Safety in maternity services: factors to consider

On 24 July, the chair of the Health and Social Care Committee, Jeremy Hunt, announced an inquiry into the safety of maternity services. This is clearly warranted given the serious concerns that have been raised about avoidable child and maternal deaths in Shrewsbury and Telford, in East Kent and earlier at Morecambe Bay.

Investigations continue in Shropshire and at East Kent, where the CQC recently found that only two of 23 recommendations made by the Royal College of Obstetricians and Gynaecologist four years ago have been fully implemented.

In announcing the inquiry, the committee asks whether clinical negligence and litigation arrangements may need revisiting and whether a blame culture may be affecting medical decision-making. 

What other factors may the committee need to consider, and what do we know already? The size and location of services are likely to come under scrutiny. But so should a number of other interrelated factors:

• Rurality – is the unit geographically isolated and, if so, how does that impact on staff recruitment and retention?
• Funding – does the unit have inescapably high costs due to its location?
• Skills and experience – does the unit have a good complement of senior, experienced and skilled clinicians?
• Workplace culture – are clinicians held fully accountable for their practice; are working relationships healthy and collegiate; can concerns be escalated promptly and resolved; is the service transparent or defensive? 

A workshop last year convened by the Nuffield Trust with representatives from the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists offered insights in some of these areas. 

Size

There is a commonly held view that services will be better and safer if they are bigger, offering a larger pool of specialist clinical expertise and equipment, economies of scale and better opportunities for learning and development. But distance matters too, and so should patient choice.

In our work on acute medical services in general hospitals, we established that more than 50% of patients in England receive their hospital care in smaller hospitals, which need support and investment to remain viable. We also established that our so-called smaller hospitals are really quite big by international standards.

The same is true for maternity services. In this country, units delivering fewer than 2,000 babies are considered small, but in France, the majority of women give birth in such units, with one in five using units which manage less than 1,000 births per year. And in Sweden, where centralisation was tried with the aim of improving safety, there was no discernible benefit for babies and some disadvantages for the health of mothers. A number of Australian studies have concluded that the closure of rural maternity services actually increases clinical risk and transfers it away from health care systems and on to women and their families. 

Smaller maternity services have all the same problems as smaller general hospitals, but have even more to contend with. They are more vulnerable to the problems posed by staff shortages and financial shortfalls and they depend on the continued viability of other services, such as paediatrics and intensive care.

Rurality

In rural and remote areas, these problems are intensified because units face inescapably higher costs and greater recruitment and training problems. Closure involves longer transfer times for mothers and poorer obstetric support in an emergency.

The evidence suggests that these offset any gains potentially offered by delivery in a larger unit. Closure of the maternity service leaves local hospitals at greater risk of merger or closure, as well as deterring younger people from moving into or staying in rural areas, thus compounding workforce shortages.

Skills and experience

It is a particular challenge for smaller maternity units in more isolated areas to balance the absolute requirement for safe services, with a measure of choice and convenience for mothers and their families. High-quality local training offers, which equip clinicians for rural practice and enable them to practise safely at the top of their licence, could be the key to achieving better, safer outcomes.

Recruitment and retention

Our joint workshop identified a range of measures that should help with recruiting and retaining staff in more remote areas. These included positive attention to the environment offered to trainee doctors and midwives and actively promoting the rewards of rural practice. Making sure, for example, that obstetric trainees spend time in rural units later in their training would allow them a greater degree of autonomous practice that would be a good preparation for life as a consultant.

We also suggested that at regional level, providers and commissioners should invest in strengthening local networks for obstetric and neonatal care. At the practical level, this includes developing an understanding of the different strengths and weaknesses of units within the network, standardising operating procedures, smoothing mechanisms for transfer, and implementing staff ‘passports’ to facilitate cross-site working.

Overcoming isolation

Smaller, rural and coastal units undoubtedly face major challenges and some imaginative solutions and bold leadership will be required to overcome them.

But large urban units have not been exempt from the problems more commonly associated with size or location. A unit may be isolated by geography or become isolated as a result of its workplace culture. Pockets of excellence or of worrying underperformance can exist within institutions, hidden in plain sight.

As the Select Committee inquiry into maternity services gets underway, it will be important to try to disentangle the financial, geographical and cultural factors that affect performance and safety.