The safety of maternity services in the UK
In not too distant history, pregnancy and childbirth was associated with very different outcomes than is the case today. In Victorian times, upon discovering a woman was pregnant, it was common place and considered to be a wise precaution to ensure that a will was put in place and a contingency plan established in case the mother didn’t survive.
It was also much more common for families to lose children during childbirth. This situation started to change during the first part of the last century with the rapid development of medical science, obstetrics and paediatricians.
Since then there has been a steady reduction of perinatal mortality as understanding, monitoring of pregnancy and application of clinical interventions, has meant that poor outcomes that sometimes occur when mother nature is left alone, have been dramatically reduced.
However, despite these great leaps forward, the UK has fallen stubbornly behind other Western European countries, coming close to the bottom of the league tables when it comes to perinatal mortality.
The question then, is why, in an age where understanding of how to monitor, assess and intervene to avoid poor outcomes, do so many avoidable perinatal deaths continue to happen in UK maternity services?
One place to look for answers is the annual figures released by the NHS Litigation Authority (NHSLA).
When an avoidable death occurs in maternity services, tort civil law allows the family to seek compensation. Such a claim is only successful if the family are able to prove that in the balance of probability the outcome could have been avoidable had a reasonable standard of care been provided. Of all the claims relating to health care, maternity claims represent by far the largest proportion, amounting to a total of £500 million per year.
The latest report from the NHSLA looking at the past 10 years of claims data states
…Cardiotocograph (CTG) interpretation (fetal heart rate monitoring), and management of labour in which the outcome was that the baby suffered cerebral palsy, accounted for 70% of the total value of all maternity claims.
This information suggests that there is an urgent need to encourage and improve high quality monitoring and early referral to an obstetrician where there is a need. Surprisingly though, for some years the RCM have lead a campaign encouraging UK midwifes to adopt the exact opposite approach. The RCM ‘Campaign for Normal Birth boldly states that ‘intervention should be the last choice’, and advocates a ‘push towards normal birth’.
Whilst the causes of avoidable perinatal deaths are clear, the ‘Campaign for Normal Birth’ is responding to a different issue. The argument goes that if the culture in maternity services is ‘fearful’ of litigation (the word ‘litigation’ can be substituted with ‘preventable perinatal or maternal harm or death’), this can result in an atmosphere and culture prevailing in which there is an increase in ‘unnecessary interventions’. I completely understand the reasons why unnecessary intervention is undesirable. Without doubt, c-sections carry associated risks (although the latest NICE evaluation found no difference in risk between caesarean and vaginal delivery), there are implications for subsequent births and c-sections also cost the NHS more.
However, figures from the NHSLA tell us that avoidable deaths (either maternal or perinatal) through unnecessary intervention is not a significant issue linked to avoidable mortality.
If you work in maternity services as an obstetrician or midwife, ask yourself (or your colleagues) how many cases you have seen in your career where a mother or baby has died due to an intervention that may not have been necessary? Ask the same question regarding how many cases you have seen where a baby has died where earlier intervention may have made a difference? I am quite certain the answer will be very different.
If the UK is going to tackle its stubbornly high perinatal death figures and reducthe number of avoidable maternity related deaths; surely we need a national campaign that addresses the underlying reasons?
In 2012, NHS Cumbria carried out a comprehensive review of perinatal mortality in the area. The review (published in 2013) included a confidential inquiry style review of all perinatal deaths in the area from 1 January 2009 to 31 December 2010.
Of the 60 cases assessed in this audit, 38 (63%) cases had avoidable factors or elements of substandard care. Fifteen of these 38 cases were identified as having avoidable factors in relation to referral to a specialist. The report states,
…many of these were a failure by the midwife to refer to an obstetrician in time for an intervention to be made.
Six (40%) of these were judged to be major in that the failure to refer significantly contributed to the death and different management would reasonably have been expected to alter the outcome.
The report goes on
…. the common themes were lack of clear care plans, no evidence of adherence to guidelines and evidence based care pathways and a failure to act on a suspicious CTG
In 18 cases, the report states ….’the lack of knowledge was judged by the panel to be major in that it significantly contributed to the death and different management would reasonably have been expected to alter the outcome.’
The report concludes
…failure to recognise the high-risk nature of some pregnancies was the most common theme identified in the case review. This ranged from not identifying factors or not acting appropriately on factors that were identified that predisposed mothers to complications, to failing to recognize when pregnancies classified as “low-risk” became abnormal.
A further insight highlighting this issue nationally is provided by this 2008 Kingsfund report. The report states
….the lack of medical experience and nursing skill in newly qualified midwives can be a problem, as they may be less likely to recognise sick mothers. This can leave midwives struggling to distinguish between normal and abnormal situations.
The report quotes from a midwife with 3-10 years’ experience who states…
Midwives [are] routinely unable to recognise the difference between normal and abnormal scenarios, resulting in inappropriate intervention for low-risk women and late/lack of referral in higher-risk situations, resulting in poor outcomes.
In the context of this recognised skill/training gap, is a campaign that describes intervention as a ‘last choice’ best addressing the fundamental issues affecting safety in UK maternity services?
It’s difficult to see exactly who the RCM is campaigning against. Every woman would like a normal birth, but the real fear is of a bad outcome. To prevent that happening, we need co-operation between all the professionals in the obstetric team, rather than campaigns about which treatment is best. Without such co-operation, there is a far greater risk of mistakes being made.
The Kingfund report also makes this point
There is a need to build mutual understanding of the respective roles and competencies of those working in midwifery and obstetrics…. while all women need midwives, some also need obstetricians; a balance between the two professions is vital.
A question we need ask, does the RCM Campaign for Normal Birth help in achieving this balance?
The last point I wish to make relates to a major issue affecting the safety of maternity services in the UK; the lack of learning from avoidable outcomes.
Three years later, the NHS Cumbria confidential inquiry found the same depressing problem. The Cumbria report concludes
….of the twenty cases identified with at least one major avoidable factor only one was reported as a Serious Untoward Incident (SUI)The report goes on ‘….. the expert panel assessed the single SUI report submitted, finding it to be inadequate and lacking in content and detail on the lessons to be learnt from the case. They found the action plan to be deficient and the audit proposal poor. The panel similarly found the four local reviews to be inadequate with little evidence of multidisciplinary reflection or learning from the cases.’
The lack of learning from avoidable poor outcomes in maternity services in the UK is a national scandal that needs to be urgently addressed. How often to do we hear the words, ‘no one comes to work in the NHS to do harm’? This is true, just as it may be true to say that no one gets in a car and drives whilst over the limit with the intention to do harm. However, harm is an inevitable outcome of drink driving if allowed to go on unaddressed and unchallenged. The failure to properly review, understand and learn from avoidable poor outcomes in maternity units is as irresponsible as drink driving. It is something that should never be tolerated or accepted.
My request to the RCM is to start a national campaign for safer birth. A campaign which responds to the clear evidence which tells us why too many babies in the UK continue to die from avoidable reasons. Let’s tackle the defensive culture that still exists in some parts of the UK’s maternity services and ensure that all avoidable deaths are properly reviewed and lessons to prevent reoccurrence always implemented. Let’s move away from campaigns which elevate one type of delivery above another and instead work to ensure all staff working in UK maternity units have the necessary skills, training and support to ensure timely interventions happen – not as a ‘last choice’ but as a decision taken by well trained and competent professionals, working together to achieve the safest outcomes for mothers and babies.
James Titcombe – May 2014