Are new lessons really being learned in maternity services?

I heard Donna Ockenden, midwife and author of the Ockenden report commenting on the Care Quality Commission (CQC) Maternity and Newborn Safety Investigation (MNSI) ,on the 8th May when the report was published. Sadly, her summary was that more funding was required and that none of the themes were new.

The report examines key factors affecting the delivery of safe maternity care in hospitals after analysis of 92 maternity investigation reports in England. I am inclined to agree that less talk, more action is required , better training and more staff.

The results were taken from investigations before June 2022. MNSI Director Sandy Lewis said: "our investigations have demonstrated very clearly how supporting staff through appropriate training, ensuring consistent and robust triage processes are in place, and implementing an effective foetal heart monitoring approach are all critically important".

It concluded the main issues affecting maternity service safety were;

• Work demands and capacity to respond;

• Intermittent auscultation;

• Organisational preparedness for predictable safety - critical scenarios, and;

• Telephone triage.

Work demands and capacity to respond

It is not surprising to hear that overwhelmed units where work demands exceeded capacity was identified in 43% of the maternity investigation reports. When this happens, a balance cannot be drawn between thoroughness and efficiency, and something has got to give. Compromise resulted in delays in monitoring pregnant women and their babies or meeting other care needs.

The capacity problem is aggravated by similar capacity challenges in other areas of maternity care, such as obstetric units and ambulance Trusts. When capacity problems start, they filter through. The report found that this could translate to women not being provided with the appropriate level of care to reflect their risk and need. It follows, that if there are enough midwives the service will be strained.

Intermittent auscultation

Is a common method used to listen to a baby's heartrate during labour in a midwife led unit where complications are not anticipated.

In 49% of investigations, the recordings were not made in line with national guidance. The reason for this, "high workload". In response, the MNSI aim to develop a toolkit to improve the way intermittent auscultation is carried out in practice.

Organisational Preparedness for Predictable Safety Critical Scenarios

The analysis identified that in 40% of cases where works systems and functions were available to deal with a situation, were not fit for purpose, hindering staff and not functioning as intended. One example was in the transfer of patients. Other alarming examples were environment, access to equipment and inadequate staff training and preparation hindering the ability of staff to respond effectively to a baby that may need resuscitation.

Put simply, these measures can make the difference between a healthy baby, damaging hypoxia causing brain injury or the death of a baby. This is at significant human and financial cost.

In response the report calls for greater simulation and stress tests to prepare for such scenarios.

Telephone Triage

An essential part of the process for understanding the stage of labour and any problems. The ladies I act for complain of being made to feel 'neurotic' on reporting, particularly when presenting as first-time mums without any knowledge of what to expect during the perinatal period. The common complaint is that they are not taken seriously.

The report confirms what I regularly hear and see, namely;

1. Variation in advice.

2. Variation in recording electronically and on paper systems.

As a lawyer I have found a lack of information sharing, and in some units the reluctance of more junior staff to escalate or ask appropriate questions. This suggests a deeper cultural problem.

At the heart of good maternity care is a combination of all these key features; appropriate staffing levels for a growing population, the correct equipment facilities and training to use it. Familiarity with emergency situations and the appropriate stress test alongside consistency in approach and awareness of guidelines and collaboration between teams should promote learning. Finally, women deserve to be listened to and taken seriously. In my experience, if they were, I would not see so many cases.

I can only hope that this further evidence strengthens the argument for change at a much faster pace than I can see happening.