Maternity services in the UK

“Serious flaws found in NHS maternity care”, is the headline in The Guardian . This and other news sources say that mothers and babies are being put at risk, and they go on to list shortfalls in maternity services. They describe them as ‘conveyor belts’ due to bed shortages, and claim that there are not enough bathing facilities or midwives.

The stories are based on a report by the Healthcare Commission, which has urged action following their survey of 150 NHS trusts, which found low staffing levels and poor facilities. With fertility and birth rates soaring – 2007 has the highest figures since 1973 – it has said that things will need to change and more midwives recruited to meet government targets that aim to grant every woman the option of giving birth where she chooses by 2009.

The Healthcare Commission chairman, Sir Ian Kennedy, acknowledges that more needs to be done to improve the quality of care and improve the experience for women. He is quoted by The Times as saying, “I do not want to be at the wrong end of another investigation report describing the deaths of babies and mother…There’s no reason why we should see that any longer.” The review took two years to complete, and while some improvements have already been made, more improvement is needed.

The government announced at the beginning of this year that extra funding equalling £330 million is planned for maternity services over the next three years, to ensure the best possible care options and services are available for all expectant mothers.

Where did the story come from?

The report “Towards Better Births: A review of maternity services in England” is an extensive healthcare audit and inspection by the Healthcare Commission – an organisation aiming to promote improved healthcare and public health in England and Wales.

What kind of scientific study was this?

The Healthcare Commission has been reviewing maternity services over the past few years. Following the identification of shortcomings in staffing, teamwork and maternal care in a number of individual trusts, a more extensive review of the entire maternity service across England was planned and commenced at the start of 2007. One in 10 requests to the Healthcare Commission had been to investigate maternity services in UK trusts and the last audit on maternity services carried out in 1995/96.

In 152 NHS trusts in England, a detailed review of maternity care services was made for all stages of antenatal care, labour, birth and postnatal care up to the point of transfer to health visiting services. They examined policies for women with particular care needs (e.g. those with diabetes, previous caesareans, twin births or mental health issues), admission rates, facilities and staffing issues.

Information for the review was obtained though an internet-based maternity questionnaire that was completed by more than 26,000 women (a response rate of 59.3% of those invited to participate); an internet-based staff survey completed by 4,950 staff; another trust-led survey of women who had just given birth; and five engagement events attended by 42 women from ethnic minorities or with particular care needs, e.g. disabled women.

What were the results of the study?

The report is very in-depth. The following are the summary of the main findings from each stage of the care process.

*_Antenatal care:_ *

Across all trusts, 36% of women rated antenatal care as excellent; 32% as very good; 20% as good; 9% as fair; and 3% as poor.
In London in particular, some women are initially presenting to maternity care services at a later stage in pregnancy, and as such these women are not receiving their booking appointment by 12 weeks. Consistent with this, not all women are receiving early dating scans (usually carried out at 10-13 weeks). In a quarter of trusts, 26% of women were booking late. Late bookings were more prevalent amongst ethnic minority groups. Across trusts, the number of women reporting that they had received dating scans was 92%.
Some women attend fewer antenatal appointments than is recommended. The recommended number of antenatal appointments prior to birth is 10, and 25% of women reported that they received fewer than this. Additionally, 22% said that they had no choice about the location for these appointments.
Nearly all women are receiving foetal anomaly scans at 18-20 weeks. However, many trusts are not following NICE guidance for Down’s syndrome screening. Although screening was offered by all trusts, only 18% offered the most effective tests.
Antenatal classes are not available in all trusts. While 60% of women attend classes overall, 28% of women experiencing their first pregnancy reported that there was an insufficient number of classes available.
Availability of specialist maternity mental health services is variable across trusts. Forty per cent have specialist psychiatrist-led services, 18% have community psychiatric nurse-led services, and 42% have no specialist maternity mental health services available. For substance abuse, 63% of trusts reported that midwives were trained in dealing with this.

