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Webinar 4 presentation slides - Life as a midwife: Professional development and career planning

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Webinar 4 presentation slides - Life as a midwife: Professional development and career planning

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SESSION 4 slides International Midwives webinar series (1)

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Making Reflective Practice Inclusive, Contemporary and Equitable | All4Maternity

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Making Reflective Practice Inclusive, Contemporary and Equitable Hannah Alice King, Midwife - Saint Mary's Hospital Manchester, Teaching Assistant for the Master of Public Health course, University of Manchester Published in The Practising Midwife Volume 24 Issue 2 February 2021 https://doi.org/10.55975/JSAP2211 Summary Reflective p

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Webinar 3 - Enabling Effective Communication RECORDING 

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Webinar 3 - Enabling Effective Communication RECORDING 

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Webinar 3 - Enabling Effective Communication

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Webinar 3 presentation slides - Enabling communication for effective, meaningful and personalised care

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Webinar 3 presentation slides - Enabling communication for effective, meaningful and personalised care

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You can access the LIVE slides here: https://www.canva.com/design/DAF2G_xLsp0/mjSj_OxnA6Hgb_n7bjFUoA/edit?utm_content=DAF2G_xLsp0&utm_campaign=designshare&utm_medium=link2&utm_source=sharebutton

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Dr Steph Heys, Sway sharing the videos around supporting women and communcation

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Dr Steph Heys, Sway sharing the videos around supporting women and communcation

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Steph's PhD work is shared via this e-learn. Please feel free to connect with her via social media @PhD-Midwife

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ReCHime (Respectful Childbirth, immersive education) Reducing traumatic birth experiences.

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Webinar 2 - Safe quality midwifery care in the UK - RECORDING

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Webinar 2 - Safe quality midwifery care in the UK - RECORDING

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Webinar 2 - safe quality midwifery care in the UK

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Birthrights website Human Rights Factsheet

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Birthrights website Human Rights Factsheet

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Every human being has the same human rights. Human rights law means that public organisations like hospitals must treat you with dignity and respect. They must consult you about decisions and follow your choices.

Every health professional who cares for you must respect your human rights in all the care they give.

Human rights laws give you the right to receive maternity care.

Human rights laws give you the right to make your own choices about your maternity care.

They say that the care that health professionals give you in maternity must respect your dignity and your freedom to make decisions about yourself (this freedom is called autonomy).

In UK law a foetus doesn't have rights. An unborn baby doesn't become a separate person with legal rights until they are born and draw breath by themselves.

In the UK, human rights are protected by law. The Human Rights Act 1998 incorporates into domestic law the rights protected by the European Convention on Human Rights. If someone believes that their human rights have been violated they can bring a legal claim in the UK courts. Human rights in maternity are not affected by Brexit.

Human rights are also protected by common law (decisions passed in the law courts in the UK over the years). This is particularly important in the areas of clinical negligence and consent.

The UK has also ratified (signed up to) the Convention on the Elimination of all forms of Discrimination against Women. This prohibits pregnancy-related discrimination. It requires the provision of appropriate healthcare during pregnancy and the postnatal period. This Convention influences the UK Courts' interpretation of the law but it is not possible to bring a legal claim in the UK under the Convention.

Human rights law sets out the way we can expect to be treated by the Government and all public bodies, such as the NHS.

This means that public bodies must respect human rights when making decisions. It also means that caregivers working in public bodies must respect human rights as they go about their work.

Human rights are also protected by clinical negligence law, which is part of the common law throughout the UK. The right to autonomy and the requirement for health professionals to seek informed consent are a fundamental part of the law of negligence.

Article 2 protects the right to life. This means that you have the right to basic life-saving health services. This includes maternity care.

Examples of experiences that might breach Article 2 include charging for maternity care if that means you decide not to receive care, or not giving enough postnatal care (care after the birth) to someone whose baby has been removed into care by social services.

You can read more about charging for NHS care in our factsheet NHS charging.

Article 3 prohibits inhuman or degrading treatment.

For example, if midwives or doctors fail to provide care which is needed to avoid preventable suffering, such as pain relief, this could be inhuman or degrading treatment.
If you ask for pain relief, or for your pain relief to be topped up, it should be given unless there are good reasons against providing it. For example, there may be a medical reason for refusing pain relief because it could cause you harm. This may be called a clinical contraindication.
Article 8 protects the right to respect for private and family life. The Courts have said that this includes the right to choose your place of birth and choice of birth companion.

It also gives you the right to physical autonomy and integrity. This means that no medical procedure can be carried out without your consent. Carrying out a procedure without your consent violates your right to physical autonomy and integrity under Article 8. It may also violate your right not to be subject to inhuman and degrading treatment under Article 3.

Failing to give you sufficient, objective and unbiased information for someone to make an informed choice, including by not providing adequate interpreting services, will also violate Article 8. The right to make choices about childbirth includes the right to decline any medical care at all.

Article 14 prohibits discrimination in the application of the other human rights and entitles people to equal treatment in their maternity care. This makes it unlawful for NHS organisations or individual caregivers within the NHS to discriminate against pregnant people on grounds such as disability, race, religion, immigration status and national origin.

In addition, the Equality Act 2010 protects people against discrimination and harassment. It recognises nine 'protected characteristics': age, disability, gender reassignment (that is, if you are transgender), marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. The Equality Act also means that it is unlawful for NHS organisations or individual caregivers within the NHS to discriminate against people on the basis of these characteristics.

This means that healthcare professionals should not make assumptions or treat you differently - either on purpose or because of unconscious bias - because of (one or more) of these characteristics. For example, a healthcare professional should not assume that a woman wearing a headscarf cannot speak English, or that a Black woman requires less pain relief than a white woman.

Your healthcare professionals should use your preferred pronouns. They should ensure that they provide you with respectful and appropriate care if you are a trans man.

A Trust needs to make sure that its rules don't unintentionally discriminate. For example, a same sex couple where the non-birthing partner intends to breastfeed could be discriminated against by rules that say they have to go home overnight. The Trust should have good reasons for rules such as these. When they do have good reasons, they should make exceptions on a case-by-case basis to make sure that people are not discriminated against.

If you experience discrimination or bias during your care, we can provide you with advice.

The Equality Act 2010 also requires public bodies, such as the NHS, to make sure that people with substantial physical and mental impairments can access the same maternity care as any other person. This means that maternity services have to make 'reasonable adjustments' so that people with disabilities are not placed at substantial disadvantage compared to other individuals who do not have the same impairment.

This does not mean that everyone should get exactly the same care. Under the law, treating someone equally can mean that someone should be given extra support, for example, being provided with an interpreter, in order to put them in the same position as other people who are having a baby.

In UK law a foetus doesn't have rights. An unborn baby doesn't become a separate person with legal rights until they are born and draw breath by themselves.

You are free to make choices against medical advice and cannot be forced to accept treatment whether or not it is said to be in your unborn child's interest.

If healthcare providers believe your child will be at significant risk of harm once they are born, they may make a referral to social services. However, your birth choices alone should not be grounds for a social services referral.

The only time health professionals do not need your consent to treatment is when you are not able make a decision. This might be because it is an emergency and you are unable to make your wishes known. The only other circumstance is if you have been assessed as lacking mental capacity to make the decision about treatment. The law governing this is the Mental Capacity Act 2005 in England and Wales. In Scotland it is the Adults with Incapacity (Scotland) Act (2000).

It is very rare in law for someone to be unable to make their own decisions. If you are deemed to lack mental capacity, decisions about your care must be made in your best interests.

Birthrights provides a free and confidential advice service for individuals and healthcare professionals seeking advice and information about human rights in pregnancy and childbirth. You can contact us via our contact form or by email: advice@birthrights.org.uk.

If you are unhappy with your care, you can make a complaint to the relevant healthcare provider. If you wish to seek financial compensation for ill-treatment, you should contact a solicitor specialising in medical negligence law.

You can read more about complaints and seeking legal advice on our factsheet, Making a complaint.

In Ternovszky v Hungary (2010) The European Court of Human Rights held that women are entitled to choose to give birth at home and the state is obliged to ensure that health professionals can attend them at home without fear of criminal, civil or disciplinary sanction for doing so.

In Dubska v Czech Republic (2014)the Grand Chamber of the European Court recognised that Article 8 protected women's right to make choices about childbirth, but found that the Czech government was entitled to decide whether or not to support women's choice of home birth by allowing midwives to attend them.

Read our commentary on the case of Dubska v Czech Republic (2014)

In Konovalova v Russia (2014) the Court held that a woman's consent was necessary for the presence of medical students during labour. It held that Russian law did not contain adequate safeguards to protect patients from arbitrary interferences with their private life. There was no legal provision requiring patients' consent for students' participation in their treatment and the hospital's information about students was 'vague' and did not specify the extent of their involvement in treatment. As a result, any person who is providing maternity care should be clear about their status and explain if they are a student, so that the patient can decide whether they wish to receive care from them or to have them present.

Read our commentary on the case of Konovalova v Russia (2014)

In Montgomery v Lanarkshire Health Board (2015) the UK Supreme Court affirmed a woman's right to autonomy in childbirth. It stated that:

' An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken. The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.'

This means that a birthing person is entitled to a personalised conversation about risks and benefits of the options they are considering and that they should be given information about the risks that are important to them as an individual, to support them to make their own decisions about their care.

Hospitals cannot rely solely on printed leaflets or online material to provide relevant information; there must always be a personal discussion between the individual and the health professional. This should be facilitated appropriately, for example, by providing interpreting services if required. If the person receiving care asks specific questions the healthcare professional must give full, honest and objective answers. A consent form on its own is not sufficient evidence of consent.

In Re MB (1997) the courts in England and Wales upheld the rights of patients to make important medical decisions affecting their lives for themselves: 'a competent woman who has the capacity to decide may, for religious reasons, other reasons, or for no reasons at all, chose not to have medical intervention, even though, as we have already stated, the consequence may be the death or serious handicap of the child she bears or her own death.'

This was affirmed in St George's Healthcare NHS Trust v S (1997), in which the court stated that 'an adult of sound mind was entitled to refuse medical treatment, even when his or her own life depended on receiving such treatment. In the case of a pregnant woman, that right was not diminished merely because her decision to exercise it might appear morally repugnant.'

The Scottish courts have taken the same approach (Law Hospital NHS Trust v Lord Advocate (1996)).

We believe human rights are for everyone. The law underpinning our human rights sometimes describes the rights of women who are pregnant and giving birth. We have used the language of the law and of policy where necessary for accuracy. However, we champion the rights of all those who are receiving maternity care. Our services and advice are for everyone, regardless of how they identify.

In our own advice and communications, we strive to use inclusive language to make sure all pregnant and birthing people feel welcome, safe and supported at Birthrights.
About Birthrights
Birthrights factsheets give you information about your human rights when you are pregnant and giving birth.

Birthrights champions respectful care during pregnancy and childbirth by protecting human rights. We provide advice and information to women and birthing people, train doctors and midwives, and campaign to change maternity policy and systems.

We are a charity, independent of the government and the NHS.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
Do you work with pregnant women and birthing people?

Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Human rights in maternity care: the key facts - Birthrights

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What are human rights? What are my rights when I am pregnant and giving birth? Do human rights protect an unborn child? Where do human rights come from? How do human rights apply to maternity care? What rights do I have in maternity care? Do human rights protect an unborn child?

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Review the NMC guidance for registration

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There are three types of evidence that will satisfy us that you have the necessary knowledge of English to practise in the UK. If we are not satisfied with what you send us, we will ask you to provide an alternative type of evidence.

Evidence Type 1: You have recently achieved the required scores in either IELTS (Academic) or OET.

Evidence Type 2: You have a pre-registration nurse, midwife or nursing associate qualification which was taught and examined in English. We'll need evidence that the training and assessment of pre-registration course was in English in the form of transcript and/or letter from training institute.

If this programme was completed a country that is currently not on NMC's majority English speaking countries list, you can provide supporting information from your employer (SIFE) as supplementary evidence of clinical interaction in English with people who use services, their families, carers, and other healthcare professionals. To do this, you must be currently working in an unregulated role in a health or care setting in the UK for at least 12 months full time or full time equivalent if working part time.

If you did not train in a country where English is a majority spoken language and is not eligible to use SIFE, we'll consider evidence that meets the criteria set out in our English Language guidance, but please be aware that it's likely that you'll need to provide an alternative type of evidence such as a language test.

Evidence Type 3: Employer reference that you have recently practised for one year as a registered nurse, registered midwife or nursing associate in a country where country where English is a majority spoken language.

Please click here for more information

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There are three types of evidence that will satisfy us that you have the necessary knowledge of English to practise in the UK. If we are not satisfied with what you send us, we will ask you to provide an alternative type of evidence.

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Remember in maternity, due to the Human Rights issues, we call this Informed Decision Making.......to ensure the woman/person is prioritised.

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Recommendations | Shared decision making | Guidance | NICE

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This guideline covers how to make shared decision making part of everyday care in all healthcare settings. It promotes ways for healthcare professionals and

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This guideline covers the care of women and their babies during labour and immediately after birth. It focuses on women who give birth between 37 and 42 weeks of pregnancy ('term'). The guideline helps women to make informed choices about where to have their baby and about their care in labour. It also aims to reduce variation in aspects of care.

Using inclusive language in healthcare is important for safety, and to promote equity, respect and effective communication with everyone. This guideline does not use inclusive language because it was developed before NICE's style change to use gender-inclusive language.

Healthcare professionals should use their clinical judgement when implementing recommendations, taking into account the individual's circumstances, needs and preferences, and ensuring all people are treated with dignity and respect throughout their care.

NICE has also produced guidelines on intrapartum care for women with existing medical conditions or obstetric complications and their babies, fetal monitoring in labour and caesarean birth. For information on other related topics, see our women's and reproductive health summary page.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals

Commissioners and providers

Healthy women who have had a straightforward pregnancy and give birth between 37 and 42 weeks of pregnancy

Is this guideline up to date?

Monitoring decision: Water birth: we will reconsider the evidence when the POOL study has published (expected 2024). For more information, see the May 2023 surveillance decision.

Portfolio review in May 2023: We have reviewed our guidelines portfolio to identify topics that we think will add the most value to the health and care system and have agreed that the updates on angle of episiotomy and rectal examination recommended in the 2022 surveillance report will not proceed as planned.

Guideline development process
How we develop NICE guidelines
This guideline updates and replaces NICE guideline CG190 (December 2014).

This guideline was previously called intrapartum care for healthy women and babies.

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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This guideline covers the care of women and their babies during labour and immediately after birth. It focuses on women who give birth between 37 and 42 weeks of pregnancy ('term'). The guideline helps women to make informed choices about where to have their baby and about their care in labour.

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Webinar  2 presentation slides - Thriving in practice and One Thought wellbeing interactive session

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Webinar  2 presentation slides - Thriving in practice and One Thought wellbeing interactive session

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Please write your name through word and save electronically, or print and share in your portfolio

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Dr Steph Heys - The design, delivery and evaluation of ‘Human Perspectives VR’: An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

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Dr Steph Heys - The design, delivery and evaluation of ‘Human Perspectives VR’: An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

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Stephanie Heys,

Soo Downe,

Mick McKeown,

Gill Thomson

Subject Areas

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Abstract

Citation: Heys S, Downe S, McKeown M, Thomson G (2022) The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD. PLoS ONE 17(11): e0276263. https://doi.org/10.1371/journal.pone.0276263

Editor: David Desseauve, Lausanne University Hospital: Centre Hospitalier Universitaire Vaudois (CH), SWITZERLAND

Received: March 20, 2022; Accepted: October 3, 2022; Published: November 2, 2022

Copyright: © 2022 Heys et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: SH received grant funding. Grant number 434454 Funder: The Collaboration for Leadership in Applied Health Research and Care North West Coast. URL: http://www.clahrc-nwc.nihr.ac.uk/index.php The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

List of abbreviations: VR, Virtual Reality; PTSD, Post Traumatic Stress Disorder; CP, Critical Pedagogical

Introduction

Each year it is estimated that ~30% of women experience a psychologically traumatising birth [ 1, 2]. A traumatic childbirth experience is defined as:

'A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing' [ 3].

Traumatic childbirth experiences have been associated with a wide range of negative impacts for women and their families, such as, low self-esteem, early breastfeeding cessation, and relationship issues [ 4]. Similar to other forms of trauma, a traumatic birth can lead to post-traumatic stress disorder (PTSD), a trauma- and stressor-related disorder, with 4.7% of women developing PTSD post birth [ 5].

A meta-ethnography focused on women's experiences of a traumatic birth highlighted disrespectful care practices and women experiencing a loss of control as the main contributory factors to a distressing birth experience [ 6, 7]. More recently, a comparative systematic review and meta-analysis explored the prevalence and risk factors of birth-related posttraumatic stress among parents, highlighting elevated rates of PTSD in targeted samples (those with a potential risk status) such as mothers of young age, those with pregnancy complications and women with a history of childhood trauma [ 6]. Other research has also identified the contribution of social aspects of birth to a self-perceived traumatic birth such as a lack of understanding from health care professionals regarding the individual needs of women, feelings of stigma, lack of trust in staff providing care and communication barriers [ 7- 11]. Women's experiences of poor maternity care are reported globally, including care in the UK [ 12- 15]. An international knowledge mapping exercise focused on training provision for women following a traumatic birth, acknowledge a traumatic birth experience as a key public health concern, calling for formalised care providing and training for care providers [ 16].

A traumatic birth, if left untreated, can lead to post-traumatic stress disorder, a recognised complex and serious mental health condition that affects approximately 4.7% of women in general community samples [ 5] and 19% in high-risk groups, such as women with a previous mental health illness, previous PTSD, preterm birth [ 17]. These statistics indicate that women from more complex vulnerable and disadvantages communities may be disproportionally affected.

Disadvantaged and vulnerable women's experiences of maternity care

Disadvantaged and vulnerable women have been found to be more likely to have poor access to healthcare due to issues such as mistrust of professionals [ 18- 23], social stressors such as lack of support and complex life factors [ 24], communication barriers [ 25], health literacy [ 26] and fear of stigma and judgments [ 27, 28]. Black, Asian and minority ethnic (BAME) women and those from disadvantaged and vulnerable backgrounds have a higher risk of preterm, low birth weight babies [ 29, 30], are at a greater risk of poor mental health such as depression, anxiety and stress and are more likely to die during childbirth [ 31- 34]. A recent meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries also highlighted how disadvantaged women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision [ 28]. Such findings highlight the need for increased awareness of contributory factors to such experiences amongst women accessing maternity care.

Additionally, women from vulnerable backgrounds and those with complex life factors are at an increased risk of perinatal mental health difficulties [ 35- 38] and higher rates of morbidity and mortality, in particular amongst black and ethnic minority women [ 32]. In recent years there has been significant investment in perinatal mental health following the work of the Maternal Mental Health Alliance who highlighted the disparity in specialist provision across the UK, and commissioned an economic evaluation that highlighted the costs of poor perinatal mental health at 8.1 billion per annum [ 39]. However, a lack of knowledge and skills amongst midwives regarding traumatic birth and PTSD still exist [ 40, 41]. Furthermore, as a multi-cultural society, with high levels of deprivation and inequalities, maternity professionals are increasingly required to provide services to women from diverse backgrounds. Notwithstanding this, provision in maternity education is lacking resources and knowledge to support maternity professionals to deliver an equitable service [ 42]. Global and national initiatives call for the identification of enhanced approaches to address issues of disrespectful, inequitable and biased maternity care [ 43- 46], acknowledging opportunities to harness digital solutions and technologies to support this [ 47].

Innovative digital tools and approaches in healthcare

A recent quality improvement innovation in health care is the use of Virtual Reality (VR) to enhance educational approaches. The following definition is proposed, providing a detailed description of VR;

'Virtual reality incorporates computer-generated, interactive and highly vivid environments that enable the user to achieve a state of immersion through the ultimate experience of telepresence, and facilitate engagements in human encounters that are multi-sensorial, dynamic and resemble the user's perception and understanding of the real world' [ 48].

VR has been reported as useful in redirecting patients' attention during painful treatments and in exposure therapy for the treatment of phobias and PTSD, by creating safe imaginative spaces to encounter and overcome fears and phobias [ 49- 53]. It has been used to address eating disorders and obesity, encouraging individuals to improve body image perceptions and adopt healthier eating habits [ 48, 54]. Its use also spans multiple health disciplines including patient motor rehabilitation, aiding patients to reacquire specific skills and improve body movement in virtual environments [ 55]. Several authors have reported an increase in knowledge retention when using VR tech as opposed to conventional teaching methods [ 56- 58]. A recent scoping review focused on the use of VR as an application to assist pregnant women identified how this technology has different applications in pregnancy, from reducing anxiety and pain to exercise training [ 59]. VR has also been used to provide midwifery students with a virtual, internal anatomical view of pregnancy, its physiological progression and fetal and placental positions [ 60]. More recently a cross-sectional survey and observational study included an evaluation of VR within a midwifery curriculum with findings suggesting VR enhances engagement, creates authentic active learning experiences and supports students to visualise and better understand abstract concepts [ 61].

Drawing on the utilisation of VR as an embodiment experience to enhance sensory experience offers a unique approach to midwifery training and education, allowing professionals to experience care from the perspective of the woman. This study capitalised on this approach to develop, design and evaluate an immersive educational programme utilising VR to raise awareness of traumatic birth experiences amongst vulnerable and disadvantaged population groups for maternity care providers.

Methods

A critical pedagogical (CP) framework underpinned the design, development, and evaluation of the immersive education programme. CP allow participants to recognize connections between individual problems and experiences and the social contexts in which they are embedded [ 62]. Realizing one's consciousness '('conscientization') is the first step in achieving ' praxis', defined as the ability and knowledge to take action against oppression through liberating education [ 63]. Within the context of this educational programme, CP was used to facilitate midwives 'conscientization' via illuminating situations of power within the social space of birth. The social space relates to the international interactions between women and healthcare providers. As detailed within a secondary discourse analysis focused on experiences of women who have had a traumatic birth [ 64], interpersonal interactions play a key role in how women experience childbirth. In our study, it was considered that helping midwives to identify how these interpersonal situations can contribute towards a traumatic birth would facilitate 'praxis'.

A three-phase interlinking model based on the writings of Freire helped to frame the CP approach undertaken; 'listening and naming', 'dialogue and reflection' and 'promoting of transformative social action [ 62]. Full details of work undertaken in each of the three phases to design, develop and deliver the educational programme is illustrated in Table 1 and described as follows:

a) 'Listening and naming' relates to learning the problems, issues and real-world experience of the learners. In the case of this study-the contributory factors to traumatic birth within the social space of birth. This work involved three stages:
i) Identifying triggers: Similar to work undertaken by Wallerstein & Bernstien [65], the educational programme was designed to present real life situations of traumatic birth from within women's accounts. This stage involved a systematic review and meta-synthesis of available literature exploring the birth experiences of disadvantaged and vulnerable women [28] and a further 10 interviews undertaken in North-West UK (June-August 2017) to ensure the insights from the review were still relevant. This information was synthesised using a qualitative content analysis approach to identify the 'meaning units', defined as 'the constellation of words or statements that relate to the same central meaning' [66]. The focus here was to identify 'triggers' that created situations of traumatic birth within the social context of childbirth (see Table 1 for overview of key triggers identified).

This evidence, as well as wider research into traumatic birth and PTSD onset [ 1, 2, 17, 67, 68] was used to develop a theoretical PowerPoint presentation on traumatic birth and particular issues faced by vulnerable/disadvantaged women to be used within the educational programme.

1. ii) Script development: This stage included developing a script to depict one woman's birth experience that included all identified triggers. A script writer (and screenplay director) was employed to support the process with all included authors providing input and feedback. Clinician input on drafts of the script was also provided with various stakeholder engagement and feedback.

2. iii) Filming the scenario: This aspect included hiring three professional actors (who acted the roles of a woman in labour, a midwife and a doctor) who were filmed using 360-degree camera technology. The screenplay director led this work with actors performing the birth scenario within one NHS maternity Trust in North-West UK. Elsasser & Hagener (2015) highlight the importance of creating a narrative field that tells a story with the props, content and set alongside the narrative and actors [69]. Filming within an NHS maternity hospital provided scenarios with a familiar environment and culture to facilitate critical reflection [65, 70]. The completed film was 7 minutes in length (see S1 File for script narrative).

Participants used VR headsets to enable 360 viewing of the filmed scenario with audio. The VR viewing provided a first-person experience of care, allowing for spatial and sensory reflective experience.

b) 'Dialogue and reflection' allow for a problem-posing approach, encouraging critical thinking amongst participants. This stage involves learners being encouraged to think critically, enabling them to focus on learning as opposed to outcomes. We drew on the SHOWED model for this phase (see Fig 1). This model was adapted from Freirean techniques [71] and provided a practical guide for the inclusion of critical questioning in sessions with learners after they had viewed the VR content.

Through dialogue in education, people can name, interrogate, and re-imagine their reality [ 72]. Dialogue in this section encouraged a deeper look at the social space of birth and factors that impact upon women's experience and the potential for a traumatic birth. This included discussing care practices from different viewpoints to facilitate critical consciousness.

The SHOWED approach was used at two points. First, after the learners had watched the filmed scenario as part of a critical discussion. Second, after additional information was provided about the woman (named as Emma in the script).

'Emma is new to the area, she is originally from London fleeing from an abusive relationship. She is 17 years old and had a history of sexual abuse and drug use. She spent some time prior to arriving in the area in a women's refuge, this is her first baby'

This process relates to 'culture circles' [ 73] in terms of how revisiting a familiar environment with a critical eye allows participants to open up dialogue on dehumanising aspects of a scenario. Participants were given this additional information and encouraged to discuss interactions within the scenario that may have further impacted upon Emma's experience, as well as a wider reflection on practices that may cause situations of trauma for women who may have complex life situations.

c) 'Promoting of transformative social action': The final phase in the Freirean model is the promotion of transformative social action, or the critical action phase [71]. This process is where those taking part in the programme take part in the continuous process of action and reflection to facilitate praxis [74]. Critical action has been identified as having three different forms: campaigning, awareness raising and education [75]. Campaigning or convincing an organisation or government to change policy could be at one end of the spectrum of possible change [71]. On the other end, this can relate to equipping learners with the tools they need to identify inequality and injustice so that they can seek change if that is what they desire [75]. It is this 'education phase' that was targeted in the programme-to promote transformative action by influencing how people think and react [70].

Wallerstein and Bernstein (1988) describe this step of a CP as a group effort to identify problems, through the process of critically assessing the social and historical roots of the problem to be addressed and then developing strategies to improve current practices [ 65]. Within the education programme it encouraged participants to reflect on practice from the woman's midwife's, and doctor's perspective within the shared video, and to write ' practice points'. The aim was to consolidate learning into a shareable format for knowledge translation and to facilitate conscientization. As a final activity in the programme, participants were asked to work as a group to identify and name five key points for practice that could have a personal impact upon a woman's childbirth experience, and to document these on a pre-prepared template poster to be displayed in their clinical areas. This was described to participants as actions that could be shared with colleagues (i.e. once the poster is displayed it can be a focus for continued discussions/conversations and prompt actions of others) and individually implemented when caring for women during labour and birth.

Evaluation elements

Evaluation was undertaken in two stages. First, bespoke pre- and post- training questionnaires were developed that included Likert scales and open-ended questions. The initial questionnaire gathered a baseline of participant's knowledge of traumatic birth and PTSD, knowledge of risk factors associated with traumatic birth and PTSD. These issues were then revisited within the post-training questionnaire to provide an assessment of how the programme had influenced knowledge and attitudes. Attendees were also asked additional questions at this juncture to explore their experiences of the training. They were asked to indicate how useful the training programme was in terms of raising awareness of traumatic birth/PTSD following childbirth and how to improve women's birth experiences measured on a scale of 1 -very useful to 5- not useful at all. An open question of 'Do you have any thoughts on the use of VR?' was also included (see S2 File for questionnaires).

