“Providing safer and more personalised maternity care, and ensuring every woman, no matter where they live in England, is provided with the very best care before, during and after their pregnancy is crucial…”
- Chief Nursing Officer for England, Dame Ruth May, 2023
Improving maternity care is a key Government and NIHR priority. In March 2024, an NIHR Evidence webinar showcased research from our recent Collection, Maternity services: evidence to support improvement.
This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A.
Background
Pregnancy and childbirth is usually a positive and happy experience culminating in a healthy mother and baby. But on the rare occasions when things go wrong, the effects can be life-changing.
Evidence on safety and quality in maternity care suggests a need for improvement despite some positive trends. Rates of stillbirth and neonatal deaths in England fell by 20% and 30% respectively between 2010 and 2021. However, other indicators of quality have declined in recent years, and some hospitals have had notable failings. Outcomes for black and Asian women and those from more deprived areas in the UK are significantly worse than for others.
Numerous investigations into failings in maternity services have led to multiple sets of recommendations. The report into maternity services at East Kent Hospitals (2022) identified four areas that are critical to high-quality maternity care. They are:
- kind and compassionate care
- teamwork with common purpose
- capacity to identify poor performance
- organisational oversight and response to challenge.
These four areas reflect priorities for improvement set out in the NHS England Three Year Delivery Plan (2023).
Research findings discussed at the webinar will help hospital boards, and professionals in maternity services, address the four areas.
Features of safety in maternity units
“While learning from failure is essential to improve safety, inquiries into adverse events have not always produced the desired impact. ‘Positive deviance’ offers a different approach to safety. In a positive deviance framework, we ask: ‘What are the kind of behaviours, processes, and systems that contribute to safe care?’”
Elisa Liberati, Senior Research Associate, THIS Institute, Cambridge
Elisa Liberati and colleagues undertook a multiphase qualitative study (2020) to identify behaviours, processes, and systems that promote safety in maternity units, and to generate practical guidance for learning and safety improvement.
The first phase of the study was an in-depth ethnographic study of a high performing maternity unit. At the time of the research, the Southmead Hospital in Bristol was identified as one of the safest maternity units in the UK; it had sustained safety improvements since 2000, after it developed and implemented a training program called PROMPT.
The second phase involved observations and interviews in 5 additional maternity units, which had also taken part in the PROMPT training, but had different experience of its implementation. This phase helped to refine understanding of the other local conditions (on top of PROMPT) that are associated with safety.
Finally, the team undertook an extensive stakeholder consultation. This included 65 interviews with 7 stakeholder groups, such as pregnant people and their partners, clinical front line staff, clinical managers, members of relevant professional bodies, and improvement experts.
The team identified seven key features of safe care in maternity services. Each is important on its own, but features reinforce and depend on each other to promote safety at a system level.
In the webinar, Elisa Liberati highlighted 3 of the key features.
- Teamwork. Cooperation is central to all activities; people across disciplines and professions understand and value each other's roles. Hierarchies are flexible: when assigning tasks, the team prioritises skills and experience over seniority or professional grouping, meaning that the person best suited to the task takes it on. Staff look after each other: they recognise that disagreements are inevitable and settle them through thoughtful discussion. Staff wellbeing and morale are recognised as important contributors to safety. “There’s a really good relationship between the doctors and the midwives… I definitely felt very welcomed…” (registrar).
- Technical competence. Units expect a high standard of skills and knowledge from staff; they invest in high-quality training and protect staff’s training time. Senior staff offer opportunities to ask questions after complex clinical situations. There is a mix of formal training (including multidisciplinary learning, skills drills and real-life simulations) and informal learning (mentorship, mutual observation and collective reflection, for instance). Units protect social spaces to facilitate informal learning. One participant said: “...There was a lot of… informal one-to-one teaching going on in the communal coffee room. Somebody will say… ‘Do you know what you do in this sort of situation?”
- Effective coordination. The unit can respond quickly to emerging risks and emergencies. Multiple systems (IT programmes, whiteboards, and so on) capture up-to-date information for each patient. Systems identify risks early and indicate how and when to respond. Both hard data (hospital statistics) and soft data (staff and family views) are considered. On-site training helps staff to improve their situational awareness and respond appropriately in real-life situations. Good communication, structured handovers and regular team huddles, as well as ward rounds, give a shared understanding of the unit in real-time. One registrar said: “We’re not fire-fighting, we’re trying to anticipate what’s going to happen and where risk is.”
The importance of culture, behaviours and processes in the findings suggests that relatively low-resource changes can make a big difference to patient safety. However, in the webinar Q&A, Elisa Liberati also stressed the importance of structural factors, such as staffing levels and availability of equipment.