_Labour care:

Across all trusts, 50% of women rated labour care as excellent; 25% as very good; 13% as good; 7% as fair; and 5% as poor.
Not all women are able to make the choice of where they would like to give birth. This limitation is, in part, due to the small number of midwife-led units. By the end of 2009 the government is aiming for all women to have the choice of where they wish to give birth. Although 80% of the women surveyed reported that they had been given the choice of where they wished to deliver their baby, only 50% of these women said that they were given sufficient information to make this decision. Two-thirds of trusts are obstetric-led while only two of the trusts identified were midwife-led.
Midwife-led care should be the ideal for uncomplicated pregnancies and births. However, many women are experiencing a birth with some degree of medical intervention. Across trusts, only 40% of births were reported as “normal”, while this figure fell to less than 32% in a quarter of trusts.
Rates of caesarean section are higher than recommended in most trusts. The average rate across trusts was 24% of births; the WHO recommended rate is only 15%.
Some women did not receive the pain relief that they wished to. Overall, 64% of women surveyed said that they definitely received the pain relief that they wished, and 28% had received the pain relief they wanted to some extent. However, in a quarter of trusts, up to 25% said that pain relief was insufficient. Gas and air is used as pain relief by 80% of women during labour; 32% use the opioid drug pethidine; 30% opt for an epidural to completely numb the lower half of the body; and 11% opt for a water birth to ease labour pain.
One fifth of women were concerned by being left alone during labour and in one trust this was reported by as many as 40% of women.
Overall, in most cases, the same midwife did not provide care throughout labour. The figure was variable across trusts, but on average only 20% of women reported care from the same midwife throughout.

_ Across all trusts, 50% of women rated labour care as excellent; 25% as very good; 13% as good; 7% as fair; and 5% as poor._Postnatal care:

In general, the quality of postnatal care is reported the most unfavourably. Across all trusts, 30% of women rated postnatal care as excellent; 29% as very good; 21% as good; 12% as fair; and 8% as poor.
Following normal vaginal delivery, the average hospital stay is 1.4 days (1.7 for first-time mothers; 1.2 for previous mothers), two days for an assisted vaginal delivery and 3.4 days following a caesarean. On average 73% of women were satisfied with the length of their hospital stay after birth. Following normal birth, 12% felt their stay was too short; 15% too long. Following caesarean, 15% felt their stay was too short; 11% too long.
Some women reported that they would like more midwife care. Women should receive up to six weeks of midwife care before being transferred to health visiting services, with all trusts planning at least two midwife home visits and other clinic or telephone contacts. The average number of midwife contacts after hospital discharge was reported by women to be 4.3. Overall 21% percent of women said that they would like to have received more contact; this was as high as 51% in one trust.
Breastfeeding rates are poor. Across the country, 70% of women initially start breastfeeding, but this figure is highly variable between trusts - from 30 to 92%. The current target is to increase the rate of women who start breastfeeding by 2% each year.

_ In general, the quality of postnatal care is reported the most unfavourably. Across all trusts, 30% of women rated postnatal care as excellent; 29% as very good; 21% as good; 12% as fair; and 8% as poor.*_Facilities:_ *

There was a shortage of delivery beds in some trusts. The average trust has 3.6 beds per 1000 births per year, but some trusts had as few as two per 1000 births (hence used by more than one woman in a 24-hour period).
Many trusts have shortages of showers and baths. One bath per delivery room was reported by 16% of units; 38% of units reported having one shower per delivery room.
Few women are able to use a birthing pool: 11% reported any use and 3% reported giving birth in water.
Many women report some level of uncleanliness of bathrooms and toilets with only 49% giving the response on the survey of ‘very clean’.
While all trusts had emergency services available, interventional radiology services (procedures carried out under radiology guidance) were not available in 26% of units.