Field notes of discussions were undertaken on the day by GT to capture critical reflections. Participants were also re-contacted ~6 weeks after the educational programme had been delivered to the impact of attendance upon participants knowledge and practice, alongside exploring how participants found sharing learning (practice points) in their work areas.

Running the event

The immersive educational programme was delivered in an NHS Trust in the North West of England on the 10 th of April 2018. The session was booked six weeks in advance through liaising with the practice education midwife and in close collaboration with the delivery suite coordinator. Fostering relationships with clinicians was important to ensure that delivery did not adversely impact upon clinical practice, as some participants attended during work hours. The programme was organised in the education centre at the host Trust, booked for 12 mid-day with food and refreshments provided to the participants. All participants were provided with an information sheet about the programme and associated evaluation. A reminder email was sent to each participant the week before, providing details of the location and time. At the start of the day, participants were asked to introduce themselves, were provided with an overview of the planned activities and then asked to sign a consent form (see Table 2 for overview of all activities).

Ethics approval and consent to participate

Ethics approval was gained from Health Research Authority (Integrated Research Application System number (blinded for review) and (blinded for review)). Written consent was gained from participants and all methods were carried out in accordance with the Health Research Authority guidance for researchers and ethics committees and the Declaration of Helsinki.

Data analysis

Quantitative data captured within the Likert scales were analysed descriptively using SPSS. A thematic approach was undertaken to analyse the open text answers, field notes, and email follow-up comments. Braun and Clarke's (2006) approach of reading and re-reading, organising the data into codes and then into themes that represented the whole data set was first undertaken by SH and GT with final interpretations shared with all authors [ 76].

Results

In total 10 participants attended the immersive educational training programme. Participants included two student midwives (n = 2) (who were also qualified nurses). The remaining participants' clinical backgrounds included roles working on the local midwife-led birth centres (n = 3), joint research and clinical roles (n = 2) and centralised hospital labour ward (n = 3).

Based on the baseline questionnaire, all participants stated that they had received no training in relation to traumatic birth / PTSD throughout the course of their midwifery career. Answers to the same questions asked at both stages to assess influence of the programme on knowledge and attitudes, overall demonstrated a positive shift.

These data identified that while only three (30%) participants agreed they had 'good' understanding of how traumatic birth/PTSD onset following childbirth was caused at baseline, all participants either agreed or strongly agreed with this question after delivery of the programme. Similar baseline scores were recorded for the question 'do you feel able to recognise women at risk of traumatic birth/PTSD onset. In terms of being able to impact on women's experiences, baseline and endline measures were all positive.

In the following section, we report on five key themes to emerge from the field notes, qualitative comments to open-text questions in the questionnaires (n = 10) and email contacts (n = 10) collected ~6 week after delivery of the educational programme. Key themes identified were 'Identifying and meeting knowledge gaps', 'Becoming the other', 'Nurturing professional empathy and understanding' and ' Understanding and adopting a critical social lens'. These themes are presented below.

Identifying and meeting knowledge gaps

As reflected within the baseline questionnaire data, midwives spoke of the lack of training about traumatic birth/PTSD:

'I'd never have thought it would have been that prevalent, because you don't really hear about PTSD as a midwife, its more postnatal depression, I've never had any training on PTSD so I would not have known what to look out for' (P1)

N = 10 participants demonstrated knowledge gaps in identifying factors that contribute to traumatic birth experiences for women, and a lack of confidence in identifying PTSD post-birth. For example, one believed traumatic births to be only attributed to physical trauma rather than it being a complex phenomenon that can include psychological trauma:

'Birth trauma is when the woman experiences trauma such as an instrumental birth or a grade one section, it can also be when a woman had a tear or a shoulder dystocia and may need a debrief about her experience' (P1)

Participants also reflected on situations contributing to trauma emphasising emergency situations, or an intervention-based birth, rather than it being a subjective experience that can occur irrespective of how a woman gives birth. For example, one midwife reported:

'Birth trauma can happen when there is an emergency and a woman is scared for her life, for example a grade 1 section or a forceps delivery' (P8)

Positive shifts however were noted in these knowledge gaps within the post-evaluation questionnaire with participants listing a range of relevant factors such as previously disclosed/undisclosed trauma, poor interpersonal interactions and poor information giving. All bar one participant felt the training programme had been 'very useful' (remaining participant recording 'useful') in terms of raising awareness of traumatic birth/PTSD following childbirth and how to improve women's birth experiences. All respondents in follow-up email correspondence stated that attending the training has enhanced their understanding of a traumatic birth and PTSD:

'I feel I am more knowledgeable about risk factors for birth trauma and PTSD following the training' (P2)

All participants highlighted a need for training of this nature in the follow up emails.

Becoming the other

Insights from participants reflected on the experience of 'becoming the other' in the VR scenario and how powerful this was for learning and reflection. One of the midwives reflected:

'Wow that was powerful, you really become the other, I felt like I was in the room' (P3)

Midwives indicated that the feelings and thoughts the film evoked enabled them to appreciate how 'helpless' women must feel:

'It was interesting to be looking up all the time because I was on the bed, that must be really uncomfortable and intimidating, you just forget that dynamic of the situation in practice' (P6)

And the lack of communication between Emma and the midwife/doctor:

'The silences in the room were unnerving for me being the woman, I wanted her [the midwife] to ask me if I had understood what the doctor had said I thought why is she not talking to me' (P10)

Another highlighted the sense of reality VR methodology invoked, in which she was searching for support around her within the 360 environment:

'The worst bit for me was when everyone left the room, I was looking around to see if I had a birthing partner' (P5)

Overall, the VR stimulated operational and emotional critical reflections about how women in labour must feel. This included how social interactions had the potential for women to feel alone and excluded from care decisions. The participants highlighted (in follow-up email contacts) the difficulty in explaining to others the psychosocial impacts this had upon them. This suggested how the immersive nature of the education programme was a crucial facet:

'It was hard to explain the programme to someone else other than it was really useful and powerful. I also don't think you can get across to people the emotion attached to the session or viewing the scenario, they need to attend themselves, I think that would be better' (P5)

Nurturing professional empathy and understanding

Participants referred to their own practice in identifying with the midwife in the film but also highlighted potential issues, e.g. 'we can be very paternal, but that's not empowering' (P5) and ' two [midwife/doctor] people against one, that this is what we are going to do to you' (P2). A risk-based approach to care was highlighted during the discussions with one participant empathising with the midwife in the scenario:

'I don't think she was being purposefully uncaring she was just very task orientated as she had a lot to do and probably wanted to make sure everything was safe before they went to theatre, she did ask if she had anyone to go with her, so she was thinking about the woman needing support' (P6)

This comment generated a critical debate around the use of language and exploring effective communication and information giving. For instance, one participant reported:

'Yes, but then she never followed it up when the women said no, she could have said don't worry I will be with you in theatre and I will support you' (P7)

Reflections were made on the impact of prescriptive care on a woman's ability to advocate for herself, thereby highlighting issues surrounding choice and consent:

'It was all 'we are going to do this', there was not much chance for the woman to disagree or ask questions and although they were doing what needed to be done I think they could have put it to the woman a bit better' (P8)

Participants critically discussed the practices they saw within the scenario. They framed these responses from the woman's perspective, but also considered real-life difficulties of keeping the woman at the centre in everyday practice. This encouraged participants to consider how the situation may have impacted upon the ability of the midwife in the scenario to provide good care. One stated:

'It's horrible to see but we have all been there, I feel that the midwife could have done with some support herself to better support the woman' (P1)

With another midwife responding:

'It's easy to forget that there may be a midwife in another room who needs supporting and feeling like that when your busy with your own work, makes you think twice' (P6)

These comments highlight how the programme appeared to nurture professional empathy and to view care from multiple perspectives; 'It really saddens me to read those [women's quotes shared during delivery of the presentation] I'd hate to think that I've ever made a woman feel that way' (P7).

Understanding and adopting a critical social lens

During the discussions, participants discussed frustrations of working in a system that did not facilitate individualised care, leaving them feeling overworked and under resourced. One midwife expressed her frustrations at feeling under scrutiny in situations such as the one presented in the scenario:

'I mean she's trying her best, she's in task mode, she needs to get everything sorted before she goes to theatre or they will probably shout at her for not having the right paperwork, you know what it's like '(P8)

This was an interesting take in which the participant empathised with the midwife in the scenario as she identified the pressures and oppressive environment in which she worked. When the discussion moved to consideration of how complex factors may influence women's care, some referred to how they observed judgemental care in practice:

'Women who come in who may have had other children removed, you hear others label those women as selfish and irresponsible for having a baby if they can't look after it' (P8)

Others highlighted how health environments fostered a culture of stigma and discrimination:

'That happens in healthcare full stop, even in nursing people will say that those accessing A+E with drug problems, alcohol issues etc., people will stand there and say that they are draining the system' (P3)

The VR film did, however, stimulate critical consideration of the environment on women's vulnerability; 'It's strange as I've never been in that position myself, but I felt vulnerable and I didn't like how it felt looking at my legs in stirrups, I felt exposed' (P5), as well as the need to share risk factors and to minimise adversity for women. This was in relation to the vaginal examination performed within the scenario, and how this may have been traumatic for the woman with a complex history:

'She could have a history of sexual abuse and the vaginal examination could have traumatised her, it was a man too and the midwife never asked if the woman was ok with that, she [midwife] probably didn't have any notes she could check either as she was out of area' [ 3]

With this conversation stimulating a further valuable point of reflection of how women may choose not to disclose prior abuse due to a lack of trusting relationship with their midwife; ' not many women are going to disclose sensitive information like that in the 15 minutes they get seeing a midwife' (P7). Adding the critical context about Emma appeared to enhance the midwives' ability to make connections between interpersonal interactions and the possibility of contributing to a traumatic experience.

Reflections on educational programme

All participants provided positive feedback to the training and considered it should be offered on a mandatory basis:

'It's so difficult working full time and keeping up to date with CPD [continual professional development] stuff, I think it would be great to having something like this in mandatory training, it's definitely needed' (P5)

The most valuable aspect was around the use of VR as it afforded an experience that could not be achieved using traditional methods:

'It's one thing being told how to be and what not to do by someone stood at the front of a classroom, it's another thing having those things happen to you [via VR] and you feeling helpless to do anything about it' (P10)

VR offered a unique immersive tool to place midwives in a unique and empathic position to connect and understand women's realities, as well as how the 'private' nature of the immersive experience helped to enhance reflection:

'I thought it was great because it's good for looking at your own behaviours and reflecting upon them, usually in training everyone feels they have to put on their best performance because everyone is watching your every move, with this [the VR training] it's more of a private thing because you're watching thinking 'oh I do that', 'maybe I should change the way I think about that' (P3)

Suggestions for development of the programme included to use the VR concept to train for emergency situations such as neonatal resuscitation and obstetric emergencies and filming a positive birth experience to demonstrate how care could be enhanced.

'Stimulating praxis'

Following on from discussions during delivery, critical considerations of social aspects of care were also transposed into five agreed practice points that emphasised openness, empathy and continuity, namely ' Inclusive handover'; ' Be considerate of disclosed and undisclosed history of trauma'; ' One to one care in labour'; ' Use positive language' and 'Put yourself in the woman's shoes. ' Although as all respondents (in email follow-up) stated that sharing practice points was difficult, this suggests that further work is needed (and considered further in the discussion).

Discussion

This study has provided the field of midwifery education with the potential to create reflective and immersive tools to enhance interpersonal care delivery. However, as yet VR remains an unexplored method to instigate behavioural change amongst healthcare professionals, where other approaches have so far been used to observe behaviour, not to demonstrate behavioural change [ 77]. As far as we are aware, there are no prior studies utilising VR that were designed to enhance reflective practices and raise awareness of interpersonal interactions during maternity care delivery. In a UK midwifery context, the findings of this study suggest that framing such approaches within a critical pedagogy can influence critical and reflexive thinking, with the potential to enable midwives, and, potentially, other health care professionals, to improve problem solving and the identification of and resistance to oppressive aspects of care [ 78]. Additionally, VR in healthcare education could be used as a vehicle for behavioural change, acknowledging the strong emotional experience of those who participated in this study.

Critical pedagogies aim to illuminate dehumanisation, placing emphasis on the importance of being critical of how things are and respecting the agency and capabilities of participants [ 79]. In this study, these insights emerged organically during reflective discussion with midwives, as they noticed and reflected on dehumanising aspects of the scenario during labour and birth. Instead of midwives receiving, filing, and storing deposits of learning material delivered, praxis was encouraged through the facilitation of reflection, theory and action embedded with the critical pedagogical approach [ 74]. The digital educational resources focused on enhancing relational, respectful, and humanistic care during labour and birth, and appeared to stimulate acknowledgment of political, social and inequality structures that impact upon maternity care experiences.

The adoption of technology is often faced with resistance from professionals. Critical factors include perceived ease of use; less time to interact with patients; issues with navigating complex interconnected systems; and a concern that technology will replace the human interaction in caring professions [ 80, 81]. In contrast, Benjamin and Jennings (2010) proposed that technological advances may sweep away oppressive aspects of a technocratic culture, pointing out the progressive possibilities in new technologies of cultural production [ 82]. The use of technology to enhance the user experience has been supported in the arts, especially within film, radio, and photography [ 49, 83, 84]. Benjamin & Jennings (2010) concur, stating how new and contemporary forms of art that utilize technology maintain their cultural power through the aura of the authentic and original [ 82]. Evaluation data gathered from Human Perspectives VR suggested that a key value of the education programme was its use of VR technology to stimulate affective response. The sensory experience enabled emancipatory praxis, demonstrating how technology can contribute to progressive forms of education in midwifery aimed at improving care experiences.

Immersive scenarios offer an innovative and engaging way of presenting evidence-based feedback as part of a co-collaborative approach to knowledge production and translation. First-person reflections and feedback from women in maternity care should not just serve as a vehicle to capture comfort measures but become fully integrated into the system to drive change, learning and quality improvement strategies. This novel approach to engaging participants with performative content opens up unprecedented opportunities to use immersive narratives in maternity education to improve women's birth experiences, through the technological embodiment of the 'other'. The creation of a private learning space within which empathic reflexivity can occur offers a powerful moment of conscientisation for facing and challenging unhelpful self-other distinctions.

It is important that innovators, researchers and educators approach the use of technology as an emancipatory endeavour with care and thought, ensuring that the correct ethical and moral frameworks are considered [ 85]. It is also worth acknowledging potential negative effects of VR and a resistance to its use, with considerations warranted in exploring the emotional and physical impacts associated. Digital innovations are at the forefront of strategies deployed by the DOH and NHS suggesting that technology has the power to transform services and save the NHS billions in cost and reduce health inequalities [ 47]. That said, caution must be applied ensuring that technology is utilized within a humanistic framework to ensure emancipatory, as opposed to exclusionary, outcomes [ 86]. Freire's (2018) Pedagogical theory provides a valued reference point for considering the views and consequent behaviours that people express, and to stimulate challenge through the process of problematisation and conscientisation [ 64]. Recommendation for future studies include follow up interviews with participants to evaluate if their raised awareness of birth trauma and PTSD also resulted in an improvement in care delivery.

This paper has highlighted how immersive critical pedagogies could help illuminate how power structures filter into relational care practices, both in terms of how this process affects organisational cultures and how it affects communication and interpersonal interaction between maternity professionals and women during birth.

Conclusion

The findings of this study demonstrate that Human Perspectives VR can provide an experiential form of creating and delivering immersive content for midwives, and, potentially, other health professionals such as doctors and obstetricians whose training differs from midwifery based educational programmes. It can enable participants to experience context, dialogue, spatial awareness, and emotional response within the virtual space of labour and birth. Becoming the 'other' was a powerful tool to stimulate educational reflective content, enhancing participating midwives' critical awareness of practices that could cause situations of traumatic birth and subsequent PTSD. Findings from the delivery of the programme highlight the need for adequate training for midwives on traumatic birth and PTSD and a consideration for developing further immersive educational programmes. A critical approach to delivering maternity education in practice offers a space to reflect upon and challenge a nexus of power, institutional norms and practices that may lead to oppressive and impersonal care experiences, for women, birthing people, and for health care practitioners.

References

1. 3. Leinweber J., Fontein‐Kuipers Y., Thomson G., Karlsdottir S. I., Nilsson C., Ekström‐Bergström A., et al. (2022). Developing a woman‐centered, inclusive definition of traumatic childbirth experiences: A discussion paper. Birth. https://doi.org/10.1111/birt.12634

2. 5. Heyne C. S., Kazmierczak M., Souday R., Horesh D., Lambregtse-van den Berg M., Weigl T., et al. (2022). Prevalence and risk factors of birth-related posttraumatic stress among parents: A comparative systematic review and meta-analysis. Clinical Psychology Review, 94, 102157. pmid:35584590

3. 16. Thomson G., Diop M. Q., Stuijfzand S., & Horsch A. (2021). Policy, service, and training provision for women following a traumatic birth: an international knowledge mapping exercise. BMC health services research, 21(1), 1-10.

4. 48. Krueger M. W. (1993). An easy entry artificial reality. In Virtual Reality (pp. 147-161). Academic Press.

5. 64. Kuipers Y. J., Thomson G., Goberna-Tricas J., Zurera A., Hresanová E., Temesgenová N., et al. (2022). The social conception of space of birth narrated by women with negative and traumatic birth experiences. Women and Birth. pmid:35514007

6. 70. Sharma M, Romas J. Theoretical Foundations of Health Education and Health Promotion. Jones & Bartlett Publishers. 2012.

7. 74. Freire P. Pedagogy of the oppressed. New York: Herder: Myra Bergman Ramos; 1968.

# data[].attributes.attachment_link.title
The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

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Background A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers.

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Letter to the Secretary of State for Health and Social Care from Donna Ockenden

30 March 2022

Dear Secretary of State

I publish the final report of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, at a time when the NHS continues to face significant challenges arising from the coronavirus (COVID-19) pandemic. In the 2 years of this pandemic since early 2020, the NHS and its staff have had to be ever more innovative in the ways services are delivered to ensure the provision of high-quality care to patients.

NHS staff - including maternity teams who have worked throughout this pandemic - are exhausted. We have seen so many frontline NHS staff go above and beyond the call of duty to support and care for their patients in these truly extraordinary times. Our NHS is rightly held in high regard by so many for the lives it saves and the care it provides.

However, this final report of the Independent Maternity Review of maternity services at the Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve, and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.

This review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths. Kate's and Pippa's parents have shown an unrelenting commitment to ensuring their daughters' short lives make a difference to the safety of maternity care.

It was through their efforts that your predecessor, the former Secretary of State for Health Jeremy Hunt, requested this independent review. When it commenced, this review was of 23 families' cases, but it grew to include reviews of nearly 1,500 families, whose experiences occurred predominantly between 2000 and 2019.

This final report follows on from our first report, which was published in December 2020. In the first report, we outlined the local actions for learning ( LAfL) and immediate and essential actions ( IEAs) to be implemented at the trust and across the wider maternity system in England.

This second report builds upon the first report in that all the LAfL and IEAs within that report remain important and must be progressed. For this second report, my independent maternity review team have identified a number of new themes that we believe must now be shared across all maternity services in England as a matter of urgency to bring about positive and essential change.

Our LAfL for the trust and IEAs must be implemented by the Shrewsbury and Telford Hospital NHS Trust with the IEAs considered by all trusts across England in a timely manner.

Since the publication of our first report, the government has introduced a range of measures and invested very significantly in supporting maternity services across the country. This focus and funding is a significant stride in the right direction. Much of this funding is for workforce expansion. NHS Providers, as cited in the recent Select Committee report has estimated the cost of full expansion of the maternity services workforce to be £200 to £250 million. We endorse and support this view.

In the last year since our first report was published, we have seen significant pressures in maternity services in the recruitment and retention of midwives and obstetricians. Workforce planning, reducing attrition of maternity staff, and providing the required funding for a sustainable and safe maternity workforce is essential. Continuing progress on funding the maternity multi-professional workforce requirements now and into the future will mean that we can continue to ensure the safety of mothers and their babies, and meet the government's key commitment to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring soon or after birth by 2025.

In our first report, we wanted to ensure that families' voices were central as, for far too long, women and families who accessed maternity care at the trust were denied the opportunity to voice their concerns about the quality of care they had received. Many hundreds of families who received maternity care at the trust have told us of experiencing life-changing tragedies that have caused untold pain and distress. In order to ensure families' voices are heard, listened to and acted upon within maternity services, the NHS will need to continue progress on the role of the independent senior advocate role within maternity services that was an IEA in our first report.

Secretary of State, through our work to date we have recognised a critical need for timely and independent reviews of serious maternity incidents to ensure lessons are learned and changes implemented effectively. We note and endorse the creation of a Special Health Authority to oversee maternity investigations, taking over the work of the Healthcare Safety Investigation Branch. We fully support your view that the provision of "independent, standardised and family focussed investigations of maternity cases that provide families with answers" is essential.

We further urge that there must be a timeliness to this work since delay in introducing change and learning leads to the risk of repeated incidents, as we saw at the Shrewsbury and Telford Hospital NHS Trust. We would expect that learning and service change from maternity incidents be introduced into clinical practice within 6 months of the incident occurring, and that all investigations are independently chaired.

Finally, and importantly, Secretary of State, we state that the Department of Health and Social Care ( DHSC) and NHS England and Improvement ( NHSEI) must now commission a working group - independent of the Maternity Transformation Programme - that has joint Royal College of Midwives ( RCM) and Royal College of Obstetricians and Gynaecologists ( RCOG) leadership to make plans to guide the Maternity Transformation Programme around implementation of these IEAs and the recommendations of other reports currently being prepared.

Thank you, Secretary of State, for your ongoing support.

Yours sincerely,

Donna Ockenden

Chair of the Independent Maternity Review

Why this report is important

The impact of death or serious health complications suffered as a result of maternity care cannot be underestimated. The impact on the lives of families and loved ones is profound and permanent.

The families who have bravely contributed to this review know all too well the devastation which follows such events, and have explained to my review team and me that they want this review to answer their questions. Families have also clearly explained that they want what happened to them to matter, and to ensure that, in future, voices such as their own are listened to and heard, and that meaningful and sustained changes will be made to try to ensure that what happened to them will not happen to others in future.

The accounts of families involved in events at maternity services at the Shrewsbury and Telford Hospital NHS Trust has not only put a spotlight on this service, but also on other maternity services across England, as can be seen by recent reports of concerns in a number of other trusts. That is why this report aims to not only address specific concerns about the Shrewsbury and Telford Hospital NHS Trust, but to provide IEAs for all maternity services across England. Sometimes that spotlight can feel harsh to staff on the front line doing their very best in what are often extremely challenging circumstances. As a multi-professional clinical review team, largely made up of midwives and doctors currently working on a daily basis in NHS maternity services across England, we understand that.

Even now, early in 2022, there remain concerns that NHS maternity services and their trust boards are still failing to adequately address and learn lessons from serious maternity events occurring now. We recognise that maternity services have very significant workforce challenges and this must change. Clearly, workforce challenges that have existed for more than a decade cannot be put right overnight. However, it is our belief that if the 'whole system' underpinning maternity services commits to implementation of all the IEAs within this report, with the necessary funding provided, then this review could be said to have led to far-reaching improvements for all families and NHS staff working within maternity services.

The size and scale of this review is unprecedented in NHS history. After reviewing the experiences of so many families, and listening carefully to both those families and to the past and present staff who came forward, we have been given a once-in-a-generation opportunity to improve the safety and quality of maternity service provision for families across England - now and in the future.

Donna Ockenden

Chair

Executive summary

This independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust ('the trust') commenced in the summer of 2017. It was originally requested by the Rt Hon Jeremy Hunt MP when he was Secretary of State for Health and Social Care, and commissioned by NHS Improvement, to examine 23 cases of concern collated by the tireless efforts of the parents of Kate Stanton-Davies and Pippa Griffiths, who both died after birth at the trust in 2009 and 2016 respectively.

Since the review was commissioned, it has grown considerably. Our independent and multi-professional team of midwives and doctors reviewed the maternity care of 1,486 families, the majority of which were patients at the trust between the years 2000 and 2019.

It has previously been reported that this review was considering 1,862 family cases. However, after removing duplication of recording, and excluding cases where there were missing hospital records or consent for participation in the review could not be obtained, the final number of families included in this review is 1,486. Some families had multiple clinical incidents - therefore, a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.

In line with the terms of reference, the review examined the trust's internal investigations where they occurred. In addition, the review team has considered:

external reports into the trust's maternity services over these years (national regulatory reports and locally commissioned reports)

local clinical governance processes, policies and procedures

ombudsman and coroner's reports

Throughout this process, our priority has been to ensure that the families impacted by the maternity services at the trust are heard. They wanted to understand what had happened to them, as well as ensure that, finally, lessons are learned so that no further families experience the same harm and distress that they did.

Families were offered a variety of methods to engage with the review team, and share accounts of their care and treatment. Throughout this report, we have included vignettes of the care received by families, either through our review of their maternity care considering the documentation that was received from the trust, or by quoting family members directly from their communication with the chair of the review or team members.

As well as listening to families, the review team wanted to ensure that staff had an opportunity to be heard also. In 2021, the review team interviewed 60 present and former members of staff about their opinions on the maternity services they worked within. We also offered staff the opportunity to complete a questionnaire for the review, which 84 staff did. We have included vignettes of these interviews and questionnaires throughout this report in order to ensure that staff voices are clearly heard.

In the final weeks leading up to publication of the report, a number of staff withdrew their co-operation from the report and therefore their content (or 'voice') was lost from the report. The main reason for withdrawing from the report as cited by staff was fear of being identified. This was despite our reassurance that staff would only ever be identified as 'a staff member told the review team...''

Within this report, we have included a timeline of events that led up to the commissioning of this independent review (see 'Concerns that led to this review' below or Chapter 1 of the full report). This highlights a number of cases that became known of, many in the public domain between 2001 and 2016, as well as a number of external reviews from the various commissioning and regulatory bodies that took place during the period under review.

It would be expected that the number of incidents featured in this timeline would have warranted closer scrutiny of maternity services at an earlier point than we are at now. However, in our opinion, due to concerns around other clinical areas within the trust and also due to the significant turnover at executive and board level, issues within maternity services remained largely unseen. This was to the detriment of the families receiving care.

Patterns of repeated poor care

Through the review of 1,486 family cases, the review team has been able to identify:

thematic patterns in the quality of care and investigation procedures carried out by the trust

where opportunities for learning and improving quality of care have been missed

For example, in the 9 months preceding the avoidable death of Kate Stanton-Davies in March 2009, the review team has identified 2 further incidents of baby deaths that occurred under similar circumstances.

In May 2008, baby Joshua was born in poor condition at Ludlow midwifery-led unit, and was transferred by air ambulance to the Royal Shrewsbury Hospital Neonatal Unit. Joshua's mother was considered to have a low-risk pregnancy and, even after she reported episodes of severe uterine tenderness and tightening at 31 weeks, this risk profile was not changed. She reported reduced baby movements the day before her labour at 37+5 weeks gestation, but, on her admission, the baby's heart rate was not monitored appropriately. Joshua was delivered with no signs of life and died at 6 days old when care was withdrawn.