Kind and compassionate care around the induction of labour
“There are many discussions and debates around the induction of labour, but what is clear is that there's no one method, or place, or timing, that is right. Women's preferences and choices should be key to decision-making about the induction of labour.”
Rose Coates, Research Fellow, University of London
In the UK, around 1 in 3 women in labour are induced (2018 figures). Most studies of the induction of labour focus on safety. However, Rose Coates and colleagues wanted to explore women’s experiences of the induction of labour. Their 2019 study analysed existing evidence and included 10 studies (from 2010 - 2018) involving 157 women. The studies took place in the UK, Australia, USA, Brazil and Ireland.
The research identified 4 themes.
1. Making decisions
“[The decision] was presented as a choice, but they were definitely encouraging me to strongly consider it rather than waiting.” Jay A, and others
Many women felt decisions about the induction of labour were made for them, not with them. Women said they were not informed of the benefits and risks, and therefore couldn’t make decisions. Many were unclear why their induction had been booked. Some felt information was withheld and their feelings not considered. Conversations were often rushed. Women were concerned about any intervention (including induction or further interventions such as a caesarean), but thought clinicians knew best and trusted them.
2. Ownership of labour
“Things happened that I feel the leaflet did mention but needed more discussion … like the pain and how bad it was.” Murtagh M and Folan M
Some women felt that they weren’t in control and were under-prepared for the induction. For example, they didn’t know if they would need to stay in hospital after treatment, how long the process would take, and how severe the pain might be. Some women felt they were part of a checklist.
3. Women’s social needs
“You didn’t want to pester the [staff] because you knew they were busy but you thought: ‘oh, how long can I sit here?’” O’Brien E, and others, 2013
Some women felt forgotten or alone, that they were not listened to, and that their pain was not believed. Some felt they were given no choice, and had to have a vaginal birth. However, others felt comfortable and prepared for labour by clinicians. They valued being able to choose a date for induction, or a method of delivery. Having friends and family present could help women to feel supported.
4. Environment
“Had I been at home I probably would have had a lot more [sleep]… It was just from a new bed, a new environment, a hospital sterile kind of environment” Oster C, and others
For some women, the busy and noisy hospital environment increased anxiety. Women felt restricted and could not always move about or see family or those there to support them. Women disliked being moved according to their stage of labour. However, hospitals were seen as a safe place to labour and give birth to their baby. Women who were induced at home felt comfortable and enjoyed being able to continue with daily activities.
Ensuring women feel in control of their labour
Good-quality, timely information and support helps women to be involved in decision making, and can nurture a sense of ownership and control over their labour. Women need to understand the balance of benefits and risks, and be clear that induction of labour is a choice; they have the right to refuse it. Compassionate support from clinicians and loved ones in a comfortable, private and safe environment is likely to improve their experiences.
In the webinar, Rose Coates said that both research and practice need to prioritise women’s experiences. This will help identify the areas for improvement that matter to women. In particular, more research is needed on the experience of women from ethnic minorities.
The role of hospital boards in improving maternity care
“Here are some questions for boards. How often do you visit maternity wards and outpatients? Do you welcome invitations from maternity staff to have conversations with them? How well do you understand what matters to women, their families and partners?”
Naomi Chambers, Professor of Health Management, University of Manchester
Hospitals are led by board members who have oversight over performance, staffing, integration with other health services, and other matters. They balance hospital finances, staffing, and public and other interests.
Naomi Chambers said that the consequences of poor leadership from hospital boards can be catastrophic. For example, as the inquiry on the Mid-Staffordshire NHS Foundation Trust (the Francis Report) found, the board bore significant responsibility for the failings in quality and safety of care.
In a mixed methods study (2019), Naomi Chambers and colleagues examined the roles boards perform, and the behaviours that make them successful. The team examined literature on hospital boards, surveyed 381 NHS board members, and interviewed 13 national policymakers. They also carried out 6 hospital case studies; they interviewed stakeholders (including patient and clinician organisations, healthcare regulators, and the Department of Health and Social Care), held focus groups and observed board meetings.
Characteristics of effective hospital boards
Effective boards focused on patient care and prioritised evidence-based learning, quality improvement and safety. These boards actively looked for areas of improvement; they sought out and acted on the concerns of patients, staff, and regulators. They gathered data on safety and quality of care in detailed, timely reports. Effective boards supported staff and protected them from negative pressures. They promoted a culture of compassionate care and leadership. Board members who were visible to staff and patients were most effective. They prioritised safety over financial sustainability, despite increasing workforce pressures. Systems and processes were flexible to allow for quality improvement.
