Concerns about care in NHS maternity services John Tingle


he Care Quality Commission (CQC) and the National Audit Office (NAO) have recently examined the provision of maternity services in England and have found major patient safety care failings (CQC, 2013; NAO, 2013). Some are related to communication between patients and health professionals and between health professionals themselves. There are implications for the whole NHS as many failings have been repeated in other areas of care provision. The NHS just does not seem to be able to learn from the errors of the past. These errors can result in expensive clinical negligence court claims, and many are simple ones that should never have happened in the first place had proper reflective care taken place.

Setting the scene: the NAO report The NAO scrutinises public spending for Parliament and is independent of Government. When the NAO investigated outcomes across the NHS, it found significant and unexplained local variation in performance against indicators of quality, safety, cost, and efficiency. Together these factors show there is substantial scope for improvement and the NAO concluded that the Department of Health has not achieved value for money for its spending on maternity services. The terms ‘quality’ and ‘safety’ have particular significance and the report goes into more detail on these points.

Some figures The report indicates having a baby as the most common reason for admission to hospital in England. In 2012, there were 694 241 live births. Maternity care cost the NHS around £2.6 billion in 2012–13, equivalent to around £3700 per birth. The cost represents around 2.8% of health spending, about the same proportion as a decade ago. The number of births is currently at its highest level in 40  years, placing increasing demands on NHS maternity services. Over recent years, there has also been an increase in the proportion of ‘complex’ births, such as multiple births and those involving women over 40 or with obesity or pre-existing medical conditions. These complexities increase the risks of childbirth, meaning care often requires greater clinical involvement. John Tingle is Reader in Health Law, Nottingham  Law School, Nottingham Trent University


Some key findings Women’s overall experience The report suggests that women’s experiences of maternity care are positive. In 2010, 84% of women

reported that the care they received during labour and birth was excellent or very good, compared with 76% for antenatal care and 67% for postnatal care. Between 2007 and 2010, there was similar improvement across all three parts of the care pathway. There were, however, significant inequalities in reported satisfaction between white women and black and minority ethnic women.

Providing safe care The NAO report states that outcomes in maternity care are good for the vast majority of women and babies but, when things go wrong, the consequences can be very serious. In 2011, 1 in 133 babies were stillborn or died within 7  days of birth. This mortality rate has fallen, but comparisons with the other UK nations suggest there may be scope for further improvement.The NAO found wide, unexplained, variations in the performance of individual trusts in relation to complication rates and medical intervention rates, even after adjusting for maternal characteristics and clinical risk factors. This variation may be partly as a result, the report says, of differences in aspects of women’s underlying health not included in the data and inconsistences in the coding of the data. Data for England and Wales combined showed that 46 women died from causes related to ‘pregnancy, childbirth and the puerperium’ (the 6-week period following birth) in 2012, compared with 47 in 2007. This is equivalent to 1 in 15 000 births. In 2011, there were 5183 perinatal deaths (stillbirths and babies dying within 7 days of birth), which equates to a perinatal mortality rate of 7.5 per 1000 births (or 1 in 133). This rate has fallen over time (from 7.7 per 1000 births in 2007).

Clinical negligence claims As in other parts of the NHS, litigation in maternity care is rising—the number of claims increased by 80% in the 5 years to 2012–13, according to the NAO. The cost to the NHS for litigation cover against maternity claims totalled £482 million in 2012–13. Nearly a fifth of spending on maternity services is for clinical negligence cover. The report goes into more detail on clinical negligence rates and makes the point that adverse outcomes can have serious consequences for the taxpayer as well as for the women and babies concerned. In 2012–13, there were 1146  clinical negligence claims relating to maternity care, equivalent to around one claim for every 600 births. The number of claims increased by 80% in the 5 years from 2007‑08 to 2012–13, which is consistent with the rise in claims across the NHS as a whole (88%). Over the last decade, the most common reasons for maternity claims listed in the report have consistently been mistakes in the management of labour, relating to caesarean sections, and errors resulting in cerebral palsy. The average

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John Tingle discusses two reports that reveal major patient safety care failings in maternity services.