In January 2009, baby Thomas was born following his mother's long, slow labour, which stretched over more than a day. His mother, who had given birth to a large baby during a previous pregnancy, had been treated as a low-risk case throughout this pregnancy, and no check for gestational diabetes was conducted. She had been due to give birth in a midwifery-led unit, but was admitted to the antenatal ward in the consultant-led unit. The review team found that, despite abnormal heart rate readings, a high dose of oxytocin infusion was used, and his mother was infrequently monitored. In the hour before birth, examinations showed signs of obstructed labour and uterine rupture, as well as difficulties establishing the baby's heart rate, but despite this, a ventouse delivery was attempted before an emergency caesarean was conducted. Thomas briefly had a heartbeat but, at 34 minutes of age, resuscitation was stopped.

Then, on 1 March 2009, Rhiannon Davies gave birth to Kate Stanton-Davies at the Ludlow midwifery-led unit, despite reporting a reduction in her baby's movements in the 2 weeks before the birth. There was a lack of appropriate heart rate monitoring during labour and missed opportunities to manage Kate's health as she was born severely anaemic. Kate suffered a cardiopulmonary collapse at 90 minutes of life and was transferred by air ambulance to a tertiary neonatal unit, where she died shortly after arrival at 6 hours of age.

The review team found evidence of poor investigation into all 3 of these cases, which took place within less than a year of each other, as well as a lack of transparency and dialogue with families. This resulted in missed opportunities for learning, and a lost opportunity to prevent further baby deaths from occurring at the trust.

Unfortunately, these 3 cases were not isolated incidents and, throughout this review, we have found repeated errors in care that led to injury to either mothers or their babies. During our work, we have considered all aspects of clinical care in maternity services including:

In total, 12 cases of maternal death were considered by the review team. They concluded that none of the mothers had received care in line with best practice at the time and, in three-quarters of cases, the care could have been significantly improved. Only one maternal death investigation was conducted by external clinicians, and the internal reviews were rated as poor by our review team. These internal investigations frequently did not recognise system and service-wide failings to follow appropriate procedures and guidance. As a result, significant omissions in care were not identified and, in some incidents, women themselves were also held responsible for the outcomes.

As part of the review, 498 cases of stillbirth were reviewed and graded. One in 4 cases were found to have significant or major concerns in maternity care that, if managed appropriately, might or would have resulted in a different outcome.

Hypoxic ischaemic encephalopathy ( HIE) is a newborn brain injury caused by oxygen deprivation to the brain. There were significant and major concerns in the care provided to the mother in two-thirds (65.9%) of all HIE cases. After the baby had been born, most of the neonatal care provided was considered appropriate or included minor concerns. However, these were unlikely to influence the outcome observed.

Most of the neonatal deaths occurred in the first 7 days of life. Nearly a third of all incidents reviewed (27.9%) were identified to have significant or major concerns in the maternity care provided that might or would have resulted in a different outcome.

The review team found that, throughout the review period, staff were overly confident in their ability to manage complex pregnancies and babies diagnosed with fetal abnormalities during pregnancy. There was sometimes a reluctance to refer to a tertiary unit to involve specialists such as paediatric surgeons and geneticists in care. For example, the neonatal unit at Royal Shrewsbury Hospital continued to work as a neonatal intensive care unit for many years after it had been re-designated as a local neonatal unit. Although the review team noted that care provided by staff in the unit was generally good, it was operating beyond its designated scope. Staff suggested this was due to a lack of capacity within the surrounding services, but this view has been rejected by the neonatal network.

Internally, within maternity services at the trust, women were frequently not referred to or discussed with colleagues from the wider multidisciplinary team. It has been observed that there were repeated failures to escalate concerns in both antenatal and postnatal environments. There are also multiple examples within this report where there were delays in women being:

admitted to the labour ward during induction of labour

assessed for emergency intervention during labour

reviewed by consultants in the postnatal environment

On occasion, this resulted in families being discharged from hospital, but later readmitted for emergency procedures due to becoming extremely unwell through the lack of earlier appropriate review of care. Other examples of a lack of appropriate escalation are of obstetric anaesthetists involved at the last minute, not enabling them to assess women appropriately for urgent obstetric interventions.

Failure in governance and leadership

Throughout the various stages of care, the review team has identified a failing to follow national clinical guidelines, whether it be for the monitoring of fetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation. This, combined with delays in escalation and failure to work collaboratively across disciplines, resulted in the many poor outcomes experienced by mothers or their babies, such as sepsis, HIE and, unfortunately, death.

Some of the causes of these delays were due to the culture among the trust's workforce. The review team has seen evidence within the cases reviewed that there was a lack of action from senior clinicians following escalation. The review team has also heard directly from staff that there was a culture of 'them and us' between the midwifery and obstetric staff, which engendered fear among midwives to escalate concerns to consultants. This demonstrates a lack of psychological safety in the workplace and limited the ability of the service to make positive changes.

Unfortunately, these poor working relationships were also witnessed by families and, in some cases, mothers have described the additional stress these interactions had on them at one of the most vulnerable moments in their lives.

In addition, repeatedly throughout this review, we have heard from parents about a lack of compassion expressed by staff - either while they were still receiving care or in follow-up appointments and during complaints processes. Examples include clinicians being unprepared for follow-up briefings with families, and response letters to complaints including inaccurate information, justifying actions or omissions in care, and in some cases even including explanations that laid blame on the family themselves for the particular outcome.

As summarised earlier, there were often delays in escalation of care to appropriate clinicians. In part, these delays in care could be attributed to staffing and training gaps at the trust. The review team found there were significant staffing and training gaps within both the midwifery and medical workforce that negatively affected the operational running of the service. The review team identified how it was widely accepted that the labour ward co-ordinator did not have supernumerary status, often having their own clinical caseload, preventing them from being readily accessible to junior staff and the wider midwifery team for clinical advice, care planning and support.

Similarly, the medical staff rotas have been overstretched throughout the time period covered by the review. Inadequate support from consultant obstetric and anaesthetic services caused a consistent lack of clinical expertise to be available. Where locum doctors filled in rota gaps, there is evidence of them being unsupported and, on occasions, unsafe clinical practice was not addressed or challenged. Staff also cited suboptimal staffing levels and unsafe inpatient-to-staffing ratios to the review team, and said they often felt fearful and stressed at work due to poor staffing levels.

The review has found the trust leadership team up to board level to be in a constant state of churn and change. Therefore, it failed to foster a positive environment to support and encourage service improvement at all levels. In addition, the trust board did not have oversight or a full understanding of issues and concerns within the maternity service, resulting in neither strategic direction and effective change, nor the development of accountable implementation plans.

Our consideration of clinical governance processes and documents at the trust has shown that investigatory processes were not followed to a standard that would have been expected for the particular time the incident occurred. The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings, and some significant cases of concern were not investigated at all. In fact, the maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the trust went unknown until this review was undertaken.

Where investigations took place, there was a lack of oversight by the trust board. Unfortunately, the review believes this has persisted in some incident investigations as late as 2018 to 2019 considered as part of this review.

This meant that consistently, throughout the review period, lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result.

There were a number of external reviews carried out by external bodies, including local clinical commissioning groups and the Care Quality Commission, during the last decade. The review team is concerned that some of the findings from these reviews gave false reassurance about maternity services at the trust, despite repeated concerns being raised by families. It is the review team's view that opportunities were lost to have improved maternity services at the trust sooner.

This review has considered all aspects of maternity care at Shrewsbury and Telford Hospital NHS Trust and, as a result, has made a significant number of recommendations for improvement of care across each of the maternity disciplines.

In total, more than 60 LAfL have been identified specifically for the trust in light of the care received by the 1,486 families featured in the review. The review team are encouraged by staff reports that, following our first report in December 2020, there does seem to have been a recent improvement in maternity services at the trust with increased numbers of senior clinicians employed.

It is recognised that many of the issues highlighted in this report are not unique to Shrewsbury and Telford Hospitals NHS Trust, and have been highlighted in other local and national reports into maternity services in recent years. This is why the review team has also identified 15 areas as IEAs that should be considered by all trusts in England providing maternity services. Some of these include:

the need for significant investment in the maternity workforce and multi-professional training

suspension of the midwifery continuity of carer model until - and unless - safe staffing is shown to be present

strengthened accountability for improvements in care among senior maternity staff, with timely implementation of changes in practice and improved investigations involving families

It is absolutely clear that there is an urgent need for a robust and funded maternity-wide workforce plan, starting right now, without delay and continuing over multiple years. This has already been highlighted on a number of occasions, but is essential to address the present and future requirements for midwives, obstetricians, anaesthetists, neonatal teams and associated staff working in and around maternity services. Without this, maternity services cannot provide safe and effective care for women and babies.

In addition, this workforce plan must also focus on significantly reducing the attrition of midwives and doctors, since increases in workforce numbers are of limited use if those already within the maternity workforce continue to leave.

Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe and compassionate maternity care locally and across England.

Concerns that led to this review

The Ockenden review into the Shrewsbury and Telford Hospital NHS Trust maternity services spans the period from 2000 to 2019 and was commissioned by the then Secretary of State for Health Jeremy Hunt MP at the end of 2016. Donna Ockenden was asked to lead the review, then comprising of 23 families, in the summer of 2017. The following is a chronology of reports and reviews into the trust's maternity services over this time.

This timeline shows the failure of the trust's maternity services to listen to families and learn from critical incidents spanning the entire period of the review.

In 2001, a woman gave birth to a baby in very poor condition who subsequently died at 21 minutes of age. The cause was due to failure to recognise abnormalities in the fetal heart monitoring. The family felt that there was no attempt to be honest with them in subsequent correspondence from the trust and they claimed that, as well as clinical mistakes, there was obfuscation and a cover-up. The family subsequently took legal action against the trust in order to get answers that they had been unable to get from the trust before litigation commenced.

In 2002, a baby girl named Olivia died following a traumatic ventouse and forceps delivery. The subsequent independent medical report prepared for this family found severe failings in obstetric care. The mother described how at that time she felt like a 'lone voice in the wind' trying to raise concerns about the trust's maternity unit. Olivia's mother made multiple attempts to publicise what had happened to her daughter including appearing on national television on the 'This Morning' programme in 2006.

Olivia's mother told the review chair in late 2018:

I hope that, by speaking out, other women who've suffered in childbirth will come forward ... to expose the cover-ups that clearly happen... at the time, because I ended up on This Morning as well, talking about this, and the amount of women that day that phoned in, who'd gone through similar things, and it gave me a kind of peace because I knew that they were getting help in the right direction.

2007: Healthcare Commission

In 2004, 2 babies were born in poor condition that resulted in cerebral palsy. These cases were reported in the local press at the time and the solicitor who represented both families wrote to the then regulator of NHS trusts, the Healthcare Commission ( HCC) and the Shropshire and Staffordshire Strategic Health Authority calling for an inquiry. The review team has not seen any evidence that an inquiry took place.

Three years after the experience of these families in April 2007, the HCC wrote to the then CEO of the Royal Shrewsbury Hospital regarding its concerns about the maternity service. The HCC said they had received concerns in March 2006 with regards to poor care resulting in birth injuries. The allegations raised with the HCC were that:

staff failed to recognise and act upon abnormal cardiotocograph (CTG) tracings

there was non-adherence to the National Institute of Health and Clinical Excellence (NICE) guidelines

there was a lack of, and inappropriate, staff training

visited the maternity service and said it was satisfied that CTG training for staff and a CTG audit had been introduced, and that the trust was following NICE guidance

considered that the concerns raised did not meet its criteria for an investigation and therefore did not undertake one, but suggested areas for improvement with a plan to monitor the implementation of the recommendations until it was satisfied that sufficient progress had been made

noted the trust's low caesarean section rate of 14% in 2005 compared with the UK national average of 23.2%

did not examine unplanned admissions to the neonatal intensive care unit (NICU), rates of HIE or relevant other near misses

This was a significant lost opportunity for learning at an already troubled trust.

In the letter from the HCC to the trust dated April 2007, the following recommendations were made:

The trust should send a copy of the latest CTG audit to the HCC and ensure that staff are aware of it for their learning. Trends, learning and improvements should be identified and acted upon.

Lack of or inappropriate staff training

Skills drills training programmes should be evaluated and revised where necessary.

Risk management systems (including incident reporting, root cause analysis, actions plans, follow-up and learning from incidents)

The trust needs to improve the quality of the action plans resulting from clinical incident cases and high-risk case reviews - that is, the actions need to be clearly measurable, the accountable person named and they should have timescales.

How policies and procedures are rolled out to staff and embedded in practice

Policies and procedures should be reviewed in a timely manner, in line with national guidance, and staff should be clear of any revisions.

Clinical governance

The trust should share its revised clinical governance structure with the HCC.

Clinical risk adviser

The trust should consider the need for permanent additional resource for the clinical risk adviser for the children and maternity service.

2008: baby Joshua in 2008 and 2009: baby Kate Stanton-Davies

In March 2009, baby Kate Stanton-Davies died following her birth at Ludlow Birth Centre. Richard Stanton and Rhiannon Davies, Kate's parents, have up to the present day voiced their concerns about the circumstances surrounding Kate's death and about the safety of maternity services at the trust.

The Ockenden review team notes that another baby was born the year before, in May 2008, also at Ludlow Birth Centre. Baby Joshua died a few days after birth after also being born in a very poor condition. A review of this case by the review team has noted that there were significant concerns in the care provided to Joshua's mother and that there was not an appropriate investigation. The coroner did not hold an inquest, following receiving information provided by the trust, but the family explained to the review chair that they were not involved in these discussions between the trust and the coroner.

In summary, the births of baby Joshua and Kate Stanton-Davies have similar features. Both mothers presented with antenatal clinical concerns and reduced fetal movements, there were concerns during the labours, there were resuscitation concerns for both babies and both babies required air ambulance transfer. Both families were dissatisfied with the internal investigations and failure to obtain answers to their questions.

A paediatric death review (an internal investigation by the trust) occurred in September 2008 following the death of baby Joshua in May 2008. The minutes of the meeting state that all midwives were up to date with neonatal resuscitation and:

advised all midwives to call 999 at the first sign of mother or baby being compromised.

This was also stated in the action plan which said:

an ambulance should be called as soon as there are indications that transfer of mother or baby may be required due to the time lag in the ambulance arriving.

When Kate Stanton-Davies was born 10 months after baby Joshua in the same birth centre, an ambulance was not called for 90 minutes despite signs that Kate was seriously unwell from birth.

One overarching theme from this review is that, over the years, there has been a failure within maternity services at the trust to investigate and learn from serious clinical incidents. It is apparent that baby Joshua's death in 2008 did not result in any actions or learning. It is also noted that when the subsequent death of Kate Stanton-Davies was investigated by Debbie Graham, Ms Graham could not locate any definitive guidance for the operating of Ludlow midwife-led unit for 2009. This was despite the fact that, after the earlier death of baby Joshua, these issues were raised as being of importance to ensure the safety of mothers and babies, yet no action appears to have been taken.

Joshua's parents were scathing of the trust, and their lack of transparency and openness and their failure to learn. In a meeting with the review chair in early 2022, Joshua's mother told of:

phoning and phoning the [Royal] Shrewsbury Hospital for over a year, waiting and waiting for answers... They were always on leave, always in surgery, always not available. No one spoke to me.

Joshua's father described the trust as:

ducking and diving, avoiding telling the truth. They've been dodging and weaving all these years.

Joshua's parents eventually commenced litigation in order to get the answers they wanted from the trust.

The Ockenden review team has also searched within the vast amount of information provided by the trust for relevant guidelines. The Shrewsbury and Telford Hospital NHS Trust guideline 'Resuscitation of the Neonate at a Midwife-Led Unit or a Home Birth by a Midwife and When to Summon Assistance' was first implemented in June 2010. It took just over 2 years after the death of baby Joshua and 15 months after the death of Kate Stanton-Davies to ensure this critically important clinical guideline was introduced.

In 2015, a woman had a delayed transfer from the midwifery-led unit and fetal monitoring was not undertaken during the transfer period. The baby was delivered in very poor condition and subsequently died. The family were critical of the ensuing investigation and of correspondence with the Trust, and said during a meeting with the Ockenden review team that they had been:

put off, fobbed off and had obstacles put in our way.

2013: clinical commissioning groups' review

In 2013, there was a review into the maternity services at the trust by the 2 clinical commissioning groups (CCGs). This review was commissioned following concerns over an increased incidence of serious clinical adverse events and the safety of the clinical model of maternity care in Shropshire.

The CCGs ' review of risk management focussed on reported serious incidents and near misses in the period from 1 April 2012 to 31 March 2013.

The review team has found evidence of significant underreporting and cases that should have been investigated not being investigated, so it is our view that the CCGs' review would have underestimated the scale and volume of the incidents at the time. The CCG review also looked at policies, clinical governance systems, care pathways and training, and concluded that:

there was an openness and transparency in reporting and investigation culture, which has led to a higher reporting of serious incidents than would have been reported elsewhere.

The review stated further:

there is a robust approach to risk management, clinical governance and learning from incidents.

The higher reported rate of unexpected admissions to the NICU compared with other local units was attributed in part to "diligent reporting" and a thematic analysis was recommended to understand the reasons for this higher NICU admission rate.

Of note in this CCGs ' report is a recommendation for neonatal services that:

measures to implement standards for 'Local Neonatal Units' are actioned immediately so that babies less than 27 weeks gestation receive initial stabilisation and intensive care in Shropshire before being transferred to an appropriate unit for ongoing intensive care.

There is evidence within this second Ockenden report that this recommendation was not implemented (see Chapter 12 of the full report). Furthermore, a recommendation concerning serious incidents said that the trust must:

ensure serious incident reporting is congruent with the National Patient Safety Agency (2010) and NHS England (2013) Serious Incident Framework.

There is no evidence in the documentation provided to the review team by the trust that this recommendation was actioned (see Chapter 4 of the full report). There is also no evidence that the CCG held the trust to account for meeting these very important recommendations.

The 2013 CCG review also included comments from 47 women across 13 maternity service user focus groups. It should be noted that this survey took place when the labour ward was at the much older Royal Shrewsbury Hospital prior to a move in 2014 to a new purpose-built maternity unit at the Princess Royal Hospital, Telford, so any negative comments on the condition of the estate could be reasonably disregarded.

Within the 2013 report, there were some very positive comments from women:

All of the staff involved in my care - both during my pregnancy and in labour - were excellent. The midwife who dealt with my labour was first rate.

The care we had was excellent - the midwives acted swiftly to save my daughter's life, as did the neonatal ward in Shrewsbury.

However, there were also some very concerning negative comments:

I had a terrible experience and ended up being treated for post-traumatic stress following this birth, ahead of my second child. I felt frightened and not listened to during the birth and was 'cared' for by a rude uncaring doctor.

The whole experience of labour and the birth was horrific. The midwife was horrible, the on-call consultant was bad tempered.

I felt the midwives were unprofessional and rude. I had no help with feeding and consequently felt really alone. I thought midwives would be kind and they weren't a bit. They just kept telling me how busy they were. I don't want to have another baby at Shrewsbury.

I had an awful experience giving birth, the midwife was horrible to me, I felt I got no support. Afterwards in the ward I got no help with breastfeeding.

I felt that my concerns during labour were not addressed, that I was made to have a natural birth when an emergency c-section was more appropriate just so they didn't dent their precious natural birth rate target. I felt like I was on a butcher's slab.

Although, as commented by the authors of the CCG report, 90% of the patient feedback was favourable, the 10% negative feedback contains some very concerning family stories indicating poor maternity care. The sample size of 47 women was also very small. The report thanks "the young mums who provided valuable feedback". It is of note that the families' concerns, which do not appear to have been followed up by the CCG, are very similar to many of those heard by the Ockenden review team.

The overall assessment from this CCG review was that this was a safe and good-quality service. The report states:

It is clear that Shropshire has a maternity service to be proud of and that the model of service provision is safe and robust...

The trust board reviewed this report in papers supplied to the review team and, in the minutes, it noted:

[some] concern about some families' experiences but this was in the context of generally good services.

2014: NHS Litigation Authority assessment

In March 2014, the trust was assessed by the NHS Litigation Authority. This assessed the maternity service for:

The trust was awarded the Level 3 standard - this was the highest standard available to be awarded. It should be noted that the Clinical Negligence Scheme for Trusts standards at the time were assessed almost entirely from self-reporting of guidelines and procedures.

In 2014, there was a Deanery (medical training) review into the training received by obstetrics and gynaecology staff. Under areas for improvement and with reference to clinical governance it said:

The trust must integrate clinical governance into learning outcomes for trainees and ensure that there are clear and robust mechanisms in place to learn from clinical incidents, and that any learning points are clearly disseminated to trainees appropriately.

There is no evidence that has been seen by the review team that this was actioned by the trust.

2015: Care Quality Commission report

In 2015, there was a Care Quality Commission Quality Report on Shrewsbury and Telford Hospital NHS Trust that followed on from a visit to the trust in 2014.

The overall rating for maternity services was 'good'. It is noticeable that in this CQC report other trust services such as medical care, surgery and urgent and emergency services were rated as 'requires improvement'.

The CQC did comment that staffing levels should be improved on the labour ward and also commented that:

the trust must ensure that all staff are consistently reporting incidents, and that staff receive feedback on all incidents raised, so that service development and learning can take place.

However, this comment was a trust-wide action and not specific to the maternity service.

2015: Debbie Graham's independent review

In 2015, there was an independent review by Debbie Graham, which reviewed the high-profile case of Kate Stanton-Davies and made some criticisms of the trust's response to the family.

The independent review by Graham found that, although clinical governance processes were in place in 2009, at the time of Kate's birth there was a disconnect between policy and the systemic mechanisms in place, which prevented effective clinical governance activity from being embedded into the culture of the organisation.

This lack of a safety culture within maternity services at the trust prevented Kate's death being raised as a 'serious incident'. Instead of a serious incident investigation, the death was investigated as a 'high-risk case review' and, secondly, as an unconnected midwifery supervisory investigation. Therefore, no learning started to occur from Kate's death until the findings of the coroner's inquest in 2015, 6 years after Kate died.

In its conclusions, the Graham report stated that:

the learning from these events, in conjunction with the appointment of key personnel, have led to considerable improvements in the provision of maternity services... In particular the development of advocate roles within the trust that will work to strengthen the voices of patients and their families so they may be heard in the future.

2016: baby Pippa Griffiths

Kayleigh Griffiths gave birth to her daughter Pippa Griffiths at home in April 2016. Pippa died the day after her birth due to neonatal meningitis from Group B streptococcus infection. Kayleigh Griffiths had phoned midwifery staff about Pippa's feeding, breathing and other symptoms a number of times overnight after her birth and before she died, but had been reassured. It was established at the coroner's inquest that Pippa would have survived had post-delivery literature been given to Pippa's parents and a complete systematic enquiry into her neonatal health taken place.

Kate's and Pippa's parents (Rhiannon Davies, Richard Stanton, Kayleigh and Colin Griffiths) wrote a joint letter to the trust board in April 2017 expressing concern about maternity services at the trust, discussing their own losses and other cases, and saying that nothing had been learned and nothing had changed with regards to maternity services since Kate's death in 2009. At interview with the chair of this review in December 2017, Colin Griffiths, Pippa's father, described the behaviour of the trust at the time of her death and afterwards as feeling:

like it was a sweep under the carpet, that's what it felt like.

Kayleigh, Pippa's mother, described to the chair of the review in November 2017 the significant effort the family made to try to get the trust to investigate her death in April 2016. She said:

So...I left it until late May, and then it went into June and we'd heard nothing at all from them so I phoned... and said: 'What's happening? Surely there's an investigation taking place?' And [X] said to me: 'Oh, it's just an internal thing, we're looking into it, but if you've got any questions just send them to me and I'll ask them to look at them'...

I...said : 'It's not right, you don't just have a sudden, unexplained death and then say there's no investigation and the family's not going to be involved.' So I went online straight away and got some NHS England guidance up about involving families and sent it... emailed it... And said there's got to be more to it, and I sent... some questions... And, from there, I contacted... I was just thinking something's not right and I'd seen a lot about Richard and Rhiannon Davies, and I made contact with them... I contacted the chief exec at SaTH [Shrewsbury and Telford Hospital NHS Trust] and said, you know, this has got to be investigated...

2017: Ovington review (internal)

In 2017, the Quality and Safety Committee of Shrewsbury and Telford Hospital NHS Trust] commissioned an internal review into the maternity services following on from concerns raised by bereaved parents and the increased perinatal mortality rate, which had resulted in public attention. This report, Review of Maternity Services 2007 to 2017, was authored by Colin Ovington, then working within the trust, and published in 2017.

The Ovington report made recommendations that the maternity service should ensure that governance arrangements are more transparent and open, and should improve the learning from incidents and investigations. It recommended engaging peers from other trusts to assist in the investigation and learning from incidents, and that the trust should use a standardised process for investigating stillbirths and neonatal deaths.

It is unclear whether these recommendations were ever acted upon since the review team has not been provided with or seen any connected action plan or any evidence of completion of the actions following that report.

2017: RCOG invited review

In 2017, there was a RCOG invited review and subsequent report into the maternity services based on a visit to maternity services at the trust carried out from 12 to 14 July 2017. This report noted that:

there were workforce issues, with insufficient numbers of consultants providing obstetric cover. It also noted that middle-grade rotas were not always filled by the deanery meaning that the maternity service relied on overseas trainees and locums

risk management and governance systems were inadequate with a lack of resources

incident reporting was inadequate with little evidence of widespread learning from incidents

the assessors viewed the allocation of the workforce across the sites as a patient safety issue

current morale among the midwifery workforce was very low

the midwifery manager on-call rota required managers to deal with clinical areas they had no experience with

the perinatal mortality rates had remained above average compared with rates in similar trusts. The assessors did not see evidence of action plans and resulting changes in practice to act on this concern

The RCOG report was not presented to the trust board until July 2018 and, when presented, it was prefaced by a report addendum dated 27 April 2018 that reported on interim progress on the recommendations from the original report.

2020: NHS Improvement response

Concerns were raised by families as to the time taken for this report to be presented to the trust board. On 29 November 2019, a letter of complaint was sent to the National Medical Director by 2 families.

The letter alleged that the RCOG report was withheld from the trust board for 12 months. Furthermore, it alleged that trust management sought to "water down" the RCOG report by requesting a further document (the addendum) be produced by the RCOG acknowledging improvements that had apparently been made. This addendum document was then added to the original report before being presented to the trust board in July 2018.

In response to this letter, NHS Improvement's investigation team conducted a review into these allegations and published the document 'Review of the handling of a report produced by the Royal College of Obstetricians and Gynaecologists on maternity services at Shrewsbury and Telford NHS Trust' in July 2020.

This NHS Improvement review noted that 12 months elapsed between the RCOG's site visit and the report being presented to the trust's board. It noted that, when the draft report was received 3 months after RCOG's site visit, a number of trust staff were unhappy with the findings, feeling it was not an accurate representation of the service. The CEO, in part guided by maternity staff feedback, initially did not accept the RCOG draft report.

Following further discussions with RCOG, the trust did then accept the report in early January 2018, but remained concerned about its tone and content, particularly in relation to the executive summary. The trust made representations to RCOG to address this and also proposed a follow-up exercise to evidence improvements the trust felt it had made. The RCOG declined to make any further changes to the report, but did agree to this follow-up exercise to be conducted as a 'progress review meeting' at the RCOG's premises in London. The RCOG did not visit the trust to assess the 'improvements' for themselves.

When the report was finally presented to the trust board, the covering paper was overwhelmingly positive in tone, with its 12-point summary reflecting only the most complimentary aspects of the addendum itself. The overall result was a document that gave the impression that issues in the maternity service had been largely resolved, when in fact there was still significant further work to do.

The NHS Improvement report further found that governance arrangements at the maternity service and care group level were not operating effectively in relation to the report and associated action plan. Although a lot of work was initially done to implement actions and keep the action plan updated, there had been very limited ongoing scrutiny of the plan by local or corporate governance forums. This was concerning given the severity of some of the issues identified in the 2017 RCOG report.