Naomi Chambers and colleagues described five key, interconnected roles of effective boards:
- Conscience of the organisation: set and reinforce values; listen and respond to patient and staff concerns.
- Shock-absorber: help determine local priorities in a complex policy and regulatory environment, and thus shelter staff from external pressures. This helps balance the interests of staff and external stakeholders.
- Diplomat: manage relationships across the local health economy, regionally and nationally and promote the reputation of the hospital.
- Sensor: scrutinise a wide range of organisational performance indicators to drive improvement, sense problems and develop and implement solutions. Boards can challenge behaviours to ensure patient safety, while remaining supportive.
- Coach: set ambition and direction while supporting staff; take a collaborative approach to service improvement.
The roles of sensor, conscience and coach are particularly relevant for maternity services, she told the webinar, as Boards need to discern and act on a range of performance issues and problems. Boards need regular updates on safety and quality of care, with feedback from patients and staff, as well as performance metrics; they need to triangulate this data and ask questions. Board members become receptive to signals of poor care when they visit wards and witness patient care for themselves and visit other services.
Board leadership
Leadership behaviours lay the foundations for better organisation performance, particularly in complex and challenging healthcare environments. These findings resonate with the East Kent report and other investigations, which found board weaknesses, particularly in the roles of conscience, sensor, and coach.
In the webinar, Naomi Chambers posed questions for boards to help them reflect on their practice and improve maternity care. These included:
- how often are maternity services discussed at board meetings?
- how do you track service improvement strategies and objectives in maternity services?
- how does the quality of your maternity service compare with others in the UK?
- how do you and maternity clinicians in your organisation learn from others?
Finally, she drew attention to the publication Organising Care Around Patients (2021) which includes a chapter on stories of experiences of users. This book provides a framework for humane, safe, and high quality services based on the principles of kindness, attentiveness, empowerment, professional competence and organisational competence.
Conclusion
“Make an effort to understand your patients’ experiences, get service users involved, because what you will find in your local setting with its own policies, staff and resources is going to be different in some ways to the published research.”
Rose Coates
Improving maternity services is a priority for the government and the NIHR, and is reflected in the NIHR Challenge on Maternity Inequalities. This, the first ever NIHR Challenge, which is backed by £50 million, will task researchers and policymakers with finding new ways to tackle maternity disparities. It will bring together a diverse consortium, funding research and capacity building, with the aim of increasing the evidence base to address inequalities in maternity care. Alongside this, NIHR programmes continue to actively seek ways to increase women’s representation in medical research through the NIHR Research Inclusion Strategy and the implementation of the Women’s Health Strategy for England.
The Collection and webinar highlight research to help maternity services improve across the 4 areas of the East Kent report. The research demonstrates:
- the importance of culture, behaviours and processes to the delivery of safe care
- the value of listening to women and involving them in decisions about their care
- how professionals need to respect each other and work effectively as a team
- the need to respond to incidents quickly and effectively
- the vital roles that boards play in providing leadership to maternity services. This includes: setting and reinforcing values; listening and responding to patient and staff concerns; scrutinising organisational performance to drive improvement; promoting a collaborative approach to service improvement.
Elements of good practice are already in place on many wards, but teams need the time and capacity to reflect on, and learn from, what works best. This includes listening to women and their families. Speakers said that both clinicians and board members can learn from this lived experience; what service users say is different from published literature, and from safety statistics. They concluded that maternity care, and improvements to maternity services, need to be guided by the experiences of women and their families.
Further reading and resources
Our previous Collection, Maternity services: evidence to support improvement, signposts other research and policy documents on improving care.
Report into maternity services at East Kent Hospitals.
Three year delivery plan for maternity and neonatal services.
A report from MBRRACE about saving lives and improving mother’s care.
The King’s Fund Tool for Improving NHS Culture.
House of Lords Library report on the performance of maternity services in England (2024).
Government response to the independent Pregnancy Loss Review.
Saving babies lives care bundle.
Pregnancy Loss Review from the Department of Health and Social Care.
Information on personalised care support plans for maternity services.
How to cite this Collection: NIHR Evidence; Maternity services: research can improve safety and quality of care; March 2024; doi: 10.3310/nihrevidence_62672
Disclaimer: This Collection is based on research which is funded or supported by the NIHR. It is not a substitute for professional healthcare advice. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
NIHR Evidence is covered by the creative commons, CC-BY licence. Written content and infographics may be freely reproduced provided that suitable acknowledgement is made. Note, this licence excludes comments and images made by third parties, audiovisual content, and linked content on other websites.