Staff provision and training:

There is variation in staffing across trusts, and some are understaffed. The average trust employs 31 midwives per 1000 births per year, but this figure varied across trusts from 23 to over 40 per 1000 births. Vacancies for midwife positions in 2007 varied from less than 0.5 in Yorkshire and Humber health authorities to about 4.5 in London.
The provision of training courses is variable across trusts and attendance is poor, with some reporting that only 40% or less of midwives and doctors had attended courses.
There is variation in supervision of midwives and insufficient presence of consultants on wards. The number of midwives per midwife supervisor varied from seven to 28, suggesting a need for review in this area. It is recommended that one consultant be present on the labour ward for 40-60 hours per week, depending on the size of the unit. Just over two thirds of trusts met this requirement, but it is concerning to find the figure to be less than 10 hours per week in some trusts.
Differing views between consultants and midwives on shared goals have been identified, suggesting a teamwork problem. Half of the trusts in the review were surveyed on this, with 28% of doctors and 58% of midwives reporting that their objectives of care were not the same. Each profession seemed to view their own as being the profession leading maternity care - views held by 54% of doctors and 67% of midwives.
Negative views of the working environment also seemed to be held. Feelings of being pressurised and finding work frustrating were held by between 60 and 80% of midwives and 40-50% of doctors. However, positive views were also high, with almost 80% of both doctors and midwives reporting their work as challenging, and 40-60% of them reporting their work as rewarding and satisfying.
IT systems that met requirements for the Connecting for Health initiative were found in only 60% of trusts, with 17% having no computer system for monitoring care, and only 15% of trusts having a system to cover from antenatal through to postnatal care.

Regarding maternal mortality – an issue raised by a few of the news stories – the review reported the following:

The main risks of death around the time of birth were related to excessive bleeding (postpartum haemorrhage or PPH), eclampsia (very high blood pressure leading to fitting), and transfer of the mother to the intensive care unit.
PPH carries the highest incidence, with average trusts reporting significant haemorrhages (greater than 1000 ml blood loss) occurring in 27 per 1000 births, and major haemorrhages (greater than 2500ml blood loss) occurring in 1.9 per 1000 births.
Women with eclampsia will normally have been identified to be at risk through suffering from pre-eclampsia during pregnancy. The average rate of eclampsia in trusts is 0.4 per 1000 births.
The average rate of transfer to the intensive care unit following respiratory or major organ failure was 1 per 1000 births.
The review was able to collect little data on the monitoring of indicators of risk to the infant’s health.

What interpretations did the researchers draw from these results?

The report summarises its key concerns for a number of trusts:

Staffing levels being below average.
Inconsistent adherence to antenatal care standards, particularly for women with at-risk pregnancies.
Inadequate continuity of care for women.
Inconsistent in-service training for doctors and midwives.
Consultants spending fewer than recommended hours on the labour wards.
Poor communication and care from staff towards mothers following the birth.
Too few beds and bathrooms in labour wards.
Poor data management within trusts.

They recommend that to effect improvements, strategic health authorities and other bodies monitoring and commissioning maternity services should give high priority to maternity services and ensure that they are monitored. This is suggested through:

Monitoring the patient pathway throughout antenatal and postnatal care through to transfer to the health visiting services, ensuring that they are in accordance with NICE guidance.
Ensuring sufficient numbers of qualified staff are available.
Regular mechanisms in place for gathering women’s views on services, and ensuring that they are taken into account in processing and planning.
Encouraging multi-disciplinary teamwork between midwives, doctors and other care providers with shared goals and objectives.
Ensuring that all staff are appropriately trained and have the required skills for a high-quality and safe provision of care.
Ensuring that there are IT systems in place that comply with Connecting for Health to allow collection of accurate data on outcomes to allow effective management and planning.
Commissioning bodies to ensure that the needs of higher risk mothers and babies and those of disadvantaged groups are met.

What does the NHS Knowledge Service make of this study?

The birth rate across England is clearly on the increase (584,100 in 2004/05 rising by 1.6% to 593,100 in 2005/06), highlighting the need for prioritising maternity care and making improvements where needed.

The Healthcare Commission states that each trust has received a report of its service performance with additional information and software to help them identify and target issues of concern. The aim is that they should work with bodies who commission services and local maternity service liaison committees to implement a plan that will address shortfalls. The Healthcare Commission states that trusts who were rated in the lowest performing categories have been the highest priority and will have already commenced this process.

The government announced at the beginning of this year that extra funding is planned for maternity services over the next three years, to equal £330 million, to ensure the best possible care options and services are available for all expectant mothers.