The NHS Improvement report noted that the trust was not obligated to commission the RCOG invited review but chose to do so and committed from the start to publish the results, knowing that this would open it up to further scrutiny. However, when the outcome was less favourable than hoped for, the primary focus of maternity services and the trust seemed to shift towards the perceived public reaction to the report, rather than getting the right internal assurance and scrutiny to ensure the necessary improvement of patient services.

Following the publication of the RCOG report, there was significant criticism in the media and from families that the body had not alerted the regulator (the Care Quality Commission) with regard to its findings. Instead, the RCOG had only released the report to the trust.

At the time, the RCOG sent reports arising from invited reviews to the service or trust that had been reviewed without always notifying regulators. Page 3 of the 2015 policy was clear that the RCOG would "encourage dialogue... with regulatory agencies and authorities" and "encourage the sharing of the report with the CQC ...".

The RCOG policy was subsequently strengthened in 2020 with the policy stating that:

the RCOG will send a copy of the final report to the organisation's healthcare regulatory bodies.

2018: Care Quality Commission

In 2018, there was a CQC report that rated the maternity service inadequate under the safety domain. Of note, there were concerns about cardiotocograph training and mandatory training. The report also commented:

We found areas of concern that were raised in our last inspection [of] December 2016 - for example, service-wide sharing of learning from serious incidents was not evident [and] not all staff could give an example of learning.

The review team has been contacted by and interviewed a number of staff who have worked at the trust over the period of this review. A number of trust staff at board level have also been contacted by the review team and interviewed - these have included some current and former chief executive officers, chairs of the trust, chief nurses and medical directors.

A number of themes have come from these interviews and, broadly, this feedback forms a consistent picture of the culture in the trust during the period of this review with the documentary evidence also considered by the review team.

It was clear from a number of staff interviews that this was a trust which had a number of problems. A board member told the review team that:

there seemed to be a number of political issues making reform of services difficult.

There were also comments that the populations of Shrewsbury and Telford differed, and that:

everybody in Telford wanted all the services in Telford and everybody in Shrewsbury wanted all the services in Shrewsbury.

One staff member said to the review team:

People just didn't do anything... and there just wasn't a culture of accountability for completion.

Another commented that:

this wasn't just a maternity unit in chaos and under pressure, this was a whole organisation where it was difficult to find an area which was not under pressure.

The review team has noted that, for many years, there have been concerns with regard to safety and performance across the whole of the trust, including the emergency department.

One interviewee described the maternity service as:

the Republic of Maternity, where, often, the maternity service seemed to consume its own smoke, and didn't like having oversight by the corporate team.

There was a disconnect both ways actually, I believe, from the corporate team to maternity and maternity to the corporate team.

Over a prolonged period, the trust board and executive team were dealing with a situation where the general standard of the whole organisation was poor and according to a staff member:

women's and children's was largely trusted to take responsibility for their own affairs and, to some extent, there was less scrutiny of them by virtue of the fact that they were perceived as being satisfactory to good.

The impression given from multiple staff interviews with the review team was that the maternity department preferred to manage its service without trust oversight.

The trust had an executive team and board that had continual change and churn over the period of this review, with documentation provided to the review team by the trust showing 10 board chairs from 2000, with 10 CEOs from 2000 to early 2020, of which 8 were in post between 2010 and the current day.

This lack of continuity at board and CEO level resulted in a loss of organisational memory and contributed to this 'self-management' and lack of oversight of a maternity service that had clearly been in trouble for many years. The overwhelming impression of the staff interviews is that, despite significant evidence to the contrary, the maternity unit, up until about 2017, was actually not considered to be a trust risk.

One staff member interviewed stated that, following serious incident reports, there would have been recommendations made, and that often these reports and recommendations were good, but what was missing was the follow-up of the actions from the recommendations. It was said that:

there just wasn't a culture of accountability for completion.

Concerns from local external bodies

In late 2021, the review team also spoke to some senior staff of the CCGs in post between the years 2013 to 2020.

We were told that the CCGs did have concerns about maternity services at the time, and were aware of the local press reports and family concerns. The CCGs had concerns about the length of time that serious incidents took to be reported and we were told by a contributor that:

reviews of serious incidents seemed to take a long, long time to happen and there was an impression of evasiveness around how the learning from those reviews was shared.

The same contributor told the review team that the CCG did have meetings with the maternity service representatives from the trust, but were assured that "things were improving" and were told that the CCGs were in any event "limited in their power to change things for the better".

It should be recognised that the CCGs were also concerned about serious incident investigations and learning from other services across the whole trust, and not just maternity.

Missed opportunities

In summary, this was a trust that had a number of problems, but the perception was that, until 2017, the maternity service was not a major risk.

The consistent message coming from both senior maternity staff and from trust board members was that external reports into the maternity service were generally favourable, and that there were more pressing problems in other services at the trust. The management of the maternity service was perceived to be competent and able, and governance concerns seem to have been managed within the service and not escalated.

The review team believes that the trust board and the CCGs were 'reassured' rather than 'assured' with regards to governance and safety within the maternity service. Although independent and external reports consistently indicated that the maternity service should improve its governance and investigatory procedures, this message was lost in a wider healthcare system that was struggling with other significant concerns.

Case studies

Thematic review of 3 cases at the trust sharing similar themes within a 9-month period (2008 to 2009)

Here we examine the case of Kate Stanton Davies and the deaths of 2 other babies that occurred within a short time period at the Shrewsbury and Telford Hospital NHS Trust. Throughout this report we highlight repeated incidents where maternity services at the trust failed to investigate, learn and make impactful changes to improve patient safety.

Within 9 months, between May 2008 and March 2009, there were 3 neonatal deaths of babies that should have led to a systematic review of governance processes, strong actions and learning as well as a coronial inquiry into safety at the trust. In all 3 cases, there are:

significant failings in the care and treatment provided

omissions in the subsequent investigation into care

failures to learn and establish processes for safe delivery in the midwifery-led unit (MLU) and consultant unit

Most concerning is a lack of transparency and honesty in communication with the families concerned, despite internal recognition at the trust that the investigations were not robust.

These case studies contain a number of technical medical terms - please see the Glossary in the full report for definitions.

2008: baby Joshua

The maternity review team has found evidence of a case that occurred 9 months earlier than that of Kate Stanton Davies. In May 2008, a baby boy called Joshua was born at Ludlow MLU in poor condition. Joshua was transferred by air ambulance to the Royal Shrewsbury Hospital Neonatal Unit and died there on day 6 after his care was withdrawn.

Joshua's mother was considered low risk with a previous pregnancy and birth, and it seems an assumption was made that she would deliver in the freestanding MLU at Ludlow. There was no analysis of risk to ensure normality and whether or not it was appropriate or not to deliver in Ludlow.

However, from 31 weeks of pregnancy the maternal risk changed. Joshua's mother reported 3 episodes of severe uterine tenderness and tightening. One occasion led to an ambulance admission to Royal Shrewsbury Hospital and this review team believes that concealed abruption should have been considered by clinicians at the time.

Joshua's mother reported decreased fetal movements the day prior to labour at 37+5 weeks gestation. No admission CTG was performed; she progressed quickly in labour, and an amniotomy performed at 9cm revealed significant meconium. Seventeen minutes later, her baby was delivered with no sign of life. No ambulance had been called in preparation for delivery and no attempt was made to perform a CTG once the meconium was identified.

Two midwives at the unit attempted to resuscitate the baby, but did not follow UK resuscitation guidance. A paediatrician doing a peripheral clinic took over the resuscitation. An ambulance road crew arrived to help. Joshua was transferred unsecured on a stretcher, and ventilated by valve and mask in the air ambulance to Royal Shrewsbury Hospital where he was ventilated, and remained comatose until treatment was withdrawn on day 6, after a head scan revealed severe widespread damage to Joshua's brain.

The review team observes that timely intermittent auscultation was not performed in labour and what monitoring did occur was not described in an accepted manner. The review team is concerned by alterations added to the notes in a different pen that appear to change the fetal heart rate recordings documented during labour.

Placental histology confirmed a significant abruption with an attached and organised blood clot. The pathologist concluded that the abruption was silent and established. Despite this, the explanation given to the parents at the bereavement consultation was that the abruption must have been acute in the final 15 minutes of labour, perhaps secondary to a tight umbilical cord causing an unpredicted, acute placental detachment. This is despite no evidence of fresh blood loss at birth or post-partum haemorrhage. The bereavement letter stated "nothing could have been done or predicted" and lacked any apology or reassurance that lessons would be learned.

The review team do not accept this opinion of the likely pathology. In addition, we observe from the maternity records supplied by the trust that the meconium revealed prior to birth was thick and established, indicating that the release was likely to have been some time before, perhaps in the days leading to labour when decreased fetal movements were reported. The review team consider that concealed abruption most likely occurred in the third trimester, contrary to the opinion offered to the parents at the bereavement appointment.

There are a number of documents provided to the review team by the trust that show discrepancies between the factual events and what was actually discussed with the parents. There are also extracts that contain additional information, which was not disclosed to the family. This information is found in incident reports filed by members of staff and communications between professionals provided to the review team by the trust.

The review team conclude that the risk management review of this incident by the trust failed to follow appropriate local investigation processes to identify the root cause. The trust also failed to decide on appropriate actions in order to prevent similar harm in the future. It is of concern that a decision to refer to the coroner was reversed by a small number of individuals within the trust who decided to manage this incident internally.

The review team has been aware of internal reports of concern around the lack of:

Documents shared with the review team by the trust show that the lack of a portable resuscitaire in Ludlow MLU had been on the maternity risk register since 2005. The trust did not support this concern and excused the lack of equipment on the basis that it would only be used by a neonatologist. There was an assessment of the resuscitation equipment at the unit, but no details were given of the outcome. The review team is concerned by the response to this risk as it demonstrates poor evidence of learning. The additional information around the maternity risk register and the fact that this was a known risk regarding Ludlow MLU was never detailed to the parents during their meeting with the obstetrician or to any other professionals outside the organisation.

A few weak action points from this case were circulated via a memorandum suggesting that change in practice was not mandatory and it was optional whether to use CTG monitoring if a woman presented with reduced fetal movements at the MLU. It also suggested it was optional to summon an ambulance when amniotomy was performed with evidence of meconium.

A clinician who cared for the baby initially stated in a letter to the clinical director in July 2008 that they had serious concerns regarding the quality of the case review. They pointed out a number of inaccuracies in the findings of the review and wrote:

I really do wonder whether they have actually read these notes and wonder [about] the quality of the case review.

I am concerned that there is evidence the parents have not received an accurate explanation of the events leading up to the birth, during the birth and the resuscitation.

2009: baby Thomas

In January 2009, after the birth and death of Joshua but before Kate Stanton-Davies was born, a multiparous mother delivered in the consultant unit. Uterine rupture was diagnosed at caesarean section after a failed ventouse and prolonged labour with injudicious oxytocin use. The baby, named Thomas, died at 34 minutes of age and was classified as an early neonatal death. The coroner agreed to the stated cause of death as:

1. Multiple organ failure.

2. Ruptured uterus and placental abruption.

No post mortem was performed.

The mother was booked for an MLU delivery despite having had a very long previous labour with a macrosomic baby. No gestational diabetes testing was performed in this second pregnancy. Numerous attendances in a long latent phase of labour were apparent and all clinical midwifery reviews highlighted a large for dates baby with poor engagement of the fetal head.

The mother was admitted to the consultant-led antenatal ward, contracting at 4cm dilatation. Nineteen hours later, she was taken to the labour ward for amniotomy at 5cm. During the 11 hours following amniotomy, there were repeated periods of abnormal CTG, and high-dose oxytocin infusion was administered for long periods of time leading to and after full dilatation. The contraction frequency was 5 in 10 minutes for long periods and poor medical input was noted. Vaginal examinations revealed classic signs of obstructed labour of a baby in the deflexed occipito-posterior position.

An hour prior to eventual birth by caesarean section, there were classic signs of uterine rupture including haematuria, breakthrough pain, hypotension, and diminished uterine activity, failure to establish between a clear fetal or maternal heart rate. The midwife sought assistance for possible uterine rupture. A ventouse delivery was initiated 35 minutes later and failed after 3 pulls. A caesarean was conducted 10 minutes later and uterine rupture with placental abruption was found. The baby briefly had a heartbeat, but at 34 minutes of age resuscitation was discontinued.

A DATIX31 submission was generated following this event and the outcome of uterine rupture, early neonatal death and major obstetric haemorrhage (4.8 litres) was classified as low harm. It was stated that the case would be discussed in a case review meeting that same month, but to date the review team has received no documents from the trust pertaining to a risk review or outcomes.

The review team has graded this incident as Grade 3 (the highest grade of harm) and has major concerns with the management of the incident and the apparent lack of scrutiny.

In a bereavement letter, the trust inaccurately informed the parents that the demise was acute and no one could be certain when the rupture occurred. No reference is made in the letter to the reasons why the mother's uterus was ruptured or to the chronic hypoxia revealed by the cord ph. There is no reference in the letter to lessons being learned or actions that could prevent such tragedy in the future.

2009: the Stanton-Davies family and baby Kate

Two months after the birth and death of baby Thomas and 9 months after the birth and death of baby Joshua, baby Kate died avoidably on 1 March 2009 after her birth at Ludlow MLU. Kate died at 6 hours of age following cardiopulmonary collapse at 90 minutes of life. She was severely anaemic and paediatric help should have been sought earlier.

The case has been reviewed extensively with a highly criticised supervisory investigation, multiple external opinion reports and, finally in 2012, a coroner's inquest with jury - all of these occurring after constant pressure from Kate's grieving parents.

The inquest concluded that Kate should not have been born at Ludlow. The 2 weeks of reduced fetal movements prior to labour was a factor in Kate being born anaemic, as she had likely suffered repeated episodes of feto-maternal haemorrhage. The MLU staff failed to provide Kate and her mother Rhiannon with midwifery expertise. Intermittent auscultation in labour was not adequate and opportunities to manage a baby in difficulty during the first hours of life were missed. Kate died shortly after arrival by air ambulance at a tertiary neonatal unit.

There have been numerous specialist opinions on this case over a long period of time. It is clear that the trust failed to fulfil its responsibility to establish the facts and establish accountability. In particular, the trust failed to:

investigate Kate's death appropriately

hold staff to account

address her parent's concerns, particularly those pertaining to the inadequacy of the supervisory investigation

Further external opinions revealed that midwives did not consider her mother Rhiannon's antenatal care as a whole and did not consider the bigger picture, which would have indicated that Kate should not have been delivered in an MLU. The trust's investigation into midwifery practice is described as ineffective and half-hearted, and the consultant feedback is criticised as being badly considered.

Consideration of these 3 cases of term babies, Joshua, Thomas and Kate, who were born and died within 10 months of each other, show that, by early 2009, there was already a systematic failure within the trust to investigate its maternity services.

Following on from their failure to investigate the deaths of Joshua, Thomas and Kate, the Shrewsbury and Telford Hospital NHS Trust completely failed to identify appropriate actions for learning from the deaths of these babies.

The review team is particularly concerned by the lack of transparency internally within the trust, and the lack of honesty and transparency with families. This is all the more concerning when it is clear that major issues in safety were apparent in both MLU and consultant settings during the period leading up to the birth and death of Kate Stanton-Davies, and before the birth and death of baby Joshua and then baby Thomas.

Our findings following the review of family cases

A total of 1,862 cases were either reported by the trust or self-referred to the review. After the closure date for referrals, the database was reviewed and 47 duplications were identified and removed, leaving 1,815 cases.

The review was intended to span the years 2000 to 2019. However, as discussed previously, some earlier and later cases were reviewed in line with the updated terms of reference. The earliest case reviewed occurred in 1973 and the latest in 2020.

Total clinical incidents reviewed

After excluding cases for which hospital records were missing, or where consent for participation in the review was not given or could not be obtained, the final number of families whose cases were reviewed was 1,486.

It is important to note that some families had more than one clinical incident reviewed, as some mothers had more than one pregnancy during the review period.

In total, 1,592 clinical incidents were reviewed. Table 1 outlines the number of families and clinical incidents throughout the review period.

Table 1: time period of family cases included in this review

In line with the terms of reference underpinning this review, we reviewed all 1,592 clinical incidents and analysed 2 aspects:

1. We graded the care provided by the trust as set out below in 'Grading of care'.

2. We reviewed all the maternity governance documentation provided to the review team, and graded the quality and appropriateness of the incident investigation in line with national frameworks at the time.

Grading of care

All the clinical incidents were reviewed by members of the review team, which comprised:

obstetricians

midwives

neonatologists

other specialists, where appropriate

The clinical care was graded using an established grading of care scoring system (Table 2) developed by the Confidential enquiry into stillbirths and deaths in infancy (CESDI), which was similarly used in the Morecambe Bay investigation report by Dr Bill Kirkup OBE.

Further details on the findings and the IEAs recommended by this review are described in the accompanying chapters in the full report.

Table 2: grading of maternal and newborn care provided

Grade

Summary description of care

Detailed description of care

Tables 3a to 3e show the grading of care for the major incident categories. For the incident categories HIE, neonatal death and cerebral palsy or brain damage, the investigation into mother and baby is considered as one family.

It is important to note that a mother or baby can be in more than one category, and this includes the maternal morbidity category and the combined category.

In addition, some mothers had more than one pregnancy where a clinical incident occurred during the period of the review (for example, a stillbirth in one pregnancy followed by another incident in a subsequent category).

Maternal deaths

Table 3a: clinical review findings for maternal deaths

There were 12 maternal deaths reviewed and, in 9 of the 12 cases (75%), the review team identified significant or major concerns in the care received. Maternal deaths are further discussed in Chapter 10 of the full report.

Stillbirth

Table 3b: clinical review findings for stillbirth

498 cases of stillbirth were reviewed and graded. One in four cases were found to have significant or major concerns in care which, if managed appropriately, might or would have resulted in a different outcome.

Table 3c: clinical review findings for HIE

HIE is a newborn brain injury caused by oxygen deprivation to the brain. There were significant and major concerns in the care provided to the mother in two-thirds (65.9%) of all cases.

After the baby had been born, most of the neonatal care provided was considered appropriate or included minor concerns - however, these were unlikely to influence the outcome observed.

Neonatal death

Table 3d: clinical review findings for neonatal death

Most of the neonatal deaths occurred in the first 7 days of life. Nearly a third of all incidents reviewed (27.9%) were identified to have significant or major concerns in the maternity care that might or would have resulted in a different outcome.

Cerebral palsy or brain damage

Table 3e: clinical review findings for cerebral palsy or brain damage

All of the families in this group self-reported to the review. The diagnosis of cerebral palsy was often made some years following their maternity episode.

On reviewing the medical records, where it was found that the neonatologists at the trust had recorded a diagnosis of HIE in the early neonatal period, a small proportion of families were subsequently transferred to the HIE incident category.

From the remaining cases of cerebral palsy, more than 40% were identified to have significant or major concerns in maternity care which might have resulted in a different outcome. The grading of neonatal care in most of the cases was either appropriate or with only minor concerns.

Maternal morbidity

Within this group were families who did not meet the incident categories identified in the NHSEI and trust-led open book exercise conducted in the autumn of 2018 (maternal death, stillbirth, neonatal death and HIE).

There were 614 women in this group, and they included women who:

experienced morbidity such as admission to intensive care

had had a caesarean hysterectomy

had severe sepsis or major haemorrhage, or reported having experienced rare adverse outcomes such as eclampsia, amniotic fluid embolus or a cardiac arrest

Our reviewers identified significant and major concerns in the care provided to 1 in 4 women in this group. The care provided to the baby was considered appropriate in more than 90% of records reviewed.

Combined category

This group included families who were outside the other categories. Some of these families self-reported. This category included :

There were 58 cases reviewed in this group. Most of these cases were graded as receiving appropriate care or care with only minor concerns.

Quality of investigation

We graded the quality and appropriateness of clinical incident investigations undertaken at the trust throughout the time period of the review. Nationally, investigative processes have improved over time and this is described further in Chapter 4 of the full report.

Table 4 outlines the grading system used for the clinical incidents from 2011 onwards.

Table 4: grading of investigations from 2011 onwards

Appropriate

Incident investigated by team of clinicians.

Appropriate collection of evidence (statements, notes, policies and so on).

Appropriate care and service delivery problems identified.

Strong recommendations for improvement with clear plan for implementation.

Families involved in investigation by compassionate communication with family at time of incident.

Feedback to family once investigation concluded.

The tables below show the results for stillbirths and neonatal deaths for the period 2011 to 2019. The maternal death investigations are discussed more fully in Chapter 10 of the full report.

Where there was no trust investigation, this is shown. In some cases, the review team reported 'unable to grade', which was usually due to incomplete documentation. Only where there was sufficient documentation for a review was a grading of 'appropriate' or 'poor' given.

Table 5: stillbirths (2011 to 2019)

In the period 2011 to 2019, 68 (40%) of the 168 stillbirths reviewed did not have an investigation. Of those where an investigation occurred, 36% were found to be appropriate. Family involvement was graded as appropriate in 33% of cases.

Table 6: neonatal deaths (2011 to 2019)

In the period 2011 to 2019, 33 (43%) of the 77 neonatal deaths reviewed did not have an investigation. Of those where an investigation occurred, 55% were considered to have been appropriately investigated. Family involvement was graded as appropriate in 42% of cases.

In the HIE group, there were 12 cases reviewed for the period 2011 to 2019 and, of these, 8 were investigated by the trust. This group was considered too small to draw conclusions on the quality of the investigation.

We include these immediate and essential actions ( IEAs) to improve safety in maternity services across England. These IEAs complement and expand upon the IEAs issued in our first report. We note that NHSEI has supported the implementation of these actions in trusts across England since our first report was published.

These further IEAs arise from findings from this large review into maternity services at Shrewsbury and Telford Hospitals NHS Trust. However, we are aware that similar problems may occur in other trusts across England and, therefore, these actions must be implemented widely in all maternity services.

This review is supporting and endorsing the latest Health and Social Care Committee report The safety of maternity services in England.

We agree with the select committee that the budget for maternity services be increased by £200 to 350 million a year with immediate effect. This funding increase should be kept under close review as more precise modelling is carried out on the obstetric workforce and as trusts continue to undertake regular safe staffing reviews of midwifery workforce levels.

We further agree that the DHSC must work with the RCOG and Health Education England to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come.

This work must also consider the anaesthetic and neonatal workforce, and be advised by the:

Royal College of Anaesthetists (RCOA)

Obstetric Anaesthetists' Association (OAA)

Royal College of Paediatrics and Child Health (RCPCH)

British Association of Perinatal Medicine (BAPM)

In this regard, the review team is also aware of and endorses the initiatives on workforce planning by the RCOA and the current national review of the obstetric anaesthesia workforce by the OAA in response to the first report.

We endorse the Health Select Committee view that a proportion of maternity budgets must be ring-fenced for training in every maternity unit. We also agree that NHS trusts must report this in public through their annual financial and quality accounts.

We endorse the Health Select Committee recommendation that the Maternity Transformation Programme board should establish what proportion of maternity budgets should be ring-fenced for training, but it must be sufficient to cover not only the provision of training, but the provision of back-fill to ensure that staff are able to both provide and attend training.

We endorse the recommendation that a single set of maternity training targets agreed in all maternity services in England should be established by the Maternity Transformation Programme board, working in conjunction with and advised by the main Royal Colleges and the Care Quality Commission ( CQC).

We endorse the recommendation that training targets should be enforced by NHSEI's Maternity Transformation Programme, the RCM, the RCOG and the CQC through a regular collaborative inspection programme.

Along with staffing and training, the Health Select Committee clearly articulated the need to learn from patient safety incidents. This issue has taken up a large part of both this second report and our first report, and we endorse the committee's findings that families must be involved in the investigative process, and that lessons must be learned and implemented in a timely way to prevent further tragedies.

We also note the committee recognised that maternity units appear to have been penalised for high caesarean section rates and recommended that there should be an end to the use of total caesarean section percentages as a metric for maternity services. We note the progress on this with the recent advice from NHSEI to trusts[footnote 10] to stop monitoring caesarean section rates.

The recognition that Shrewsbury and Telford Hospital NHS Trust had a lower than average caesarean section rate (and was often praised for this) was identified in our first report. We noted that some mothers and babies had been harmed by this approach, and we welcome the committee's findings and the progress on this.

This review also supports the NHS Maternity Digital Programme. We recognise this as a key enabler to improve quality and safety. The use of maternity digital notes will empower women by providing them with their own digital maternity care plan and record, discussed and agreed with them and their midwife. Enhancing and improving the digital programme will improve communication and ultimately contribute to making maternity care safer.

The Parliamentary Health and Social Care Committee report recommendations on staffing, training and learning from patient safety incidents echo much of the work of our first and now this final report. We believe there is still so much more to do in order to make the maternity service in England the safest it can be. It is our intention that implementation of these further IEAs will make a significant contribution to the delivery of safe maternity care.

Importantly: we state that DHSC and NHSEI must now commission a working group independent of the Maternity Transformation Programme that has joint RCM and RCOG leadership to make plans to guide the Maternity Transformation Programme around implementation of these IEAs, and the recommendations of other reports currently being prepared.

1. Workforce planning and sustainability

Financing a safe maternity workforce

The recommendations from the Health and Social Care Committee report, The safety of maternity services in England, must be implemented.

The investment announced following our first report was welcomed. However, to fund maternity and neonatal services appropriately requires a multi-year settlement to ensure the workforce is enabled to deliver consistently safe maternity and neonatal care across England.

Minimum staffing levels should be those agreed nationally or, where there are no agreed national levels, staffing levels should be locally agreed with the local maternity and neonatal system ( LMNS). This must encompass the increased acuity and complexity of women, vulnerable families and additional mandatory training to ensure trusts are able to safely meet organisational Clinical Negligence Scheme for Trusts and CQC requirements.

Minimum staffing levels must include a locally calculated uplift, representative of the 3 previous years' data, for all absences including sickness, mandatory training, annual leave and maternity leave.

The feasibility and accuracy of the BirthRate Plus tool and associated methodology must be reviewed nationally by all bodies. These bodies must include as a minimum NHSEI, RCOG, RCM and RCPCH.

Training

We state that the Health and Social Care Select Committee view that a proportion of maternity budgets must be ring-fenced for training in every maternity unit should be implemented.

All trusts must implement a robust preceptorship programme for newly qualified midwives ( NQMs), which supports supernumerary status during their orientation period and protected learning time for professional development as per the RCM position statement for this.

All NQMs must remain within the hospital setting for a minimum period of one year post qualification. This timeframe will ensure there is an opportunity to develop essential skills and competencies on which to advance their clinical practice, enhance professional confidence and resilience, and provide a structured period of transition from student to accountable midwife.

All trusts must ensure all midwives responsible for co-ordinating a labour ward attend a fully funded and nationally recognised labour ward co-ordinator education module, which supports advanced decision-making, learning through training in human factors, situational awareness and psychological safety to tackle behaviours in the workforce.

All trusts to ensure newly appointed labour ward coordinators receive an orientation package that reflects their individual needs. This must encompass opportunities to be released from clinical practice to focus on their personal and professional development.

All trusts must develop a core team of senior midwives who are trained in the provision of high-dependency maternity care. The core team should be large enough to ensure there is at least one high-dependency unit-trained midwife on each shift 24/7.

All trusts must develop a strategy to support a succession-planning programme for the maternity workforce to develop potential future leaders and senior managers. This must include a gap analysis of all leadership and management roles to include those held by specialist midwives and obstetric consultants. This must include supportive organisational processes and relevant practical work experience.

The review team acknowledges the progress around the creation of maternal medicine networks nationally, which will enhance the care and safety of complex pregnancies. To address the shortfall of maternal medicine physicians, a sustainable training programme across the country must be established to ensure the appropriate workforce long term.

