experienced a stillbirth or neonatal death

HQIP – 14th December 2023

The Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal confidential enquiry report on a comparison of the care of Black and White women who have experienced a stillbirth or neonatal death. It is based on deaths reviewed in England, Wales, Scotland and Northern Ireland, for the period between 1 July 2019 and 31 December 2019.

The overall findings of this enquiry were based on the consensus opinion of panel members concerning the quality of care provided for the 36 Black and 35 White mothers and their babies. This enquiry was developed to try and identify any differences in the quality of care provided to women of Black ethnicity compared with their White counterparts, and forms the main focus of this report. As such, the recommendations are targeted at trying to ensure equity for the quality of care provision for both Black and White mothers and their babies

Read the Report – MBRRACE-UK Comparison of the care of Black and White women who have experienced a stillbirth or neonatal death

RCOG publishes Good Practice Paper on Maternity Triage

RCOG – 11th December 2023

The Royal College of Obstetricians and Gynaecologists (RCOG) has published a new Good Practice Paper providing recommendations for maternity triage operational structure and pathways, to support safe care of pregnant and newly postnatal woman and people outside of scheduled appointments.

The paper recommends that maternity triage departments implement the Birmingham Symptom-specific Obstetric Triage System (BSOTS), which is the recommended triage system in England and has been widely adopted in the UK. Using this system offers standardised initial assessment and symptom-specific algorithms to identify those women who require more urgent attention in a busy clinical setting.

To support this process, the paper also recommends that women should be provided with information regarding how and when to call or to attend the maternity triage unit, and that a dedicated telephone advice line answered by a midwife is made available 24/7 outside the clinical area. Women attending the unit should be initially assessed by a midwife within 15 minutes of attendance and prioritised using algorithms which determine urgency of further investigations and seniority of review.

Read – Good Practice Paper No. 17 Maternity Triage

Maternity and neonatal voices partnership guidance

NHS England 28th November 2023

The Three-year delivery plan for maternity and neonatal services recognises that listening and responding to all women and families is an essential part of safe and high-quality care. Listening to women and families with compassion improves the safety and experience of those using maternity and neonatal services and helps address health inequalities.

Maternity and neonatal voices partnerships (MNVPs) ensure that service user voices are at the heart of decision-making in maternity and neonatal services.  The ambition for MNVPs is set out in the Three-year delivery plan for maternity and neonatal services.

The principles for MNVPs described in the guidance aim to help integrated care boards (ICBs) and trusts address the unwarranted variation in the way MNVPs are implemented across England.

Maternity and neonatal voices partnership guidance

State of Maternity Services Scotland 2023

RCM – September 2023

Although Scotland continues to be a safe place to give birth, demographic and societal changes and continuing workforce challenges mean complacency is not an option. Action is needed now to maintain safety and quality levels in maternity

Read the Report – State of Maternity Services Scotland 2023