British Journal of Nursing, 2014, Vol 23, No 3

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PATIENT SAFETY time from an incident occurring to a claim being resolved is over 4 years and the NAO says it is therefore difficult to draw conclusions about the quality and safety of current care from the claims that have been settled. The crystal clear message here is that trusts must improve risk management and patient safety strategies. The report also notes an increase in claims across the whole NHS so the message must equally apply to other care areas. There are a number of recommendations to improve performance.

The CQC report The CQC report concentrates less on the big picture of maternity care provision—financial, management and strategic objectives. Here the focus is much more on individual care delivery and trends.

Key findings for England The report states that there is evidence of improvements since the maternity survey was carried out in 2010. Compared with the last survey: ■■ There has been an increase in the proportion of women who said that they were always spoken to in a way they could understand during antenatal care and labour and birth ■■ More women felt that they were always involved during antenatal care and labour and birth ■■ More women felt that they were treated with kindness and understanding and had confidence and trust in the staff caring for them during labour and birth. However, performance in other areas has not improved since 2010 and experiences fell short of expectations: ■■ Information and support are being provided inconsistently— and in some cases, basic knowledge such as medical history was not known ■■ Information needed to make choices was not consistently provided and the choices themselves were not universally offered to women ■■ Fewer women reported that they were not left alone during labour or birth at a time that worried them ■■ Almost one in five women felt that their concerns during labour were not taken seriously and some women felt that hospital wards, toilets and bathrooms are not clean enough, especially toilets and bathrooms.

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Patient comments about communication The CQC report found 1302  women felt communication during their maternity care was poor (84% of women who shared their views). The most dominant concern among women who mentioned the issue was poor communication between maternity staff and themselves. For example, women said that sometimes they were not told when they had hospital appointments, there were issues around the timeliness of information with test results being given too late, and many felt when they had questions or concerns, they were given inadequate explanations and conflicting information by midwives and hospital doctors. They reported that it was hard to get advice before or after the birth of their baby, and a number felt they were not taken seriously by health professionals during their antenatal care: Women reported being spoken to in ways that were

British Journal of Nursing, 2014, Vol 23, No 3

disrespectful, patronising or condescending; being spoken to in ways that made them feel anxious or that made them feel they were not being listened to by maternity staff.There were also examples of inappropriate and rude comments being made on postnatal wards. Other women expressed concern about poor communication between staff members, which impacted on the care they received. Examples included women feeling that medical issues were missed, and they had to stay in hospital unnecessarily because staff did not speak with each other about their progress.

Complaints about information provision The report relates findings from 308 women who described their experiences of accessing information or being kept informed during their maternity care. The report states that 53 women (17%) said they had been well informed but the majority were unhappy with this aspect of their care, with 81% of these women reporting they had not been given enough information or were not kept well-informed about issues during their pregnancy or beyond. Women were particularly unhappy with the lack of information during antenatal and postnatal care. Some were upset that scans were not properly explained, that pregnancy-related conditions were not explained along with their impact, or that they were not being kept informed as to why inductions were required: There were also comments about feeling unprepared for what would happen after birth. Specifically, where complications had occurred during labour and delivery, women were upset about not having any discussions or explanations about traumatic experiences. Many felt unhappy they were not sufficiently informed about what they could do after having a caesarean and some had poor information about when they would be discharged (waiting hours for decisions and then having conflicting information). ‘After leaving hospital I had a swab on my c-section wound, a few days later I was phoned to say I had MRSA. No one explained to me or my husband what was going on and what treatment I needed or how I got MRSA in my wound. They refused to swab or check my baby.’

My conclusions Everything is not doom and gloom in this area. Both reports contain some positive findings but these are overshadowed by the patient comments relayed by the CQC around communication and information, which do give cause for acute concern.There is a direct correlation between healthcare litigation and communication errors. The NAO (2013) report shows the substantial clinical negligence claims and costs in this area and the CQC (2013) report gives concrete examples of patient safety and clinical risk-adverse events that are occurring. Read together, the reports paint a worrying picture of NHS maternity care, most certainly from a patient safety and BJN clinical risk perspective.  Care Quality Commission (2013) National Findings from the 2013 Survey of Women’s Experiences of Maternity Care. (accessed 22 January 2014) National Audit Office (2013) Maternity services in England. HC 794 Session 201314,8 November 2013 (accessed 22 January 2014)


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Concerns about care in NHS maternity services.

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