2. Safe staffing

All trusts must maintain a clear escalation and mitigation policy where maternity staffing falls below the minimum staffing levels for all health professionals

When agreed staffing levels across maternity services are not achieved on a day-to-day basis, this should be escalated to the services' senior management team, obstetric leads, the chief nurse, medical director, patient safety champion and local maternity system ( LMS).

In trusts with no separate consultant rotas for obstetrics and gynaecology, there must be a risk assessment and escalation protocol for periods of competing workload. This must be agreed at board level.

All trusts must ensure the labour ward co-ordinator role is recognised as a specialist job role with an accompanying job description and person specification.

All trusts must review and suspend if necessary the existing provision and further roll-out of midwifery continuity of carer model( MCoC) unless they can demonstrate staffing meets safe minimum requirements on all shifts. This will preserve the safety of all pregnant women and families, which is currently compromised by the unprecedented pressures that MCoC models place on maternity services already under significant strain.

The reinstatement of MCoC should be withheld until robust evidence is available to support its reintroduction.

The required additional time for maternity training for consultants and locally employed doctors must be provided in job plans. The protected time required will be in addition to that required for generic trust mandatory training and reviewed as training requirements change.

All trusts must ensure there are visible, supernumerary clinical skills facilitators to support midwives in clinical practice across all settings.

Newly appointed Band 7 or 8 midwives must be allocated a named and experienced mentor to support their transition into leadership and management roles.

All trusts must develop strategies to maintain bidirectional robust pathways between midwifery staff in the community setting and those based in the hospital setting to ensure high-quality care and communication.

All trusts should follow the latest RCOG guidance on management of locums. The RCOG encourages the use of internal locums and has developed practical guidance with NHS England on the management of locums. This includes support for locums and ensuring they comply with recommended processes such as pre-employment checks and appropriate induction.

3. Escalation and accountability

Staff must be able to escalate concerns if necessary

There must be clear processes for ensuring that obstetric units are staffed by appropriately trained staff at all times.

If not resident, there must be clear guidelines for when a consultant obstetrician should attend.

All trusts must develop and maintain a conflict of clinical opinion policy to support staff members in being able to escalate their clinical concerns regarding a woman's care in case of disagreement between healthcare professionals.

When a middle grade or trainee obstetrician (non-consultant) is managing the maternity service without direct consultant presence, trusts must have an assurance mechanism to ensure the middle grade or trainee is competent for this role.

Trusts should aim to increase resident consultant obstetrician presence where this is achievable.

There must be clear local guidelines for when consultant obstetricians' attendance is mandatory within the unit.

There must be clear local guidelines detailing when the consultant obstetrician and the midwifery manager on call should be informed of activity within the unit.

4. Clinical governance - leadership

Trust boards must have oversight of the quality and performance of their maternity services

In all maternity services, the director of midwifery and clinical director for obstetrics must be jointly operationally responsible and accountable for the maternity governance systems.

Trust boards must work together with maternity departments to develop regular progress and exception reports and assurance reviews, and regularly review the progress of any maternity improvement and transformation plans.

All maternity service senior leadership teams must use appreciative inquiry to complete the national maternity self-assessment tool if not previously done. A comprehensive report of their self-assessment, including governance structures and any remedial plans, must be shared with their trust board.

Every trust must ensure they have a patient safety specialist who is specifically dedicated to maternity services.

All clinicians with responsibility for maternity governance must be given sufficient time in their job plans to be able to engage effectively with their management responsibilities.

All trusts must ensure that those individuals leading maternity governance teams are trained in human factors, causal analysis and family engagement.

All maternity services must ensure there are midwifery and obstetric co-leads for developing guidelines. The midwife co-lead must be of a senior level, such as a consultant midwife, who can drive the guideline agenda, and have links with audit and research.

All maternity services must ensure they have midwifery and obstetric co-leads for audits.

5. Clinical governance - incident investigation and complaints

Incident investigations must be meaningful for families and staff, and lessons must be learned and implemented in practice in a timely manner

All maternity governance teams must ensure the language used in investigation reports is easy to understand for families - for example, ensuring any medical terms are explained in lay terms.

Lessons from clinical incidents must inform delivery of the local multidisciplinary training plan.

Actions arising from a serious incident investigation that involve a change in practice must be audited to ensure a change in practice has occurred.

Change in practice arising from a serious incident investigation must be seen within 6 months after the incident occurred.

All trusts must ensure that complaints that meet the serious incident threshold must be investigated as such.

All maternity services must involve service users (ideally via their Maternity Voices Partnership) in developing complaints response processes that are caring and transparent.

Complaints themes and trends must be monitored by the maternity governance team.

6. Learning from maternal deaths

Nationally, all maternal post-mortem examinations must be conducted by a pathologist who is an expert in maternal physiology and pregnancy-related pathologies

In the case of a maternal death, a joint review panel or investigation of all services involved in the care must include representation from all applicable hospitals or clinical settings.

NHSEI must work together with the Royal Colleges and the Chief Coroner for England and Wales to ensure that this is provided in any case of a maternal death.

This joint review panel or investigation must:

have an independent chair

be aligned with local and regional staff

seek external clinical expert opinion where required

Learning from this review must be introduced into clinical practice within 6 months of the completion of the panel. The learning must also be shared across the LMS.

7. Multidisciplinary training

Staff who work together must train together

Staff should attend regular mandatory training and rotas. Job planning needs to ensure all staff can attend.

Clinicians must not work on a labour ward without appropriate regular CTG training and emergency skills training.

All members of the multidisciplinary team working within maternity should attend regular joint training, governance and audit events. Staff should have allocated time in job plans to ensure attendance, which must be monitored.

Multidisciplinary training must integrate the local handover tools (such as SBAR) into the teaching programme at all trusts.

All trusts must mandate annual human factor training for all staff working in a maternity setting. This should include the principles of psychological safety and upholding civility in the workplace, ensuring staff are enabled to escalate clinical concerns. The content of human factor training must be agreed with the LMS.

There must be regular multidisciplinary skills drills and on-site training for the management of common obstetric emergencies, including haemorrhage, hypertension and cardiac arrest, and the deteriorating patient.

There must be mechanisms in place to support the emotional and psychological needs of staff, at both an individual and team level, recognising that well-supported staff teams are better able to consistently deliver kind and compassionate care.

Systems must be in place in all trusts to ensure that all staff are trained and up to date in CTG and emergency skills.

Clinicians must not work on labour wards or provide intrapartum care in any location without appropriate regular CTG training and emergency skills training. This must be mandatory.

8. Complex antenatal care

Local maternity systems, maternal medicine networks and trusts must ensure that women have access to pre-conception care

Trusts must provide services for women with multiple pregnancy in line with national guidance.

Trusts must follow national guidance for managing women with diabetes and hypertension in pregnancy.

Women with pre-existing medical disorders, including cardiac disease, epilepsy, diabetes and chronic hypertension, must have access to preconception care with a specialist familiar in managing that disorder and who understands the impact that pregnancy may have.

Trusts must have in place specialist antenatal clinics dedicated to accommodate women with multifetal pregnancies. They must have a dedicated consultant and specialist midwifery staffing.

These recommendations are supported by the NICE guideline (NG137) on twin and triplet pregnancy (2019).

NICE guideline (NG3) on diabetes in pregnancy (2020) should be followed when managing all pregnant women with pre-existing diabetes and gestational diabetes.

When considering and planning delivery for women with diabetes, clinicians should present women with evidence-based advice as well as relevant national recommendations. Documentation of these joint discussions must be made in the woman's maternity records.

Trusts must develop antenatal services for the care of women with chronic hypertension. Women who are identified with chronic hypertension must be seen in a specialist consultant clinic to evaluate, and discuss risks and benefits to treatment. Women must be commenced on aspirin 75 to 150mg daily from 12 weeks gestation in accordance with the NICE guideline (NG133) on hypertension in pregnancy (2019).

9. Preterm birth

The LMNS, commissioners and trusts must work collaboratively to ensure systems are in place for the management of women at high risk of preterm birth

Trusts must implement NHS Saving Babies Lives Version Two (2019).

Senior clinicians must be involved in counselling women at high risk of very preterm birth, especially when pregnancies are at the thresholds of viability.

Women and their partners must receive expert advice about the most appropriate fetal monitoring that should be undertaken dependent on the gestation of their pregnancies and what mode of delivery should be considered.

Discussions must involve the local and tertiary neonatal teams so parents understand the chances of neonatal survival, and are aware of the risks of possible associated disability.

There must be a continuous audit process to review all in-utero transfers and cases where a decision is made not to transfer to a Level 3 neonatal unit and, when delivery subsequently occurs, in the local unit.

10. Labour and birth

Women who choose birth outside a hospital setting must receive accurate advice with regards to transfer times to an obstetric unit should this be necessary

Centralised CTG-monitoring systems should be mandatory in obstetric units.

All women must undergo a full clinical assessment when presenting in early or established labour. This must include a review of any risk factors and consideration of whether any complicating factors have arisen that might change recommendations about place of birth. These must be shared with women to enable an informed decision regarding place of birth to be made.

Midwifery-led units must:

complete yearly operational risk assessments

undertake regular multidisciplinary team skill drills to correspond with the training needs analysis plan

It is mandatory that all women who choose birth outside a hospital setting are provided with accurate and up-to-date written information about the transfer times to the consultant obstetric unit. Maternity services must prepare this information by working together and in agreement with the local ambulance trust.

Maternity units must have pathways for induction of labour ( IOL). Trusts need a mechanism to clearly describe safe pathways for IOL if delays occur due to high activity or short staffing.

Centralised CTG-monitoring systems must be made mandatory in obstetric units across England to ensure regular multi-professional review of CTGs.

11. Obstetric anaesthesia

In addition to routine inpatient obstetric anaesthesia follow-up, a pathway for outpatient postnatal anaesthetic follow-up must be available in every trust to address incidences of physical and psychological harm

Documentation of patient assessments and interactions by obstetric anaesthetists must improve. The determination of core data sets that must be recorded during every obstetric anaesthetic intervention would result in record-keeping that more accurately reflects events.

Staffing shortages in obstetric anaesthesia must be highlighted and updated guidance for the planning and provision of safe obstetric anaesthesia services throughout England must be developed.

Conditions that merit further follow-up include, but are not limited to:

Anaesthetists must be proactive in recognising situations where an explanation of events and an opportunity for questions may improve a woman's overall experience, and reduce the risk of long-term psychological consequences.

All anaesthetic departments must review the adequacy of their documentation in maternity patient records and take steps to improve this where necessary as recommended in the General Medical Council's Good medical practice.

Resources must be made available for anaesthetic professional bodies to determine a consensus regarding contents of core data sets and what constitutes a satisfactory anaesthetic record in order to maximise national engagement and compliance.

Obstetric anaesthesia staffing guidance to include:

the role of consultants, SAS doctors and doctors-in-training in service provision, as well as the need for prospective cover, to ensure maintenance of safe services while allowing for staff leave

the full range of obstetric anaesthesia workload including elective caesarean lists, clinic work, labour ward cover, as well as teaching, attendance at multidisciplinary training and governance activity

the competency required for consultant staff who cover obstetric services out of hours, but who have no regular obstetric commitments

participation by anaesthetists in the maternity multidisciplinary ward rounds, as recommended in the first report

12. Postnatal care

Trusts must ensure that women readmitted to a postnatal ward and all unwell postnatal women have timely consultant review

Postnatal wards must be adequately staffed at all times.

All trusts must develop a system to ensure consultant review of all postnatal readmissions and unwell postnatal women, including those requiring care on a non- maternity ward.

Unwell postnatal women must have timely consultant involvement in their care and be seen daily as a minimum.

Postnatal readmissions must be seen within 14 hours of readmission or urgently if necessary.

Staffing levels must be appropriate for both the activity and acuity of care required on the postnatal ward, both day and night, for both mothers and babies.

13. Bereavement care

Trusts must ensure that women who have suffered pregnancy loss have appropriate bereavement care services

Trusts must provide bereavement care services for women and families who suffer pregnancy loss. This must be available daily, not just Monday to Friday.

All trusts must ensure adequate numbers of staff are trained to take post-mortem consent, so that families can be counselled about post-mortem within 48 hours of birth. They should have been trained in dealing with bereavement, and in the purpose and procedures of post-mortem examinations.

All trusts must develop a system to ensure that all families are offered follow-up appointments after perinatal loss or poor serious neonatal outcomes.

Compassionate, individualised and high-quality bereavement care must be delivered for all families who have experienced a perinatal loss, with reference to guidance such as the National Bereavement Care Pathway.

14. Neonatal care

There must be clear pathways of care for provision of neonatal care

This review endorses the recommendations from the Neonatal Critical Care Transformation Review (December 2019) to:

expand neonatal critical care

increase neonatal cot numbers

develop the workforce

enhance the experience of families

This work must now progress at pace.

Neonatal and maternity care providers, commissioners and networks must agree on pathways of care, including the designation of each unit and on the level of neonatal care that is provided.

Care that is outside this agreed pathway must be monitored by exception reporting (at least quarterly), and reviewed by providers and the network. The activity and results of the reviews must be reported to commissioners and the LMS or LMNS on a quarterly basis.

Maternity and neonatal services must continue to work towards a position of at least 85% of births at less than 27 weeks gestation taking place at a maternity unit with an onsite NICU.

Neonatal Operational Delivery Networks must ensure that staff within provider units have the opportunity to share best practice and education to ensure units do not operate in isolation from their local clinical support network. For example, senior medical, advanced neonatal nurse practitioner and nursing staff must have the opportunity for secondment to attend other appropriate network units on an occasional basis to maintain clinical expertise and avoid working in isolation.

Each network must report to commissioners annually what measures are in place to prevent units from working in isolation.

Neonatal providers must ensure that processes are defined that enable telephone advice and instructions to be given, where appropriate, during the course of neonatal resuscitations. When it is anticipated that the consultant is not immediately available (for example, out of hours), there must be a mechanism that allows a real-time dialogue to take place directly between the consultant and the resuscitating team if required.

Neonatal practitioners must ensure that, once an airway is established and other reversible causes have been excluded, appropriate early consideration is given to increasing inflation pressures to achieve adequate chest rise. Pressures above 30cm H ₂O in term babies, or above 25cm H ₂O in preterm babies may be required. The Resuscitation Council UK's Newborn Life Support (NLS) Course must consider highlighting this treatment point more clearly in the NLS algorithm.

Neonatal providers must ensure sufficient numbers of appropriately trained consultants, tier 2 staff (middle-grade doctors or advanced neonatal nurse practitioners) and nurses are available in every type of neonatal unit ( NICU, local neonatal unit and special care baby unit) to deliver safe care 24/7 in line with national service specifications.

15. Supporting families

Care and consideration of the mental health and wellbeing of mothers, their partners and the family as a whole must be integral to all aspects of maternity service provision

Maternity care providers must actively engage with the local community and those with lived experience to deliver services that are informed by what women and their families say they need from their care.

There must be robust mechanisms for the identification of psychological distress, and clear pathways for women and their families to access emotional support and specialist psychological support as appropriate.

Access to timely emotional and psychological support should be without the need for formal mental health diagnosis, as psychological distress can be a normal reaction to adverse experiences.

Psychological support for the most complex levels of need should be delivered by psychological practitioners who have specialist expertise and experience in the area of maternity care.

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Ockenden review: summary of findings, conclusions and essential actions

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30 March 2022 Dear Secretary of State I publish the final report of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, at a time when the NHS continues to face significant challenges arising from the coronavirus (COVID-19) pandemic.

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Racism Matters: Action needed to support Black people in maternity

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Racism Matters: Action needed to support Black people in maternity

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Webinar 1 - Midwifery in the UK and wellbeing programme overview RECORDING 

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Webinar 1 - Midwifery in the UK and wellbeing programme overview RECORDING 

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Webinar 1 presentation slides - Midwifery in the UK and One Thought wellbeing programme introduction

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Webinar 1 presentation slides - Midwifery in the UK and One Thought wellbeing programme introduction

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Share your experiences and views of the One Thought online programme

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Share your experiences and views of the One Thought online programme

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Please take time to join the research, where you can share your experiences as an International Midwife or Midwife supporting internaitonal midwives and how you experience the One Thought online programme.

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Thriving in practice

Safe, quality midwifery care in the UK context

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Care Quality Commission 2022 Maternity Survey

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Care Quality Commission 2022 Maternity Survey

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Care Quality Commission 2022 Maternity Survey | All4Maternity

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Care Quality Commission 2022 Maternity Survey Sam Todd - Birth Centre Manager and Professional Midwifery Advocate, Birmingham Women's and Children's NHS Foundation Trust Twitter @samueltodd16 Introduction The findings of the Care Quality Commission (CQC) 2022 Maternity Survey were published January 11, 2023.1 The purpose of the survey is to provide an insight into the experience [...]

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Safety, equity and engagement in maternity services

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Safety, equity and engagement in maternity services

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Contents
Impact of poor care Introduction Effective teamworking and culture Equity in maternity services Maternity Voices Partnerships and engagement
Foreword

In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent.

Last year, CQC's briefing Getting safer faster: key areas for improvement in maternity services highlighted our continued concerns about the variation in quality and safety of maternity services across the country. Despite the greater national focus on maternity in recent years and the welcome improvements it has led to, the pace of progress has been too slow and action to ensure all women have access to safe, effective, and truly personalised maternity care has not been sufficiently prioritised to mitigate risk and help prevent future tragedies from occurring.

We were pleased to see that recommendations in the first Ockenden Report (December 2020) supported our view that improvements in the key areas of training and true engagement and involvement with individuals and groups who use maternity services through Maternity Voices Partnerships are required.

Following the publication of 'Getting safer faster' we launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience.

Building on our previous calls for action, we also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups.

This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships. While based on only a small sample of inspections, and therefore not representative of a national picture, the report captures the key issues that we found persisting in some services, and that we are concerned may be occurring to some extent in other maternity units.

We know that there are many maternity services that are providing excellent care, but we remain concerned that there has not been enough learning from good and outstanding services - or enough support for that learning from the wider system. Issues such as the quality of staff training; poor working relationships between obstetric and midwifery teams, and hospital and community-based midwifery teams; a lack of robust risk assessment; and a failure to engage with, learn from and listen to the needs of local women all continue to affect the safety of some hospital maternity services.

Although rare, serious complications and maternity deaths have a lasting impact on families and their loved ones. The devastation caused in such circumstances cannot be underestimated. It is essential that we have a system that is open, and that recognises, investigates, and learns when things go wrong, so that families get the truth, and safety continually improves.

We must also be honest about the inequalities that exist for some people. Women from Black and minority ethnic groups have poorer experiences of care and face additional risks. While maternal deaths are rare maternal mortality rates are significantly higher than for women from Black and minority ethnic groups than for women from White groups. Addressing inequalities in access and tailoring maternity services to best meet the needs of the local population is a critical area for action and something that good services are prioritising. We welcome the recent NHS pledges to improve equity for mothers and babies and race equality for staff.

The importance of good leadership, effective governance, a strong safety culture and a proactive approach to addressing health inequalities is not unique to maternity - they are fundamental components required across all services and typify the challenges we want to help tackle as part of our new strategy.

Safe, high-quality maternity care is not an ambitious or unrealistic goal. It should be the minimum expectation for women and babies - and is what staff working in maternity services across the country want to deliver. This report identifies areas for action with the aim of helping to accelerate the current pace of change and to support maternity services, along with their trust boards and stakeholders, to focus on the steps they can take now to ensure that women and babies get consistently good, safe care.

Impact of poor care

Tinuke's story

From midway through my pregnancy there were signs of pre-eclampsia, including high blood pressure and protein in my urine. Pre-eclampsia is life threatening for both mother and baby, but it's easily treatable. If you can spot it in time, it's just an aspirin tablet that can vary your chances. However, I wasn't diagnosed until a last-minute midwife appointment at the end of my pregnancy. By that time, I was so swollen that I was advised to go straight to the hospital by my midwife, which of course was really worrying to hear as a first-time mum.

At the hospital, I was told that I would need to be induced. My labour progressed really quickly, but the midwife refused to believe that I was actually in labour. I was left alone for hours without any pain relief. I remember at one point I was vomiting; I was literally bent over and there was fluid coming out everywhere - it was awful. By the time my waters finally broke and I was checked over I was eight centimetres dilated, so the window for being given any pain relief was gone.

By the time I was told I could push, I was so exhausted that I had to have an assisted delivery. It's not how I wanted to bring my son into the world. The whole experience was extremely traumatic and could all have been avoided if I had been listened to.

Introduction

The risks to mothers and babies during pregnancy and in the postnatal period, and the opportunities to identify and manage them effectively, have been the subject of many inquiries and reviews. In 2015 the government set out an ambition to reduce the rates of stillbirths, neonatal deaths, maternal deaths and brain injuries in babies that occur during or soon after birth by 50% by 2030. This was then brought forward to 2025 in the Long Term Plan. To deliver on this ambition and the vision set out in Better Births, NHS England established the national Maternity Transformation Programme, of which CQC is an active member.

Our ratings data shows that the improvement in the safety of maternity services is too slow. In our report ' The state of care in NHS acute hospitals 2014 to 2016', published in April 2018, we raised our concerns that half of all maternity services were rated as requires improvement or inadequate for the key question 'are maternity services safe?'. Our Getting Safer Faster briefing in March 2020 showed that this had improved slightly to 39%. Latest figures from July 2021 show that 41% of services are rated as inadequate or requires improvement (figure 1). It is important to note that this should be considered in the context of the more risk-based approach to inspection we have taken during the pandemic, which has meant that our inspections have been focused on those services where we have the biggest concerns.
Figure 1: Number and percentage of NHS maternity services by their rating for 'safe' from first rating (paler bars) to current rating (bold bars) (31 July 2021)
Source: CQC

Issues we have highlighted in our previous publications continue to cause concern. These include staff not having the right skills or knowledge; poor working relationships; poor risk assessments; and not learning from when things go wrong.

To explore these issues in more depth, we visited nine maternity services where we had concerns between March 2021 and June 2021. As part of these inspections, we also looked at how these services worked with their local Maternity Voices Partnerships to engage with women, and looked at what they were doing to address inequalities for women and babies from Black and minority ethnic groups and women from deprived groups.

It is important to note that this report reflects only what we found on our visits to a small number of services. It is not a national picture of all maternity services. However, we are concerned that many of the issues raised in our report may be occurring in other maternity services.

Challenges in maternity care for women from Black and minority ethnic groups

Women from Black and minority ethnic groups experience additional risks compared to White women that, without the right interventions, can lead to poor outcomes. For example, we know that:

Black women are four times more likely to die in pregnancy and childbirth than White women. For Asian women it is two times more (read Saving Lives, Improving Mothers' Care 2020).

Mortality rates remain higher for Black or Black British babies and Asian or Asian British babies. While stillbirth rates for these groups have reduced over the period 2015 to 2017, neonatal mortality rates have increased over the same period (read Better Births Four Years On: A review of progress).

Further evidence of poorer maternity outcomes for Black and minority ethnic women can be seen in our analysis of Hospital Episode Statistics data on readmission rates per 1,000 deliveries from January 2018 to December 2020. This analysis shows a consistent trend of Black women having the highest rate of readmission to hospital during the six-week postpartum period, while White women consistently had the lowest rate. This includes any emergency or maternity related admission in that six-week period (figure 2).
Figure 2: Readmissions per 1,000 deliveries by ethnicity (January 2018 to December 2020)
Source: Hospital Episode Statistics

Our analysis, comparing readmission rates and their 95% confidence intervals, also suggests that Black women had a significantly higher rate of readmission in the postpartum period over the course of 2020 than all other women. There was a 30% difference between the readmission rate for Black women and rate for White women (93 readmissions per 1,000 deliveries for Black women compared to 68 readmissions per 1,000 deliveries for White women).

The additional risks faced by women from Black and minority ethnic groups have been exacerbated during the COVID-19 pandemic, highlighting the urgent need to improve equity in maternity. During the pandemic, the UK Obstetric Surveillance System (UKOSS) study found that more than half of pregnant women admitted to hospital with COVID-19 infection in pregnancy were from Black or other ethnic minority groups. Black women were also eight times more likely to be admitted to hospital with COVID-19 during pregnancy than White women, while Asian women were four times more likely.

In June 2020, the Chief Midwifery Officer, wrote to all NHS midwifery services highlighting the impact of COVID-19 and the additional risks faced by women and babies from Black and minority ethnic communities. The letter called on services to take four specific actions to minimise this additional risk.

As part of our inspections, we looked at how services were addressing these actions. We have also worked with Five X More and National Maternity Voices to better understand the issues faced by women from Black and minority ethnic groups, and help develop our approach to equity and engagement in our focused inspection programme.

It is important to note that when writing about ethnicity in this report we use the term women from Black and minority ethnic groups. This is the preferred term of CQC's Race Equality Network when we are not able to refer to specific groups. In terms of census ethnicity categories, we intend this term to include women from the following groups:

Black, African, Caribbean or Black British

Asian or Asian British

mixed or or multiple ethnic groups, or

other ethnic groups

What we did

During 2019-20, we developed and piloted a programme of focused inspections to look specifically at the safety of maternity services. Building on the learning from these pilot inspections, between March 2021 and June 2021 we visited nine maternity services where we had concerns about the safety of the service and, alongside our focused inspection, we explored specific questions around teamwork, culture, equity and engagement. At the time of our visits, the country was emerging from the third COVID-19 lockdown and the NHS was starting to recover from the winter peak in cases. Like all services, this created challenges for maternity care.

Our activity included looking at the actions that services are taking in response to the letter from the Chief Midwifery Officer to ensure they are providing equitable care for women from Black and minority ethnic groups during pregnancy, such as provision of continuity of carer and how they are addressing additional risks from COVID-19.

As part of the visits, we also reviewed a small sample of maternity notes at some of the sites visited to check whether information around vitamin D, ethnicity and a number of risk factors was being recorded. Following inspection, inspectors were interviewed about their observations.

It is important to note that these inspections were not intended to cover every aspect of the current, larger, maternity core service inspection framework. However, we will use the findings from these focused inspections to support the development of our new operating model, in line with the themes of our new strategy.

In addition to our inspections, we interviewed 11 Maternity Voices Partnership (MVP) chairs - eight from the areas where we carried out our visits, and three from different areas. MVPs are an NHS working group made up of women and their families, commissioners and providers who work together to review and contribute to the development of local maternity care. Many MVPs are still in early stages of being established. We asked about their experience of working with maternity services to engage with their local population. This includes ensuring the voices of women using services are being heard. Themes emerging from these interviews were then explored in further detail through two engagement sessions with Five X More and National Maternity Voices.

Effective teamworking and culture

Key points

In some services we found a lack of consistent and clear leadership, management, governance and assurance processes. This included a lack of oversight of services and problems in them.

The culture of services we inspected varied, with evidence of poor working relationships between obstetric and midwifery teams, and hospital and community-based midwifery teams in some services.

Poor teamworking, was also characterised by staff feeling unsupported or not feeling confident to seek support from senior colleagues or being afraid to challenge decision-making.

While we saw some evidence of multidisciplinary team training, there were concerns that not all staff were engaged with training. The quality of training and support for staff to maintain and develop their individual capabilities and core competencies also varied between the trusts we looked at.

As we reported in Getting Safer Faster, successful services have good team working and an effective, collaborative leadership team. National maternity reports, including the first Ockenden review, Each Baby Counts Final progress report 2020, and the Morecambe Bay Investigation Report, have focused on why good clinical leadership is fundamental to successful maternity services.

Good leadership is crucial as it creates a team culture of inclusivity and openness with effective communication, escalation and clear routes of accountability. This is necessary for good clinical care and also helps to also drive a culture of safety and improvement.

This section explores the impact of leadership, teamwork and culture in maternity services.

Leadership and culture

The article ' Understanding the dynamics of organisational culture change ', highlights that, in maternity services, the leadership team is strongest when the service level manager, midwifery and obstetric leaders are all in place and work well together to provide care that meets the needs of all women using the service.

The first Ockenden review set out initial findings from the independent review of the maternity services at the Shrewsbury and Telford hospital NHS Trust. This highlighted the importance of strengthening leadership and oversight for maternity, addressing toxic workplace cultures and fostering more collaborative approaches in maternity services.

In the services we inspected, we were concerned about the lack of consistent leadership and management teams, as well as weak links between parts of some maternity services. For example, in one service there was uncertainty about how a new standalone midwifery unit would integrate into the service as it wasn't clear how it would be staffed. At another service, staff were not clear about arrangements for transferring women between units in the same trust.

We found that in some of the services we visited either the service level manager, midwifery leader or obstetrics leader was not in post, or that one of these positions was held by an interim postholder (most often the midwifery lead). The article ' Understanding the dynamics of organisational culture change ' highlights that having a stable leadership team is known to improve organisations' focus on patient safety. Despite improvements in midwifery leadership skills, there needs to be a more collaborative approach to developing leadership skills for maternity service leads. This includes developing formal leadership development programmes for maternity teams.

In a number of the services we looked at there was a lack of a common purpose and a sense of a maternity 'team'. We heard that this could lead to a disconnect between midwives who worked in the community and those that worked in acute settings. For example, some community midwives told us that they felt their concerns about the complex needs of some of the women they looked after were not acted on. In some cases, these midwives had stopped reporting concerns as a result.

One provider had carried out work to review and strengthen the governance and assurance processes from maternity service level to board. Information about incidents was presented to staff in a weekly report. This information was then collated on a monthly basis for review by the service level leadership team, which included the Board Safety Champion. In turn, this formed the basis of the report to the trust quality committee. While this change was new, it was anticipated that staff would feel more empowered to report incidents because they would be able to see how the information would be used for learning and to make safety improvements.

Learning and improvement

In the article ' Seven features of safety in maternity units' it highlights that when staff feel able to speak up without fear of retaliation or embarrassment, it can lessen the development of harmful blame cultures and help to foster a culture of openness. In turn, this can help to improve the safety of the service. The article ' Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals ' shows that services that encourage incident reporting can facilitate system learning. This leads to better standards of care and improved responsiveness to problems.

The culture of services we looked at in our review varied. At one trust, where the maternity service was split across three sites, we found cultures were very different between the locations. One site reported that staff felt respected, supported and valued, but another site reported the opposite. Despite having a single governance structure, there were no formal arrangements for staff to spend time across the sites. This could result in missed opportunities for learning.

We heard many examples of poor incident reporting across the services we visited. We found that in most services staff didn't always recognise what constituted an incident or how to grade the incident correctly. We also heard about the pressures faced by staff with the practicalities of incident reporting. In one service, a midwife told us that they did not have time to report incidents due to the amount of activity in their work area.

More worryingly we found evidence at one service where some maternal deaths had not been reported via NRLS or investigated as serious incidents. At another service, some staff made allegations of cover-ups when things went wrong and that incidents were often not reported.

Despite these issues around incident reporting, most services we visited had processes in place to learn from incidents, though the extent to which these were successful varied. Examples of these processes included: identifying and categorising incidents, monitoring incidents using dashboards, ensuring appropriate communication and escalation of incidents.

Trusts with a learning culture tended to show more thorough learning from incidents, which translated into creating improvements. We saw evidence of this improvement during our inspections, with one service introducing formal cardiotocograph trace (CTG) training and support following incidents.

Services used a variety of methods to share learning. This included face-to-face events, such as open meetings, huddles and debriefs, as well as written newsletters, local intranet and posters.

In services that did not have a clear culture of learning, we found that action may not have been taken. For example, in one service, we heard that issues with language barriers and access to interpreters had been known about for many years, but the service had only just started to make changes following an external review.

In another service we witnessed a disconnect between the senior leadership team's perceptions of incident management to the reality of the actions being taken on the frontline. For example, while managers told us that a short briefing was circulated to staff during daily handovers, in reality this was not taking place effectively.

Some maternity services told us that they used external reviews, for example by the Healthcare Safety Investigation Branch, as a way of receiving feedback and learning from incidents. We heard how the investigation reports were used by some services to identify themes, create action plans, develop new training and issue guidance to staff. In one service, the HSIB report highlighted concerns about the interpretation of CTGs. Following this review, the service implemented a new training programme that included a test to ensure that staff were competent to interpret CTGs in clinical practice.

While it is positive that services are seeking external support, in some cases services in our review appeared to rely too heavily on this process, for example delaying responding to or learning from incidents internally until after external review.

To further the learning process, some services told us about the progress they had made with quality improvement (QI). This is a structured approach, using set methods and tools, that seeks to continuously improve quality of care and outcomes for patients. One service told us that they had employed a dedicated QI midwife to lead and progress several projects and ensure that QI training was mandatory for all new midwives. Another service had created a maternity improvement group.

Support and teamwork

The culture of a service can have an impact on staff support and teamwork, with staff feeling less supported in hospitals that have a blame culture and/or cultural issues around staff bullying. For example, in one service we visited we saw evidence of a poor culture when a nurse mistook an inspector, who was dressed in scrubs, for a member of staff and shouted at them to answer the phone.

In the same service, multiple people reported being hesitant about challenging poor practice or decision-making due to fears around losing their jobs. In addition, different staff groups were accusing one another of bullying and this had led to a very hostile working environment with divisions between teams.

The NHS Improvement report on Shrewsbury and Telford's handling of a review of its maternity services identified that poor cultures can foster poor relationships between staff members and result in a fear to challenge. The Each Baby Counts final report also highlighted that siloed working as a result of these environments can have a hugely detrimental impact on a woman's care, particularly if there are concerns that need to be escalated to more senior members of both midwifery and medical teams.

While staff in some services felt comfortable seeking advice and support from senior colleagues, this was not the case for staff in other services. For example, staff in one service told us that they did not feel confident in knowing when to call a consultant in from home." Some community midwives also told us that they did not feel able to raise concerns about the complexity of some women who had been booked for home delivery. Not being clear on when to involve consultants or lacking the confidence to liaise with colleagues to escalate concerns and seek support when required puts the safety of women and their babies at risk.

We welcome new guidance from the Royal College of Gynaecologists (RCOG) that outlines recommended standards to define when consultants need to be involved in discussions about patient care. This includes a trigger list of situations where consultants are expected to attend to make it easier for midwives to escalate concerns.

How well supported staff we met during our review felt was also influenced by staffing levels. Having fewer staff due to sickness, vacancies or strain from COVID-19 meant that people were less able to support one another.

This is supported by a 2019 article in the British Medical Journal, which raised the issue of problems with stress and burnout within maternity services, and the impact on the maternity workforce. It is also supported by The UK WHELM study, which highlighted that low levels of management support, professional recognition and opportunities for development contributed to burnout, depression, anxiety and stress.

Through our visits, we found that one service had tried to improve this situation by agreeing with their finance department that they could pre-empt a vacancy and hire new staff. As a result, this service did not have any vacancies. This stability had fostered good relationships in the department, and staff felt supported.

Despite his example of positive action, staffing has remained a challenge for others. For example, we heard that where services had interim and new leadership positions, staff felt less supported.

How services responded to incidents also affected how supported staff felt. For example, in one service senior staff had taken responsibility for incidents, while in another they had documented clear action points. As a result, staff felt better supported. We also heard of support being provided through 'hot debriefs' immediately after an incident and/or a meeting at a later date.

We also heard good examples of occupational health and specialist counselling being offered to staff following incidents. In one service, we heard about restorative sessions led by a representative from the professional midwife advocate. Feedback following incidents was reported to improve support throughout the incident process, and in some services had led to changes in training or the delivery of a service.

However, one service we visited reported that they found it challenging getting all staff together after an incident. While initial support was good, improvements were needed for longer term support.

The visibility of the senior leadership team was another theme that emerged from our review of maternity services. We found several services where the senior leadership team lacked visibility and staff relied on one another for support.

However, there were positive examples of engagement through staff surveys, listening events and walkarounds which contributed to staff feeling supported and safe. Across a number of services, we heard of measures including 'wobble rooms', a timeout pod and a wellbeing lounge.

Team training

The first Ockenden review of maternity services at Shrewsbury and Telford Hospital highlighted that 'staff who work together must train together'. This has been supported by other clinical articles, published in the BJOG: an international journal of obstetrics and gynaecology and the British Medical Journal, that show evidence that multidisciplinary training in maternity can improve patient outcomes for both mothers and their babies.

In most of the services, we found evidence of regular multi-professional training but the impact of this training was not always consistent or evaluated.

In one service we visited, training involved both the medical and midwifery teams, and was centred around the themes emerging from incidents. This included the management of massive obstetric haemorrhage and shoulder dystocia. As a result of this training, the ROTEM machine (a machine used to analyse blood during massive obstetric haemorrhages) was used less as haemorrhages were better managed, and there were fewer admissions to the neonatal unit due to fractures from managing shoulder dystocia. The same service had also implemented 'trolley dashes'. This involved educational staff visiting staff in different areas with a trolley full of equipment and doing quick learning sessions on topics such as postpartum haemorrhage and cord prolapse.

In another service we heard about a practice development manager who introduced unannounced 'skills and drills' sessions. These are short training sessions that are based on real themes from incidents used to improve practical skills and train for specific scenarios. For example, one of these sessions was based on the real-life incident of a woman giving birth to twins in the toilet. Other services reported using simulation suites and formal training programmes, such as trauma and risk management training.

While we saw some good examples of multidisciplinary learning, at other services some staff members, including consultants and anaesthetists, were not always attending multidisciplinary training. In addition, we found that skills and drills training was lacking in a few of the hospitals. As a result, we were concerned that staff did not have the required skills and knowledge to perform certain tasks. For example in two of the services we visited, we found that staff were not trained for the event of an emergency evacuation from the birthing pool. This could have potentially severe consequences on the management of emergencies.

The COVID-19 pandemic had a significant impact on the provision of training. To address this, the services we visited had mostly switched to delivering training virtually, with a hope to return to face-to-face training as the pandemic eased. One service reported that some of their training had been paused during the pandemic as staff were required to provide patient care and could not be released to attend training.

As well as providing multidisciplinary training, services must make sure that staff are supported to develop and maintain individual core competencies, and to work effectively as a team at all times. We are concerned that this is not happening. For example, at one service we heard that a lack of familiarity or ease with using instrumental delivery methods was a possible cause for Caesarean sections being performed at full cervical dilatation. Leaders of maternity services must tailor the training requirements for individuals to ensure that they are 'fit for purpose'.

Equity in maternity services

Key points

The majority of services we visited had carried out some work to implement the four actions from the Chief Midwifery Officer to support maternity equity for women from Black and minority ethnic communities. However, we were concerned that in many cases the actions had been interpreted quite narrowly.

While maternity services should discuss the importance of vitamin D during pregnancy, recording of discussions about vitamin D was often inconsistent or absent in the services we visited. This creates the risk that vitamin D is not being discussed and/or offered to women who need it.

The pandemic has meant that nearly half the services we visited had paused their continuity of carer teams. However, it was positive that where teams were in place, we saw a focus on women with higher risks.

Engagement by both services and Maternity Voices Partnerships was often generic rather than tailored to better target different groups within their local population, such as women from Black and minority ethnic groups.

As part of our inspections, we looked at the arrangements services have put in place to address the four actions of the Chief Midwifery Officer to support Black and minority ethnic women and women living in deprived areas during the pandemic.

While we found evidence of services addressing some of these actions, we were concerned that in many cases the actions had been interpreted quite narrowly rather than considering what further actions were needed to make services truly equitable and safer for all women, as well as ensuring that all women felt informed and supported. We heard limited evidence about additional work that services were doing to support equitable access outside of the four actions.

Two positive exceptions were where services had created specific roles to promote equity. One service had created a midwifery role to work on the policies and pathways to deliver care to women from Black and minority ethnic groups, and another had introduced an equality and inclusion role to assess the training needs of staff. However, in both cases, it was too early to tell whether these roles were having a positive effect on equity.

This section explores in more detail what we found in relation to the four actions, continuity of care and engagement with women from these communities.

Action 1: Increasing support of at-risk pregnant women

At four trusts where we looked at this directly, we were told that in line with the first action from the Chief Midwifery Officer they had reduced the threshold for women from Black and minority ethnic groups to come in for assessment at the day assessment unit or labour ward for medical review.

In some services, we heard that staff were aware of the higher risks faced by women from Black and minority ethnic groups. Steps taken to increase awareness included adding relevant risks on to triage forms, holding monthly multidisciplinary meetings to discuss women at high risk, and reminding midwives and clinicians of the increased risks for these women.

Action 2: Reaching out and reassuring pregnant women from Black and minority ethnic groups with tailored communications

We looked directly at this issue in seven of the maternity services we visited. How well maternity services had used tailored communications to reach pregnant women from Black and minority ethnic groups varied.

In a few trusts we heard that they had worked collaboratively with their Maternity Voices Partnerships (MVPs) to co-produce videos to share messages around accessing care and the additional risks for certain groups. One MVP chair described how they worked with a mother with a young baby, who is a GP and a Black woman, to create a video talking about the risks and misconceptions for Black women during pregnancy, birth and postpartum and the importance of taking Vitamin D during pregnancy. This video was then shared via social media.

Another service had worked in partnership with the local MVP to share information around risks for women from Black and minority ethnic groups using a mobile application.

We heard of services using other methods of contact to reach out to women of Black and minority ethnic groups. For example, one service had used the information they held on women's ethnicity to write to all women from Black and minority ethnic groups to advise them on good health and risk reduction during pregnancy throughout the pandemic.

However, heard of services using other methods of contact to reach out to women of Black and minority ethnic groups. For example, one service had used the information they held on women's ethnicity to write to all women from Black and minority ethnic groups to advise them on good health and risk reduction during pregnancy throughout the pandemic.

At another service we heard an allegation that there was discriminatory behaviour from staff towards women who did not speak English. We were given an example of a midwife shouting at a woman because she could not understand English. Senior leadership were aware of concerns around how staff treated the women who used the service and said they had begun to challenge these behaviours. An external review had previously identified risks with women who have difficulty reading or speaking English being unable to access interpreters. In response, the service had installed phones in rooms to improve access to interpreters.

While it is positive that some services were taking steps to try to reach out to and involve women from Black and minority ethnic groups, there were some concerns about how this was being done. For example, reliance on digital technology, such as sharing information via Facebook, risked excluding women who did not have access to or were not comfortable using the internet.

Through our engagement with Five X More and National Maternity Voices we also heard concerns that sharing information about risks, without empowering women to understand what these risks mean and any steps they can take to minimise them, could be scary for women and lead them to disengage or limit contact with maternity services.

Action 3: Ensuring hospitals discuss vitamins, supplements, and nutrition in pregnancy with all women

It is well known that due to low sunshine levels, people living in the Northern Hemisphere may not get enough vitamin D, and women from Black and minority ethnic groups who have melanin pigmented (darker) skin, or who cover their skin when outside, may be particularly at risk. As a result, the Royal College of Obstetricians and Gynaecologists advises that all pregnant women consider taking 10 micrograms of vitamin D a day to keep their bones and muscles healthy. The National Institute for Health and Care Excellence (NICE) guideline ' Vitamin D: supplement use in specific population groups ' also recommends that health professionals discuss and record this with all pregnant women.

At some of the services we visited, we found that discussions about vitamin D were not being consistently documented. This creates the risk that vitamin D is not being discussed and/or offered to women who need it.

Only three out of the 10 sites we inspected were recording vitamin D in all the notes reviewed, and at five of the sites vitamin D was not documented in any of the notes reviewed.

Action 4: Recording of ethnicity and other risk factors for all women

Ethnicity was recorded in the majority of women's maternity case notes at most of sites we visited. However, recording of other risk factors was more variable. For example, across the nine sites where we reviewed a small sample of maternity notes, only three consistently recorded age. A similar picture was seen when recording body mass index (BMI) and postcode. We were unable to confirm whether this was because services were only recording this information where there were concerns relating to age, BMI or social deprivation.

While it is positive to see that the majority of services we visited were recording information about women's ethnicity, it was not always clear whether services were using this information, for example to review outcomes for women from Black and minority ethnic groups, using this information effectively, to learn from incidents or to personalise care. As a result, inequality may not be recognised as a safety issue. Important differences in experiences and outcomes for Black women compared to women from Asian or mixed heritage groups - or White women - can be missed.

Similarly, where services were not consistently recording risk factors such as a person's BMI, this meant they would not be able to use this information to review and make changes to the care and support offered.

Through our work with Five X More we also heard concerns about using the equality data collected to stimulate change. We heard that while the increased risk of poor outcomes for Black and minority ethnic women is well established nationally, there is currently no national target to reduce these inequalities.

Our work with Five X More has confirmed to us the importance of collecting and reviewing data to stimulate change, and ensure that opportunities for learning are not missed. This includes measuring the impact of such changes.

Continuity of carer

The 2016 Cochrane Review highlighted that women who receive midwife-led continuity of carer are less likely to experience pre-term births or lose their baby in pregnancy, or in the first month following birth.

The continuity of carer scheme was set up to provide consistent, coordinated care throughout women's pregnancies. The NHS Long Term plan set out a target that by March 2021, most women would receive continuity of the person caring for them during pregnancy, during birth and postnatally. It also set out the target that for women from Black and minority ethnic groups, and women from deprived groups, 75% should receive continuity of care by 2024, as it has been linked to significant improvements in clinical outcomes for these women.

At the time of our inspections, just over half of the services we inspected had active continuity of carer teams providing support to small numbers of women in their community they had identified as being at higher risk. Where services did not have these teams in place, we heard that they had either been put on hold or disbanded, primarily due to staffing issues in the pandemic.

None of the continuity of carer teams had an explicit focus on supporting women from Black and minority ethnic groups. However, one service had plans to identify Indian women who would be looked after by the continuity of carer teams. Another team had focused their resource on a geographical area with a relatively high proportion of women from Black and minority ethnic groups. Other continuity of carer teams were focused on deprived areas, women with diabetes, women with previous maternity loss and other vulnerable groups.

Safeguarding

An MBRRACE rapid review, published in May 2020, highlighted the safeguarding risks to women from domestic violence, mental health and systemic biases. These interrelated risks can prevent women with complex and multiple problems receiving the care they need, and impact on the care of Black and minority ethnic women. While these risks are not new, evidence from statutory and voluntary agencies suggests that the risks increased during lockdown. For example,  Refuge  reported a 60% increase in calls and online requests following the start of the first lockdown in March 2020.

We looked at what action services were taking in relation to safeguarding in eight of the maternity services we visited. We heard about a range of specialist clinics and specialist midwife roles in place to support women around safeguarding. This included bereavement clinics, female genital mutilation (FGM) clinics (previously traumatic experience clinics), as well as midwives specialising in teenage pregnancy, perinatal mental health, vulnerable women and FGM.

We heard that during the pandemic, two services had noted an increase in domestic violence cases. Another service was putting together a business case for a midwife role specialising in domestic violence. However, at one service we found that they were not recording whether domestic violence was assessed during all appointments, which was a risk. This service had picked up on the need to educate staff around domestic violence and were running pop-up sessions to educate staff around the risks and indications for safeguarding.

Targeted engagement

We found limited evidence that the maternity services we visited were targeting engagement towards women from Black and minority ethnic groups and women living in deprived areas. Only three out of seven trusts described specific pieces of engagement work they had carried out to hear the voices of women from Black and minority ethnic groups.

In some areas where the population was mainly White, inspectors felt that services viewed engaging with women from minority groups as a low priority. Some services told us they had found it challenging to engage with their local population but had no clear strategies on how they would tackle this. In other services, most of the work that was being done was not targeted towards specific communities and, as a result, was not representative of women with higher risks of poor outcomes, such as women from Black and minority ethnic groups.

A number of services acknowledged that work to engage women from Black and minority ethnic groups was lacking, or staff were unable to articulate whether anything was being done.

However, positive examples of targeted engagement we heard of included:

One service participating in a Local Maternity System survey around cultural safety in working with women from Black and minority ethnic groups.

One service's MVP working with the Local Maternity System to recruit diversity champions to build links with local communities.

Another service, supported by their MVP, holding weekly focus groups to better understand the issues faced by women from Black, Asian and minority ethnic groups.

A number of MVP chairs we spoke with raised concerns over how their trusts communicated with women during the course of the pandemic. In particular, two chairs felt that the MVP social media pages had become the sole method of communicating updates to women using the maternity services (which lacked their own social media pages). One chair acknowledged how risky this was because not everyone was aware of, or used, the MVP's Facebook page. Another MVP felt that the language their maternity service had used to communicate information around accessing maternity services during the pandemic was not reassuring to women.

Maternity Voices Partnerships and engagement

Key points

We heard that working relationships between MVP chairs and maternity services varied. While some MVP chairs felt they had a strong working relationship, others felt unsupported by their service.

MVP chairs told us that they were concerned MVPs were not fully representative of their local area, and that engagement with Black and minority ethnic women could be improved.

MVP chairs told us that funding was a major challenge to effective engagement and enabling women from Black and minority ethnic groups or from deprived areas to get involved.

We heard that reliance on digital technology during the pandemic made it harder for women without the access to, or skills to use, digital technology to keep informed and have their voices heard.

Joint working between trusts and Maternity Voices Partnerships

As part of our review, in seven services we looked directly at how well they were working with their local Maternity Voices Partnerships (MVP).

Several services we visited felt they had a good relationship with their MVP. Services also told us they had a range of interactions with MVPs and that the consultant midwife was often the key point of contact for the MVP. Two services described different meetings or workstreams that the MVP was involved in at the service, including the labour ward forum, weekly sitrep meetings and the maternity improvement group. Three services told us that they attended MVP meetings.

Most services were able to describe examples of where they had worked together with the MVP to engage their local community. This included working with the MVP to review communications and online content, sharing messages within the community, and supporting Q&A sessions on Facebook to collect feedback.

This was supported by our interviews with chairs of MVPs who told us that, at a minimum, they had worked with their local service to review outward-facing documents produced by the service to ensure they were accessible to women (for example, personal care plans, information around labour and COVID-19 information packs).

While these examples are positive, through our engagement with MVPs, Five X More and National Maternity Voices, we heard concerns that reliance on digital technology to engage women and provide them with the information they needed could exclude women who do not have the access to, or skills to use, digital technology.

In some cases, MVP chairs we spoke with felt they had a strong working relationship with the service. In these cases, we heard examples of greater co-working and collaboration, and that the MVP was embedded more deeply within the workings of the trust. One particular MVP chair described how they were invited to be part of a panel for an internal review looking at how the trust was meeting safety recommendations.

"I have been really involved in everything and co-producing as well, not just reviewing things as a tick-box exercise. We're involved from the start with any big changes and our opinions are taken forward...[I'm] treated as an equal." MVP chair

However, this was not the experience of all MVP chairs we spoke with, some of whom viewed their relationship with the maternity service more negatively. In these cases, the MVP chairs told us that they felt unsupported by the trust and that it was down to the MVP to lead the relationship.

We heard that negative relationships were also characterised by poor communication between the trust and the MVP. This included a lack of transparency around the governance processes and MVPs not kept updated and informed about relevant work, as well as a lack of response and follow up to feedback.

Embedding the role of the MVP into trust activities

Where the MVPs we spoke with felt that working with maternity services was not consistently collaborative, we heard that the role of the MVP was not well understood by the trust and was not strategically embedded within the trust's processes.

"[It] feels shambolic, I think sometimes [the trust] are just not sure where [the MVP] could and should be because they are constantly responding to things rather than strategically thinking 'it would be helpful to have the MVP here, here and here - let's get those in the diary and start a conversation about complaints and safety." MVP chair

This had led to issues such as the MVP not being involved early enough in the process to give meaningful feedback and the trust being defensive to suggestions from the MVP. For example, we heard how one MVP was sometimes only given sight of documents after they had already been shared with the public in what felt like a tick-box exercise rather than meaningful co-production.

Raising concerns over safety

The MVP chairs we spoke with generally had clear and direct channels of contact via phone or email with the head of midwifery or other specified roles at the maternity service. They also felt confident that they would be able to raise safety concerns.

However, some MVP chairs told us that they felt unsure as to how they would raise a safety concern with the service and were unaware of any official documented procedures around this. Some chairs told us that they had experienced a lack of transparency around the governance processes and lack of follow-up in response to safety concerns.

"When concerns arise, one thing that puts us in quite a compromised position is we hear some things that are really quite worrying and then we pass those worrying things up and if something doesn't happen as a result of them... [it] devalues our status as MVP and that's problematic because it can erode that trust that we work hard to build." MVP chair

MVPs and engagement

MVP chairs we spoke with told us that they used a variety of methods to gather feedback from women who use maternity services. These including online listening events where people who use services could openly share their experiences, as well as focused surveys on topics such as reduced foetal movements.

Engagement with women from Black and minority ethnic groups or other minority groups was mostly through local groups that represented these communities. The MVP chairs we spoke with were at different stages of their journey in setting up these networks.

Most MVP chairs we spoke with felt that MVPs needed to improve how they engaged with women from minority groups, and ensure that they were better represented. There was little evidence that the maternity services proactively supported the MVPs we spoke with to engage specifically with women from Black or minority ethnic groups or other women who might be more likely to have poorer experience or outcomes from care.

"I don't think the trust are actively saying 'how are you reaching [ethnic minorities]?' because they've got so much other stuff they are chasing their tails with." MVP chair

One MVP chair told us that it is typically only mothers with fewer demands on their time and more financial freedom that were able to contribute their views to the MVP. They felt that greater incentives need to be available to support mothers who are having to juggle work, children and other responsibilities to share their feedback with the MVP.

This was corroborated through our engagement with Five X More and National Maternity Voices who also highlighted the disparity in funding between different MVPs. People we spoke with highlighted how pay for the MVP chair role varies across regions, and that chairs are increasingly expected to go above and beyond their paid role. They felt that this was neither reasonable nor sustainable without an increase in contracted hours. We also heard how these issues could be a barrier to women from some communities or groups getting involved, perpetuating issues with a lack of diversity.

Some chairs we spoke with felt that the lack of diversity among MVP members limited how well they could engage with other groups of women. Connecting with women who do not speak English as a first language was noted as a particular challenge, especially as most avenues of engagement (Facebook pages, WhatsApp groups, listening events, etc) are conducted in English.

A couple of MVPs had tried reaching out to women via religious organisations, such as mosques and synagogues, but did not find this approach productive. We heard that general appeals on social media to increase the representation of Black and minority ethnic groups within the MVP were also met with limited success. This contrasts with the national Black Maternity Survey led by Five X More, which had a good response.

A major barrier to engagement was the inability to meet face-to-face during the pandemic. Before this, events such as 'walking the patch' to talk to mothers on the ward and visiting children's centres and baby groups presented opportunities to connect with women who may not have otherwise contacted the MVP.

We also heard that some women found online sessions intimidating as these could be attended by up to 30 professionals. The need to limit engagement to online platforms during the pandemic has widened inequalities for women who do not have the resources, know-how or confidence in using digital technology. In other words, digital exclusion has made it harder to hear the voices of women who are already at risk of not being heard.

That being said, the MVP chairs we spoke with did recognise that the use of digital technology had created some new opportunities for better engagement. One MVP noted that attendance of their meetings had increased, possibly because where women are less mobile with a newborn baby or lack transport they may find it easier to attend MVP meetings virtually. Online meetings have also facilitated the attendance of professionals from the maternity service as well as community group representatives and other professional stakeholders.

Next steps

For maternity services and local maternity systems

The key concerns identified in our report are not new. It is important that all maternity services, supported by wider system partners, embed changes quickly and effectively to address them. Achieving this will require a focus in the following areas:

Leadership: In line with essential action 2 of the first Ockenden review, Boards must take effective ownership of the safety of maternity services. This includes ensuring that they have high quality, multidisciplinary leadership and positive learning cultures. They must seek assurance that staff feel free to raise concerns, that their concerns and adverse events lead to learning and improvement and that individual maternity staff competencies are assured.

Voices and choices: In line with the Cumberlege review 'First do no harm', maternity services must ensure that all women and their families have information and support that allows them to make choices about their care. This includes listening to individual women and fully explaining choices, in an accessible way throughout the pregnancy journey. This includes, for example, working effectively with interpreters.

Engagement: As supported by the findings of 'Better Births' and 'First do no harm', local maternity systems need to improve how they engage with, learn from and listen to the needs of women, particularly women from Black and minority ethnic groups. They also need to make sure that targeted engagement work is appropriately resourced.

Data and risk: Services and systems should use ethnicity data they collect to review safety outcomes for women from Black and minority ethnic groups, and take action in response to risk factors. This includes working with Black and minority ethnic women to personalise care and reduce inequality of outcomes.

For CQC

In line with our strategic theme, safety through learning, we will continue to promote and check on open and honest cultures within maternity services. We will continue to:

focus on the quality of maternity leadership teams, ensuring they understand the day-to-day running of the service, are listening to staff and ensuring they feel free to speak up, and that they foster a culture that drives continuous improvements in safety.

look at how leadership teams ensure multidisciplinary staff who work together are training and learning together without barriers, and that staff are supported to develop and maintain individual core competencies and to work effectively as a team at all times.

assess the transparency of services, ensuring that they embrace learning and reporting cultures and that there is accountability and trust.

Tackling health inequalities is a core ambition of our new strategy. As part of this we will:

continue to ask maternity services about work on maternity equity and engagement during inspection and monitoring activity

continue to learn from women who use services and who face inequality

apply what we have learned to other core services and areas of our work

consider equity and engagement as issues that impact on safety

expect services to use people's experiences and equality data to review and act on outcomes and respond to the needs of their local population

continue to improve how we work with equality data to assess safety and quality of people's care and work with others to do this.

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Safety, equity and engagement in maternity services

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Impact of poor care Introduction Effective teamworking and culture Equity in maternity services Maternity Voices Partnerships and engagement In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman.

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Life as a midwife in the UK

Professional development planning

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Enabling effective communication

For personalised, respectful care

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Midwifery in the UK: Sustaining yourself across practice, education, research and leadership

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UNICEF guide to meaningful communication

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UNICEF guide to meaningful communication

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Viewpoint: Midwifery Leadership Development | All4Maternity

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Learning and support

Learning and support resources are available on the NIHR Learn platform and NHS Future Learn.

All research staff are also required to undertake training to ensure they meet the standards set out in the Good Clinical Practice guidelines for clinical trials, which in England can be accessed viaNIHRLearn.

Find out more about NIHRlearning and support opportunities.

Nursing and Midwifery at the NIHR

We aim to provide guidance, support and development opportunities for all nurses and midwives who wish to support, deliver and lead research. There are a number of projects underway to address these aims:

The Principal Investigator Pipeline Programme (PIPP), launching in Autumn 2023, aims to grow the number of nurse and midwife Principal Investigators (PIs) by developing the skills and knowledge required for the role.

The RISE (Research In Community Settings) project aims develop research-related roles for nurses and midwives in community, public health, primary care and social care settings by identifying and learning from successful community initiatives.

The NIHR, in collaboration with NHS organisations and Higher Education Institutions across England, has developed an interactive resource aimed at pre-registration nursing and midwifery students. The resource provides an overview of what being a clinical research delivery nurse or midwife entails. The resource will soon be available via the NHS Future Learn platform and has already been embedded into the student pre-registration curriculum in some parts of the country.

We are currently developing a hybrid research placement model for pre-registration nursing students to gain first-hand knowledge and experience of clinical research whilst embedded in their placement areas. The model is based on a successful pilot at Leeds and York Partnership NHS and is due to be piloted in four NHS mental health trusts later in 2023-24.

The Career Pathway Project acknowledges that opportunities for nurses and midwives to develop research careers are variable and is developing pathways that promote movement between roles. We are engaging with nurses and midwives from a breadth of specialities to gain an understanding of barriers and enablers involved in moving between different research roles.

If you would like more information on the work we are doing to improve career opportunities for nurses and midwives in research, please contact the team nursingandmidwifery@nihr.ac.uk

70@70 Senior Nurse and Midwife Research Leader Programme Alumni

The three year 70@70 Research Leader programme, named as such to celebrate 70 years of the NHS, concluded in March 2022. The programme was aimed at senior nurses and midwives to promote the importance of a vibrant integrated research culture.

The 70@70 programme implemented over 300 different research initiatives and reached at least 3000 nurses and midwives. Our leaders championed innovation and informed research priorities in their organisations. It increased the support, delivery and leadership of research by nurses and midwives across different parts of the health and care delivery system.

Examples of local and national achievements from the 70@70SNMRL alumni include:

Reproductive Health and Childbirth Champions

Reproductive Health and Childbirth Champions are research midwives and nurses, one or more in each Local Clinical Research Network, who use their experience to deliver research that benefits patients, fosters collaborative learning and provides learning and professional development opportunities. They are an integral part of the NIHRReproductive Health and Childbirth Specialty Group.

Stakeholders and Partnerships

NIHRNursing and Midwifery work closely with NHS England's Chief Nursing Office to ensure that our values and vision relating to research for nursing and midwifery are aligned. The recently publishedCNO'sStrategic Plan for Research ' Making Research Matter ' was informed by a national advisory panel, with stakeholders includingNIHRNursing and Midwifery.

Other key partnerships include the International Association of Clinical Research Nurses(IACRN) and the UK Clinical Research Facility Network(UKCRF).

Meet the team

NIHRDirector of Nursing and Midwifery

Professor RuthEndacott was appointed inaugural Director of Nursing and Midwifery at theNIHRin May 2021. Prior to her appointment, Ruth was Professor of Clinical Nursing at the University of Plymouth andMonashUniversity, Melbourne and Deputy Chair of theNIHRClinical Doctorate Research Fellowship panel. She has held leadership positions as Head of School, Head of Department and Associate Dean (Research) in the UK and Australia.

Associate Directors of Nursing

Jennifer Allison is an Associate Director of Nursing and Midwifery at theNIHRand Lead Matron of theNIHRSouthampton Clinical Research Facility. She leads a large team caring for paediatric and adult patients, and healthy participants, in early phase and complex experimental medicine studies. On the Senior Management Team of theUKCRFNetwork, she is Workforce/Education Theme Lead, building and maximising relationships across theNIHRand UK and Ireland research infrastructure. This compliments herNIHRrole where she focuses on developing the workforce and opportunities for nurses and midwives to undertake rewarding careers in research. She is the immediate Past- President of the International Association of Clinical Research Nurses and remains on their Board.

Professor CatherineHenshall is an Associate Director of Nursing and Midwifery at theNIHRand is Programme Director for the 70@70 Senior Nurse and Midwife Research Leader Programme. She is responsible for leading national strategies aimed at supporting nurses and midwives to contribute to, undertake and deliver research across England. She is a Reader in the Faculty of Health and Life Sciences at OxfordBrookesUniversity, the Head of Research Delivery at Oxford Health NHS Trust and Co-Director of theNIHROxford Health Clinical Research Facility.

Clinical Fellows

SharonDorganhas 14 years' experience in the Clinical Research Network. She is passionate about providing opportunities for nurses, midwives and allied health professionals to continually grow their research knowledge and skills. Sharon will be working on an accelerated associate principal investigator scheme for nurses and midwives.

LouiseWolstenholmeis anNIHR70@70 Senior Nurse & Midwife cohort member, experienced health visitor and practice educator. She has an interest in building research capacity in community-based nursing. Louise will be working on research roles in Community, Public Health and Social Care.

Cindy Whitbread is an experienced nurse with a breadth of knowledge and experience ranging from First in Human to Phase 4 clinical research studies. She has worked in a broad spectrum of specialties in Clinical Research Facilities as well as acute care and social care settings. She has a passion for quality improvement and a commitment to promoting equality and diversity within all areas of health and social care. She is a member of the 70@70 NIHR Senior Nurse and Midwife Leader Programme Alumni and a Clinical Fellow (NIHR Nursing & Midwifery), leading on workforce evolution through the development of the national Research Nurse and Midwife Careers Project.

Contact us

NIHRAwards, events and campaigns

NIHRNursing and Midwifery Office are delighted to sponsor three awards categories for nurses and midwives involved in research in 2023.

With the addition of a new research category at the Royal College of Nursing Awards, we are now able to offer awards opportunities for all nurses and midwives who support, deliver and lead research.

Entries for theRCNAward are open. This is a fantastic opportunity for nurses and midwives that have led a piece of research that has had an impact on patient care outcomes and / or service delivery.

Entries for research nurses and midwives for the Nursing Times Awards are also open.

International Day of the Midwife and International Nurses Day

Each May we celebrate the vital role that nurses and midwives play in leading, delivering and supporting research during International Day of the Midwife and International Nurses Day.

Catch up with 2022's week-long celebration where we shared their incredible stories and demonstrated the opportunities a career in research can bring.

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Nurses and midwives make an unparalleled contribution to clinical research. Find out more about a career in research.

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Communication During a Homebirth Transfer to Hospital

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Communication During a Homebirth Transfer to Hospital

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Celebrating IR Midwives eBook - editable - v2

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Welcome to the latest webinar series: Being a Midwife in the UK for Internationally Educated Midwives.

Here you will find the recordings from all the 4 webinar sessions, online links to articles, reports and other useful content to support your midwifery journey.

Please remember to leave us some feedback on the webinar series and we look forward to you joining our All4Maternity family!

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Summary

With this plan we aim to make care safer, more personalised, and more equitable, by:

Listening to women and families with compassion which promotes safer care.

Supporting our workforce to develop their skills and capacity to provide high-quality care.

Developing and sustaining a culture of safety to benefit everyone.

Meeting and improving standards and structures that underpin our national ambition.

Introduction

1. This plan sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. We are grateful to the many people and organisations that have shared what needs to be done including NHS staff, Donna Ockenden, Dr Bill Kirkup, and organisations representing families. Most importantly, we would like to thank those using maternity and neonatal services for informing this plan. While the birth of a baby represents the happiest moment of many people's lives, some families have experienced unacceptable care, trauma, and loss, and with incredible bravery have rightly challenged the NHS to improve.

2. The summary above sets out the benefits we expect to deliver for families through this plan. This will continue to require the dedication of everyone working in NHS maternity and neonatal services in England, who work tirelessly to support families and improve care. Most women have a positive experience of NHS maternity and neonatal services, and outcomes have improved with over 900 more families welcoming a healthy baby each year compared to 2010.

3. But we must acknowledge that there are times when the care we provide is not as good as we want it to be. Recent independent reports by Donna Ockenden on maternity services in Shrewsbury and Telford and by Dr Bill Kirkup on maternity and neonatal services in East Kent, and previously Morecambe Bay, set out many examples of poor care over years. We know that families from some groups, especially ethnic minorities, have had particularly poor experiences. We must work together to change this, and this plan sets out how we will do this.

4. In preparing this plan we have listened to what you have to say. We know all staff want women and babies to be at the centre of care, and with so many improvement initiatives it can be difficult to know what to prioritise. We know gaps in staffing mean those who provide care do not always have time to learn and improve, and on occasion, struggle to provide care to the highest standards. We have heard that some people feel disempowered by negative team cultures and a lack of strong leadership.

5. For the next three years, we are asking services to concentrate on four high level themes. Please take some time to consider these themes, what they mean to you and to the women and babies you care for. Working together, we can make a real difference.

Responsibilities

6. This plan sets out what we need to have in place, and responsibilities for each part of the NHS:

7. It is everyone's responsibility to provide or support high quality care. That includes a responsibility at each level of the NHS to understand the quality of care and identify, address, and escalate concerns. We have sought to improve our approach to quality surveillance at trust, ICS, regional, and national level. This involves bringing together all relevant partners at each level to facilitate robust understanding and action, informed by shared and accurate information. Some trusts need additional support to improve - this is provided through the Maternity Safety Support Programme (MSSP), which aligns with the overall NHS Oversight Framework and tiered support, so that support for maternity and neonatal care forms part of a wider response where needed.

What you told us

8. We could not develop this delivery plan without talking to people who use, work in, lead, or have an interest in these services. We want to thank everyone who shared their views to inform this plan. We held 50 meetings reaching over 1,000 attendees, including 191 service users, 419 workforce members, 329 leaders of services, systems, and regions, and 106 stakeholders. We additionally received 2,128 responses to our survey from 782 service users, 1,133 workforce members, 105 leaders, and 108 stakeholders.

9. While most people using maternity and perinatal services are women, the CQC Maternity Survey (2022) found that 0.65% of respondents stated that their gender was not the same as their sex registered at birth. Intersex, transgender, and non-binary people experiencing pregnancy and birth can experience particular health inequalities including poorer access and a lack of information and support in relation to their specific clinical and care needs within maternity services. The information in this plan also applies to these individuals; particularly the principles described in Theme 1.

10. While each of the groups who helped inform this plan had different areas they gave greatest importance to, there was clear agreement on what the plan's focus should be. This consensus has shaped the four themes, and the objectives within each of these.

11. The most consistent priority among those using and providing services was safe care. Delivering safe care remains central to this delivery plan.

"Safe, compassionate care, which allows you the confidence to speak up and be listened to if something is not right." (Service user)

"We need to take action and make a pledge to improve the safety of every maternity service in England." (Leader)

12. You told us how important improving equity and equality is. We have a dedicated objective on improving equity.

"Those that are most vulnerable should be enabled to have a strong voice within maternity care provision." (Stakeholder)

13. You told us that we need to be clear about who is responsible for doing what, and to bring the asks of services and systems into one place. This delivery plan sets out clear responsibilities and measures of success across services and systems.

"One clear plan that looks to encompasses the recommendations from various reports such as Better Births, Ockenden, Kirkup." (Workforce member)

Listening to and working with women and families with compassion

14. You told us that personalised care supports safety, makes women feel valued, and avoids families needing to re-tell their story - who they are or what they need. You told us it is important to join up care across maternity and neonatal pathways.

"To be treated as an individual human being." (Service user)

"Consistency! I saw so many different people I had to tell them my 'story' every time." (Service user)

"Being fully informed without judgement on pros and cons of all care offered." (Service user)

"Listening to the families using the care and embedding their voices along all pathway." (Leader)

"Supporting parents to be actively involved in the care of their baby on the neonatal unit (family integrated care)." (Service users)

Growing, retaining, and supporting our workforce

15. You told us that there needs to be enough staff in services, with the time and training to support their effectiveness as well as to protect their wellbeing.

"Safe staffing that will then provide safe and personalised care." (Leader)

"Enough staffing to feel supported, safe and provide care when it is needed." (Service user)

"Adequate staff with the appropriate training working in the right environment. Having the time and resources to listen to women and their families." (Workforce member)

Developing and sustaining a culture of safety, learning, and support

16. You told us that there needs to be a positive culture and leadership in services. Staff need to be free to speak up, in an environment that learns from experiences and incidents and does so with compassion.

"Listening, learning and facing up to failings." (Stakeholder)

"Confidence in the care provider, trust, integrity and honesty if mistakes occur." (Leader)

"Leadership training to enable managers to better manage teams and support them." (Workforce member)

"Psychological safety at work and teams that work together with a shared vision and a foundation of kindness." (Stakeholder)

Standards and structures that underpin safer, more personalised, and more equitable care

17. You told us that we need to improve our data collection to help oversight and improvement, among other important standards and infrastructure. Our fourth theme focuses on these crucial elements that support the other themes.

"Notes to be available to all staff when required rather than just to one person." (Service user)

"Delivering high quality, evidence-based care in a local environment for service users." (Workforce member)

"Improved data collection and IT systems - joined up maternity and neonatal electronic patient record systems which are user friendly and accessible." (Workforce member)

"Organisational transparency and providing in depth data to provide meaningful data that can be used to prevent as well as respond to trends and themes." (Leader)

Theme 1: Listening to and working with women and families with compassion

1.1 Listening and responding to all women and families is an essential part of safe and high-quality care. It improves the safety and experience of those using maternity and neonatal services and helps address health inequalities. Better Births identified that "women wanted to be listened to about what they want for themselves and their baby, and to be taken seriously when they raise concerns". The Ockenden report into maternity services at Shrewsbury and Telford described how families who raised concerns "were brushed aside, ignored and not listened to". This section sets out actions for personalised care, improving equity, and working with service users.

1.2 Key commitments for women and families include:

Empowering staff to ensure that all women are offered personalised care and support plans as part of their care.

Ensuring pregnant women and new mothers have access to pelvic health services in every area of England by 2024 to identify, prevent, and treat common pelvic floor problems.

Rolling out perinatal mental health services to improve the availability of this specialist care.

Investing to ensure the availability of bereavement services 7 days a week by the end of 2023/24 for women and families who sadly experience loss.

Funding to increase and better align neonatal cot capacity throughout 2023/24 and 2024/25.

Implementing local plans to reduce inequalities in experience and outcomes for women and babies, including neonatal and maternal mortality.

Ensuring local maternity and neonatal voice partnerships (MNVPs) have the infrastructure they need to be successful and put service user voices at the heart of service improvement. This includes funding MNVP workplans and providing appropriate training, and administrative and IT support.

Objective 1: Care that is personalised

1.3 Personalised care gives people choice and control over how their care is planned and delivered. It is based on evidence, what matters to them, and their individual risk factors and needs. This information can be included in each personalised care and support plan to help ensure that service users do not have to repeat their story. While many women and babies experience excellent personalised care ( CQC, 2023), it is clear from independent reports that not all do.

1.4 Our ambition is:

Women experience care that is always kind and compassionate. They are listened and responded to.

Open and honest ongoing dialogue between a woman, her midwife, and other clinicians, to understand the care she wants, any concerns she may have, and to discuss any outcomes that are not as expected.

All women are offered personalised care and support plans which take account of their physical health, mental health, social complexities, and choices. Plans consider inequalities in the broadest sense, including protected characteristics and Core20PLUS5. The care plan includes a risk assessment updated at every contact, including when the woman is in early or established labour.

Women receive care that has a life course approach and preventative perspective, to ensure holistic care for women and the best start in life for babies. This includes NHS-led smoke-free pregnancy pathways to provide practical support for pregnant women who are smokers, and evidence-based information about screening and vaccination.

Women have clear choices, supported by unbiased information and evidence-based guidelines. Information is provided in a range of formats and languages, uses terminology in line with the Re:Birth report, and is co-produced.

All women have equitable access to specialist care, including perinatal mental health services, perinatal pelvic health services, maternal and fetal medicine networks, and neonatal care, when needed.

Women experience personalised, joined-up, high-quality care right through to the postnatal period with handover to health visiting services and a GP check 6-8 weeks after birth. They are provided with practical support and information that reflects how they choose to feed their babies.

Parents are partners in their baby's care in the neonatal unit through individualised care plans utilising a family integrated care approach, together with appropriate parental accommodation.

Compassionate and high-quality care for bereaved families including appropriate accommodation, which is easily accessible but separate from maternity and neonatal units.

How we will make this happen

1.5 It is the responsibility of trusts to:

Empower maternity and neonatal staff to deliver personalised care by providing the time, training, tools, and information, to deliver the ambitions above.

Monitor the delivery of personalised care by undertaking regular audits, seeking feedback from women and parents, and acting on the findings.

Consider the roll out of midwifery continuity of carer in line with the principles around safe staffing that NHS England set out in September 2022.

Achieve the standard of the UNICEF UK Baby Friendly Initiative (BFI) for infant feeding, or an equivalent initiative, by March 2027.

1.6 It is the responsibility of integrated care boards (ICBs) to:

Commission for and monitor implementation of personalised care for every woman.

Commission and implement perinatal pelvic health services by the end of March 2024, in line with national service specifications, to identify, prevent, and treat common pelvic floor problems in pregnant women and new mothers.

Commission and implement community perinatal mental health services including maternal mental health services, in line with national service specifications, to improve the availability of mental health care.

1.7 NHS England will:

Work with service users and other partners to produce standardised information to aid decision-making, focusing on priorities identified by service users: intrapartum interventions, mode of birth, induction of labour, and pain relief.

Extend the national support offer to the 38 maternity services yet to achieve UNICEF BFI accreditation or an equivalent initiative.

Publish national postnatal care guidance by the end of 2023, setting out the fundamental components of high-quality postnatal care, to support ICSs with their local improvement initiatives. Information for GPs on the 6-8 week postnatal check will be published in spring 2023.

In Spring 2023, publish a national service specification for perinatal pelvic health services alongside associated implementation guidance.

Create a patient reported experience measure (PREM) by 2025 to help trusts and ICBs monitor and improve personalised care.

By March 2024, act on findings from the evaluation of independent senior advocate pilots as set out in the interim Ockenden report.

Invest to ensure availability of bereavement services 7 days a week by the end of 2023/24. This will help trusts to provide high quality bereavement care including appropriate post-mortem consent and follow-up.

Objective 2: Improve equity for mothers and babies

1.8 Significant health inequalities exist in maternity and neonatal care in England. For example, outcomes for women and babies from minority ethnic groups are worse than for white women, and outcomes for those living in the most deprived areas are worse than for those in the least deprived ( MBRRACE-UK, 2022). Though we know NHS staff want to provide the best care to every woman and baby, a National Institute for Health and Care Research funded study found that "multiple structural and other biases exist in UK maternity care" ( Knight, M et al, 2021).

The NHS approach to improving equity ( Core20PLUS5) involves implementing midwifery continuity of carer, particularly for women from minority ethnic communities and from the most deprived areas.

1.9 Our ambition is:

To reduce inequalities for all in access, experience, and outcomes.

Targeted support where health inequalities exist in line with the principles of proportionate universalism.

Services listen to and work with women from all backgrounds to improve access, plan, and deliver personalised care. Maternity and neonatal voice partnerships ensure all groups are heard, including those most at risk of experiencing health inequalities.

The NHS collaborates with local authority services, other public sector organisations, and a wide range of private and voluntary sector organisations (NHS Constitution, Principle 5, 2021) to address the social determinants of health, which are a significant driver of health inequalities (WHO, 2022).

How we will make this happen:

1.10 It is the responsibility of trusts to:

Provide services that meet the needs of their local populations, paying particular attention to health inequalities. This includes facilitating informed decision-making, for example choice of pain relief in labour where we know there are inequalities, ensuring access to interpreter services, and adhering to the Accessible Information Standard in maternity and neonatal settings.

Collect and disaggregate local data and feedback by population groups to monitor differences in outcomes and experiences for women and babies from different backgrounds. This data should be used to make changes to services and pathways to address any inequity or inequalities identified, to improve care.

1.11 It is the responsibility of ICBs to:

During 2023/24, continue to publish and lead implementation of their LMNS equity and equality action plan alongside neonatal ODNs, working across organisational boundaries.

Commission MNVPs to reflect the ethnic diversity of the local population and reach out to seldom heard groups.

1.12 NHS England will:

Provide regional and national support for the implementation of LMNS equity and equality action plans.

Pilot and evaluate new service models designed to reduce inequalities, including enhanced midwifery continuity of carer, and from 2023, culturally sensitive genetics services for couples practising close relative marriage in high need areas.

Continue to work with the Maternity Disparities Taskforce to explore disparities in maternity care and identify how to improve outcomes.

In spring 2023, publish the National Review of Health and Social Care in Women's Prisons. This review covers maternity and perinatal services.

Objective 3: Work with service users to improve care

1.18 Acting on the insights of women and families improves services. Co-production is beneficial at all levels of the NHS and is particularly important for those most at risk of experiencing health inequalities ( NICE, 2018). Involving service user representatives helps identify what needs to improve and how to do it. This is done through maternity and neonatal voices partnerships (MNVPs) and by working with other organisations representing service users.

1.19 Our ambition is:

1.20 In addition, neonatal parental advisory groups represent service user experience as part of operational delivery networks.

How we will make this happen:

1.21 It is the responsibility of trusts to:

Involve service users in quality, governance, and co-production when designing and planning delivery of maternity and neonatal services.

1.22 It is the responsibility of ICBs to:

1.23 NHS England will:

Determining success for Theme 1

1.24 We will determine overall success by listening to women and their families:

Our outcome measure for this theme will be indicators of women's experience of care from the Care Quality Commission (CQC) maternity survey. They will be aggregated at trust, ICB, and national levels and at national level analysed by ethnicity and deprivation.

We will use these progress measures:

Perinatal pelvic health services and perinatal mental health services are in place.

The number of women accessing specialist perinatal mental health services as indicated by the NHS Mental Health Dashboard.

The proportion of maternity and neonatal services with UNICEF BFI accreditation.

Evidence which ICBs can use includes:

Feedback on personalised care gathered via MNVPs from a wide range of service users.

Local evidence of working with women and families to improve services, including co-production.

Relevant regulation and incentivisation includes:

Case Study: Seeking Sanctuary Clinic - to enhance the maternity care of anyone seeking sanctuary

The Seeking Sanctuary Clinic, hosted in Berkshire West, is a specialist maternity clinic developed in 2021 from co-production between Royal Berkshire NHS Foundation Trust maternity team, and Berkshire West public health team, to enhance the maternity care of anyone seeking sanctuary such as refugees, asylum seekers, those fleeing conflict, undocumented migrants and people who have been trafficked.

This is a 'one stop shop' style clinic held in a children's centre, delivered in two-hour sessions held every two months, aimed specifically for these families, in addition to their usual antenatal and postnatal care. The barriers to access and inequalities that these families may be experiencing are removed where possible. For example, women are able to bring their partners and children with them, there are interpreters booked for every language in attendance, refreshments are provided and transport is available to support people to get to the clinic.

There are many health care professionals and voluntary organisations that come together at the clinic including midwifery and obstetrics. There is also accessible antenatal education with New Directions, sexual health, health visiting, a tuberculosis service, health in pregnancy advisors, Compass Recovery College (mental health and wellbeing support), Reading Refugee Support and Reading Voluntary Action.

The clinic is ever evolving, and additional professionals and organisations are invited to sessions to meet the bespoke needs of the group. Local charity The Cowshed donated to the clinic enabling each family that attends to be provided a ready-made birth bag to assist them on their journey.

The local Maternity Voices Partnership also attends to offer feedback sessions for these groups. While the project is in an initial evaluation phase, feedback so far has been very positive from service users, with more than fifty families supported so far, predominantly from Afghanistan, Syria, and Ukraine.

Theme 2: Growing, retaining, and supporting our workforce

2.1 The ambition of safer, more personalised, and more equitable maternity and neonatal services in this plan can only be delivered by skilled teams with sufficient capacity and capability. However, despite significant investment leading to increases in the midwifery, obstetric, and neonatal establishment, NHS maternity and neonatal services do not currently have the number of midwives, neonatal nurses, doctors, and other healthcare professionals they need. This means existing staff are often under significant pressure to provide the standard of care that they want to. We need to change that. The plan is informed by the best available evidence, including the QMNC framework which underpins the NMC midwifery standards. This theme sets out three areas of action for maternity and neonatal staffing: continuing to grow our workforce; valuing and retaining our workforce; and investing in skills.

2.2 Key commitments for women and families include:

NHS services will ensure the right numbers of the right staff are available to provide the best care for women and babies through regular local workforce planning, including trusts meeting staffing establishment levels and achieving fill rates by 2027/28 for midwifery.

Implementing staff retention improvement action plans to identify and address local retention issues. During 2023/24, retention midwives will be funded in every maternity unit.

Supporting the retention and recruitment of staff caring for babies in neonatal units by continuing to invest in education and workforce leads.

Providing a core competency framework that will inform local mandatory training programmes to ensure that the skills relevant to staff's roles are kept up to date.

Objective 4: Grow our workforce

2.3

The maternity and neonatal workforce encompasses a wide range of professions, including midwives, maternity support workers, obstetricians, anaesthetists, neonatologists, neonatal nurses, sonographers, allied health professionals, and psychologists. Growing our workforce requires the tailoring of interventions to professional groups, career stage, and local requirements.

2.4 Established midwifery posts have increased by over 2,000 whole time equivalent (WTE) since March 2021, with obstetric consultant posts and maternity support worker posts each increasing by around 400 WTE since April 2021. For neonatal services, we have invested to establish over 550 new neonatal nurses, care-coordinators, and workforce and education leads, and have committed to funding 130 WTE new allied health professional and over 40 WTE new psychologist posts.

2.5 Our ambition is for:

How we will make this happen

2.6 It is the responsibility of trusts to:

Undertake regular local workforce planning, following the principles outlined in NHS England's workforce planning guidance. Where trusts do not yet meet the staffing establishment levels set by Birthrate Plus or equivalent tools endorsed by NICE or NQB, to do so and achieve fill rates by 2027/28.

Develop and implement a local plan to fill vacancies, which should include support for newly qualified staff and clinicians who wish to return to practice.

Provide administrative support to free up pressured clinical time.

2.7 It is the responsibility of ICBs to:

Commission and fund safe staffing across their system.

Agree staffing levels with trusts, following NHS England workforce planning principles, for those healthcare staff where an evidence-based planning tool does not yet exist. National guidance should be considered when determining staffing levels (for example, guidelines for the provision of anaesthesia services for an obstetric population and implementing the recommendations of the neonatal critical care transformation review).

Align commissioning of services to meet the ambitions outlined in this delivery plan with the available workforce capacity. It is expected that from 2024/25 ICBs will assume delegated responsibility for the commissioning of neonatal services.

Work with trusts and higher education institutions to maximise student placement capacity, ensuring the breadth and quality of clinical placements.

2.8 NHS England will:

Assist trusts and regions with their workforce growth plans by providing direct support, including through operational delivery networks for neonatal staffing.

Boost midwifery workforce supply across undergraduate training, apprenticeships, postgraduate conversion, return to midwifery programmes, and international recruitment.

Increase medical training places across obstetrics and gynaecology and anaesthetics, to expand the consultant workforce in maternity services.

Collaborate with the Royal College of Obstetricians and Gynaecologists (RCOG) to support their work developing an obstetric workforce planning tool, to be published in 2023/24. This initiative will help establish the staffing levels required to appropriately resource clinical leadership and intrapartum care.

Objective 5: Value and retain our workforce

2.9 Our maternity and neonatal staff perform critical, life-changing work every day. We must ensure they are valued and have a fulfilling and sustainable career within the NHS. A growing number of staff who leave are aged under 55 and do so for reasons other than retirement. Some staff groups, including ethnic minority staff, are more likely to report negative experiences of working in NHS maternity and neonatal services. We need to do more to improve the experience of all our staff, to retain them within the NHS.

2.10 Our ambition is:

How we will make this happen

2.11 The NHS Long Term Plan and NHS People Plan set out how improving the experience of our NHS people will encourage them to stay with us for longer.

2.12 It is the responsibility of trusts to:

Identify and address local retention issues affecting the maternity and neonatal workforce in a retention improvement action plan.

Implement equity and equality plan actions to reduce workforce inequalities.

Create an anti-racist workplace, including for example, acting on the principles set out in the combatting racial discrimination against minority ethnic nurses, midwives and nursing associates resource

Identify and address issues highlighted in student and trainee feedback surveys, such as the National Education and Training Survey.

Offer a preceptorship programme to every newly registered midwife, with supernumerary time during orientation and protected development time. Newly appointed Band 7 and 8 midwives should be supported by a mentor.

Develop future leaders via succession planning, ensuring this pipeline reflects the ethnic background of the wider workforce.

2.13 It is the responsibility of ICBs to:

Share best practice for retention and staff support.

Highlight common or high-impact retention challenges to the national team to enable consideration of a national approach.

2.14 NHS England will:

Support retention with funding to continue a retention midwife in every maternity unit during 2023/24, with ICBs maintaining the focus on retention thereafter.

Continue to invest in neonatal operational delivery network (ODN) education and workforce leads to support the recruitment and retention of neonatal staff.

In 2023/24, provide funding to establish neonatal nurse quality and governance roles within trusts, to support cot-side clinical training and clinical governance.

In 2023/24, strengthen neonatal clinical leadership with a national clinical director for neonatal and national neonatal nurse lead.

Continue to address workforce inequalities through the Workforce Race Equality Standard.

Provide national guidance for implementation of the A-EQUIP model and for the professional midwifery advocate role to provide restorative clinical supervision in local services.

By July 2023, develop a safe clinical learning environment charter for trusts; by April 2024, develop models for coaching; and, by October 2024, embed a framework to support the standards of supervision and assessment for midwifery students. These initiatives will help to ensure high quality clinical placements for those training to be midwives.

Objective 6: Invest in skills

2.15 Staff feel valued when they are supported to develop. We are investing in our staff by ensuring they have ongoing training and career development opportunities. Effective training of frontline clinicians in technical and non-technical skills has been shown to improve outcomes, yet unwarranted variation in training and competency assessment currently exists, especially for temporary staff (for example, Stulberg et al, 2020, McCulloch et al, 2008).

2.16 Our ambition is:

How we will make this happen

2.17 It is the responsibility of trusts to:

2.18 NHS England will:

Refresh the curriculum for maternity support workers (MSWs) by June 2023.

Provide tools to support implementation of the MSW competency, education, and career development framework by September 2023.

Work with RCOG to develop leadership role descriptors for obstetricians by summer 2023 to support job planning, leadership, and development.

Establish a sustainable national route for the training of obstetric physicians, to support the development of maternal medicine networks.

Work with royal colleges and professional organisations to understand and address the challenges involved in recruiting and training the future neonatal medical workforce.

Through action set out above to grow the workforce, help to address pressures on backfill for training.

Determining success for Theme 2

2.19 We will determine overall success by listening to staff:

Our outcome measures for this theme will be the NHS Staff Survey, the National Education and Training Survey, and the GMC national training survey.

Our progress measures will be:

Establishment, in-post and vacancy rates for obstetricians, midwives, maternity support workers, neonatologists, and neonatal nurses, captured routinely from provider workforce return data.

In line with the 2023/24 workforce planning guidance, there will be an annual census of maternity and neonatal staffing groups. This will facilitate the collection of baseline data for obstetric anaesthetists, sonographers, allied health professionals, and psychologists.

To assess retention, we will continue to monitor staff turnover and staff sickness absence rates alongside NHS Staff Survey questions on staff experience and morale.

Evidence that ICBs can use includes:

Relevant regulation and incentivisation includes:

The CQC inspection criteria includes key lines of enquiry around staff skills, knowledge, experience, and opportunities for development.

The NHS Resolution CNST maternity incentive scheme incentivises trusts to evidence that training in accordance with the core competency framework is in place.

Case study: One stop obstetric ambulatory service

The Chelsea and Westminster Hospital NHS Foundation Trust cares for approximately 5,500 maternity patients per year. The maternity team identified common themes in complaints about their service, including delays in receiving care and long waits for obstetric or scan reviews. The team felt they could improve triage management, patient experience and care, through a truly multidisciplinary approach so set up a 'one stop' service since January 2021.

The team recognised a key cause of delay within the department was delays in obstetric reviews. They were able to increase consultant presence and recruit a clinical fellow with obstetric ultrasound training to work solely in the triage department for five mornings a week, to deliver a 'see and treat' set up, comparable to the way emergency departments are run.

The triage team also includes midwives and maternity support workers, who greet attendees, perform initial observations and a dedicated receptionist who enables clinicians to focus on care rather than administrative tasks. Some midwives have developed professionally to perform tasks that are usually undertaken by obstetricians, such as prescribing and performing presentation scans.

From October 2022 to February 2023 the service has had on average 850 visits per month, with around 100 ultrasound scans performed. The department answers approximately 2,500 phone calls per month, with one midwife allocated to answer phone calls each day to triage and support women.

Improvements in the new obstetric ambulatory service triage system mean the department works more efficiently and safely with staff feeling better supported. Waiting times have been reduced, with 80-95% of women seen within 15 minutes of arrival which exceeds the national KPI (within 30 minutes) for maternity triage services. Feedback from women has also been increasingly positive. The team are exploring future opportunities to expand the service hours and increase the scope of midwifery and maternity support workers, supporting the team's development and dynamic skillset.

Theme 3: Developing and sustaining a culture of safety, learning, and support

3.1 An organisation's culture is shaped by the behaviour of everyone in it. In maternity and neonatal services, a safety culture improves the experience of care and outcomes for women and babies and supports staff to thrive. We want everyone to experience the positive culture that exists in many services - poor cultures need to be challenged and addressed. The failures in care identified in the Kirkup report stemmed from weaknesses in culture throughout the organisation, including a lack of teamworking, professionalism, compassion, listening, and learning. This theme sets out actions in three areas: developing and sustaining a positive safety culture for everyone; learning and improving; and support and oversight.

3.2 Key commitments for women and families include:

Supporting staff to work with professionalism, kindness, compassion, and respect. Leaders will empower their teams to do this, with practical guidance and training through the perinatal culture and leadership programme by 2024.

Implementing an NHS-wide approach in 2023 for all incidents to support families with a compassionate response, and to ensure learning.

Listening and acting upon issues raised by staff or service users through Freedom to Speak Up (FTSU) Guardians, the complaints process, or maternity and neonatal voices partnerships (MNVPs).

Objective 7: Develop a positive safety culture

3.3 Culture is everyone's responsibility and key to enabling cultural change is compassionate, diverse, and inclusive leadership in maternity and neonatal services and beyond.

3.4 Our ambition is:

All staff working in and overseeing maternity and neonatal services:

Are supported to work with professionalism, kindness, compassion, and respect.

Are psychologically safe to voice their thoughts and are open to constructive challenge.

Receive constructive appraisals and support with their development.

Work, learn and train together as a multi-disciplinary team across maternity and neonatal care.

Teams value and develop people from all backgrounds and make the best use of their diverse skills, views, and experiences.

There is a shared commitment to safety and improvement at all levels, including the trust board, and attention is given to 'how' things are implemented not just 'what'.

Instances of behaviour that is not in line with professional codes of conduct, are fairly addressed before they become embedded or uncontrollable.

Systems and processes enable effective coordination, rapid mobilisation, and supportive communication based on agreed principles. The team can escalate concerns and, should there be a disagreement between healthcare professionals, they will be supported by a conflict of clinical opinion policy.

Staff investigating incidents are provided with appropriate training, while those staff affected by an incident are offered timely opportunity to debrief.

How we will make this happen

3.5 It is the responsibility of trusts to:

Make sure maternity and neonatal leads have the time, access to training and development, and lines of accountability to deliver the ambition above. This includes time to engage stakeholders, including MNVP leads.

Support all their senior leaders, including board maternity and neonatal safety champions, to engage in national leadership programmes (see below) by April 2024, identifying and sharing examples of best practice.

At board level, regularly review progress and support implementation of a focused plan to improve and sustain culture, including alignment with their FTSU strategy.

Ensure staff are supported by clear and structured routes for the escalation of clinical concerns, based on frameworks such as the Each Baby Counts: Learn and Support escalation toolkit.

Ensure all staff have access to FTSU training modules and a Guardian who can support them to speak up when they feel they are unable to in other ways.

3.6 It is the responsibility of ICBs to:

Monitor the impact of work to improve culture and provide additional support when needed.

Provide opportunities for leaders to come together across organisational boundaries to learn from and support each other.

3.7 NHS England will:

By April 2024, offer the perinatal culture and leadership programme to all maternity and neonatal leadership quadrumvirates including the neonatal, obstetric, midwifery and operational leads. This includes a diagnosis of local culture and practical support to nurture culture and leadership.

Objective 8: Learning and improving

3.8 Staff working in maternity and neonatal services have an appreciation and understanding of 'what good looks like'. To promote safer care for all, we must actively learn from when things go well and when they do not. To do this, we need a continuous learning and improvement approach, from teams to ICBs.

3.9 Our ambition is framed by the patient safety incident response framework (PSIRF) which provides a consistent approach across clinical specialties, including for maternity and neonatal services.

3.10 The Healthcare Safety Investigation Branch undertake investigations of incidents which meet their criteria. The responsibilities for trusts and ICBs set out below, also apply to these, or any other external investigations.

How we will make this happen

3.11 It is the responsibility of trusts to:

Establish and maintain effective, kind, and compassionate processes to respond to families who experience harm or raise concerns about their care. These should include the principles of duty of candour and a single point of contact for ongoing dialogue with the trust.

Understand 'what good looks like' to meet the needs of their local populations and learn from when things go well and when they do not.

Respond effectively and openly to patient safety incidents using PSIRF.

Act, alongside maternity and neonatal leaders, on outcomes data, staff and MNVP feedback, audits, incident investigations, and complaints, as well as learning from where things have gone well.

Ensure there is adequate time and formal structures to review and share learning, and ensure actions are implemented within an agreed timescale.

Consider culture, ethnicity and language when responding to incidents (NHS England, 2021).

3.12 It is the responsibility of ICBs to:

Share learning and good practice across all trusts in the ICS.

Oversee implementation of the PSIRF safety improvement plan during 2023/24, monitoring the effectiveness of incident response systems in place.

3.13 NHS England will:

Throughout 2023, support the transition to PSIRF through national learning events.

Through regional teams, share insights between organisations to improve patient safety incident response systems and improvement activity.

Objective 9: Support and oversight

3.14 While some trusts and ICSs do effectively support their maternity and neonatal services to improve and change; others do not. Good oversight is about understanding the issues leaders face and helping to resolve them, and having clear systems in place that promote timely escalation and intervention before serious problems arise.

3.15 Our ambition is:

Robust oversight through the perinatal quality surveillance model (PQSM) that ensures concerns are identified early, addressed, and escalated where appropriate.

Well led services, with additional resources channelled to where they are most

Leadership for change, with a focus on ensuring new service models have the right building blocks for high quality care, especially the workforce.

How we will make this happen

3.16 It is the responsibility of trusts to:

Maintain an ethos of open and honest reporting and sharing of information on the safety, quality, and experience of their services.

Regularly review the quality of maternity and neonatal services, supported by clinically relevant data including - at a minimum - the measures set out in the PQSM and informed by the national maternity dashboard.

Appoint an executive and non-executive maternity and neonatal board safety champion to retain oversight and drive improvement. This includes inviting maternity and neonatal leads to participate directly in board discussions.

Involve the MNVP in developing the trust's complaints process, and in the quality safety and surveillance group that monitors and acts on trends.

At board level, listen to and act on feedback from staff, including Freedom to Speak Up data, concerns raised, and suggested innovations in line with the FTSU guide and improvement tool.

3. 17 It is the responsibility of ICBs to:

Commission services that enable safe, equitable, and personalised maternity care for the local population.

Oversee quality in line with the PQSM and NQB guidance, with maternity and neonatal services included in ICB quality objectives.

Lead local collaborative working, including the production of a local quality dashboard that brings together intelligence from trusts.

3.18 NHS England will:

Through our regional teams, listen to the local NHS and through our national governance listen to frontline staff voices and continue to work RCOG, RCM, BAPM, and others.

Continue to work closely with national bodies, ICBs, and trusts to address issues escalated to national level.

Provide nationally consistent support for trusts that need it through the Maternity Safety Support Programme (MSSP).

Work to align the MSSP with the NHS oversight framework, improve alignment with the recovery support programme, and evaluate the programme by March 2024.

During 2023/24, test the extent to which the PQSM has been effectively implemented.

By March 2024, provide targeted delivery of the maternity and neonatal board safety champions continuation programme to support trust board assurance, oversight of maternity and neonatal services, and a positive safety culture.

Determining success for Theme 3

3.19 Achieving meaningful changes in culture will take time and progress measures are difficult to identify and can have unintended consequences. We will primarily determine overall success by listening to the people who use and work in frontline services.

3.20 Our outcome measures for this theme are midwives' and obstetrics and gynaecology specialists' experience using the results of the NHS Staff Survey; the National Education and Training Survey and the GMC National Training Survey. We will explore how to better understand the experiences of other staff groups.

The evidence ICBs can use across maternity and neonatal services includes:

Assurance from trust boards that they are using an appreciative enquiry approach to support progress with plans to improve culture.

Whether trust boards regularly share and act on learning.

Staff feedback on how incidents and issues of concern are managed.

Relevant regulation includes:
The CQC will continue to consider whether a trust has a learning and responsive culture, strong leadership, and robust governance.

Case study: NFaST - Neonatal Families and Staff Together, supporting neonatal units to become more emotionally supportive environments

In 2021, the North West Neonatal Operational Delivery Network commissioned Spoons, a Greater Manchester-based charity specialising in neonatal family support, to research how their neonatal units could become more emotionally supportive environments for service users and staff.

The project worked with 13 neonatal units and a 28-family focus group, collecting data from more than 260 parents and 250 staff members, exploring their emotional needs. The project identified that the experience of neonatal care has a profound long-term impact on parents and their infants. In turn, the experience of working on a neonatal unit is emotionally challenging and can have significant impact on a staff member's individual wellbeing.

Volunteer peer supporters, who had personal experience of neonatal care, were trained for the units. Psychological training was provided to 100 staff across four neonatal units, including doctors, nurses, and support staff. Reflective practice group sessions were led by a clinical psychologist, to help the teams collaborate and understand each other and the needs of their babies and families better.

The pool of volunteer peer supporters continues to grow, and additional peer support training has been commissioned, with a model of ongoing supervision in development. This project demonstrates the power of true collaboration between the NHS, service users and third sector partners.

Theme 4: Standards and structures that underpin safer, more personalised, and more equitable care

4.1 To deliver the ambition set out in this plan, maternity and neonatal teams need to be supported by clear standards and structures. This includes being enabled to implement best clinical practice for all families, having high quality data to inform the decisions of clinicians and leaders, and having digital tools that enable information to flow. In many areas this is already in place; this plan does not seek to introduce new standards, extra reporting, or change structures, but to ensure that these enablers are consistently implemented to support care.

4.2 Key commitments for women and families include:

Making care safer by consistently implementing best practice, including:

By 2024, an updated version of the updated Saving Babies Lives Care Bundle - a package of interventions to reduce stillbirth, neonatal brain injury, neonatal death, and preterm birth.

By 2025, the national maternity early warning score and updated newborn early warning trigger and track tools to improve the care of unwell mothers and babies, enabling timely escalation where needed.

In 2023, NHS England's new taskforce will report on how data can be used as an early warning system to detect safety issues within maternity and neonatal services, enabling action to address any issues sooner.

By 2024, the NHS will publish refreshed data and recording standards that allow us to collect more meaningful standardised data that can then be used to improve care.

Supporting the roll out electronic patient records to enable women to access their records and interacting with their digital plans and information to support informed decision-making.

Objective 10: Standards to ensure best practice

4.3 Advances in clinical practice have been crucial in the improvement in maternity and neonatal outcomes over the last decade. However, the Ockenden report found that many women cared for at the trust were not offered care in line with best clinical practice. Better Births also identified that variation in protocols, policies, and standards between services creates additional burden and hinders the ability to work together to provide effective care. Additionally, the Kirkup report highlighted the detrimental effect that sub-optimal estates have on the provision and experience of care.

4.4 Nationally defined best practice already exists, including:

4.5 Our ambition is:

Consistent implementation of nationally defined best practice with due regard to the needs of local populations to reduce variation and inequalities.

Healthcare professionals have access to shared standards and guidelines, including transfer, transport, and referral protocols, so that clinical teams across the ICS work to the same definitions of best practice care.

Where local policy varies from national standards, this is subject to careful local scrutiny through governance processes. The whole multidisciplinary team is involved when developing local guidance.

Policies and guidelines recognise women as the decision-makers in their maternity care and are not used to prevent women from seeking care that is outside these guidelines.

Neonatal care is provided in units with clear designation of the level of care to be provided. Units work together across ODNs to optimise capacity and ensure care can be provided in the right place for very pre-term or very sick babies.

How we will make this happen

4.6 It is the responsibility of trusts to:

Implement version 3 of the Saving Babies' Lives Care Bundle by March 2024 and adopt the national MEWS and NEWTT-2 tools by March 2025.

Regularly review and act on local outcomes including stillbirth, neonatal mortality and brain injury, and maternal morbidity and mortality to improve services.

Ensure staff are enabled to deliver care in line with evidence-based guidelines, with due regard to NICE guidance.

Complete the national maternity self-assessment tool if not already done, and use the findings to inform maternity and neonatal safety improvement plans.

4.7 It is the responsibility of ICBs to:

Prioritise areas for standardisation and co-produce ICS-wide clinical policies such as for implementation of the Saving Babies' Lives Care Bundle.

Oversee and be assured of trusts' declarations to NHS Resolution for the maternity incentive scheme.

Monitor and support trusts to implement national standards.

Commission care with due regard to NICE guidelines.

4.8 NHS England will:

Keep best practice up to date through version 3 of the Saving Babies Lives Care Bundle and the MEWS and NEWTT-2 tools, as well as developing tools to improve the detection and response to suspected intrapartum fetal deterioration.

Support the integration of MEWS, NEWTT-2, and other clinical tools into existing digital maternity information systems by autumn 2024.

Provide support to capital projects to increase and better align neonatal cot capacity throughout 2023/24 and 2024/25.

Over the next 3 years, undertake a national maternity and neonatal unit infrastructure compliance survey and report, to determine the level of investment needed for an environmentally sustainable development of the maternity and neonatal estate across England.

Continue to learn from research and evaluation as set out in the National Maternity Research Plan available on the FutureNHS platform.

Objective 11: Data to inform learning

4.9 The Kirkup report highlighted the need for accurate, up to date data to highlight safety issues promptly. Such data enables providers to learn and act. Work is underway to review what data is needed for monitoring, and in the meantime, the NHS should continue to use the data it already collects.

4.10 Our ambition is:

Standardised data is collected in a consistent way, primarily through the Maternity Services Data Set. Additional data collections are minimised, to focus on gathering the right data to drive insights, understanding and assurances.

Monitoring trends at both national and local level is enabled by analysing data from different sources alongside themes from MBRRACE-UK , and the national clinical audits patient outcome programme reports.

The national maternity dashboard provides demographic data, clinical quality improvement metrics and national maternity indicators enabling trusts and LMNSs to benchmark their services and inform continuing quality improvement work.

How we will make this happen

4.11 It is the responsibility of trusts to:

Review available data to draw out themes and trends and identify and promptly address areas of concern including consideration of the impact of inequalities.

Ensure high-quality submissions to the maternity services data set and report information on incidents to NHS Resolution, the Healthcare Safety Investigation Branch and national perinatal epidemiology unit.

4.12 It is the responsibility of ICBs to:

Use data to compare their outcomes to similar systems and understand any variation and where improvements need to be made.

4.13 NHS England will:

Objective 12: Make better use of digital technology in maternity and neonatal services

4.14 Digital technology will make it easier for women to access the information they need and for services to offer safe and personalised care. There is currently significant variation in the use of digital technology. While some maternity services remain almost entirely paper-based, others support personalised care with apps and benefit from an integrated electronic patient record (EPR). Most neonatal units use the same electronic product, which is designed for neonatal data capture, though some trusts and neonatal units are considering how to improve neonatal alignment with maternity and paediatrics as part of their EPR roll out.

4.15 Our ambition is:

How we will make this happen

4.16 It is the responsibility of trusts to:

4.17 It is the responsibility of ICBs to:

4.18 NHS England will:

Set out the specification for a compliant EPR, including setting out the requirements for maternity by March 2024.

Publish a refreshed digital maternity record standard and maternity services data set standard by March 2024.

Grow the digital leaders' national community, providing resources, training, and development opportunities to support local digital leadership.

Incorporate pregnancy-related data and features into the NHS App to enhance the facility for women to view their patient records via the NHS app.

Develop facets of a digital personal child health record with service user-facing tools to support neonatal and early years health by March 2025.

Determining success for Theme 4

4.19 We will determine overall success by focusing on clinical outcomes:

Outcome measures for this theme are those of our existing safety ambition: maternal mortality, stillbirths, neonatal mortality, brain injury during or soon after birth, and preterm births. We will monitor these measures nationally by ethnicity and deprivation.

The progress measures we will use are:

Local implementation of version 3 of the Saving Babies' Lives Care Bundle using a national tool.

Of women who give birth at less than 27 weeks, the proportion who give birth in a trust with on-site neonatal intensive care.

The proportion of full-term babies admitted to a neonatal unit, measured through the avoiding term admissions into neonatal units (ATAIN) programme.

A periodic digital maturity assessment of trusts, enabling maternity services to have an overview of progress in this area.

The evidence that ICBs can use includes:

Clinical audits of implementation of shared standards. A standardised tool will be provided for assuring version 3 of the Saving Babies' Lives Care Bundle.

An ICB-wide dashboard to support benchmarking and improvement. The national maternity dashboard contains LMNS benchmarking on metrics where possible.

Progress against locally planned improvements.

Relevant regulation and incentivisation includes:

The NHS Resolution CNST maternity incentive scheme supports trusts to provide safer maternity services through incentivising compliance with 10 safety actions.

The CQC key lines of enquiry for inspections will consider whether care is in accordance with best available evidence, such as NICE guidance.

Case Study: Ask A Midwife - using social media to communicate with service users

Ask A Midwife (AAM) is a social media messaging service managed by midwives, which empowers service users to make timely and informed decisions about their maternity care. AAM is coordinated centrally to ensure consistency of delivery and messaging

by the Humber and North Yorkshire local maternity and neonatal system (LMNS), and four acute trusts are now working collaboratively to offer the service via Facebook, Instagram, and email.

The service is staffed by trust midwives who have a dual role in supporting the AAM service on a part-time basis alongside their clinical work. Questions from women and families range from pregnancy, birthing options, appointments, and the care of a new-born baby.

More than 94% of queries can be answered immediately and midwives can refer women to other health professionals and support organisations where required. The service routinely averages 800 queries per month, with more than 8,500 queries answered overall in 2022 and 508 onward referrals to health professionals, maternity units, NHS 111, and pharmacies. Patient confidentiality is conducted in the same way as telephone queries would be in a hospital, but the usual ways of contacting the hospital maternity team, such as by phone, are also available.

The service also allows the LMNS to cascade timely public health updates for pregnant women, including communications around vaccinations, perinatal mental health, postnatal care, and infant feeding. For example, when the AAM team saw an increase in messages around winter viruses they responded by posting self-help information.

AAM is promoted through Maternity Voices Partnership groups, with printed postcards and posters distributed in maternity settings, Children's Centres, through direct referral by midwives, and attendance at community outreach events, such as one in Spring 2023 specifically for people from the Romanian and Polish community.

Support available to staff, trusts, and systems

The maternity hub on the FutureNHS platform has relevant material for each theme.

Theme 1: Listening to and working with women and families with compassion

Theme 2: Growing, retaining, and supporting our workforce

Theme 3: Developing and sustaining a culture of safety, learning, and support

Theme 4: Standards and structures that underpin safer, more personalised, and more equitable care

Acknowledgements

This plan has been developed with contributions from clinical leaders within NHS England and a wide range of partners, including but not limited to:

The Independent Working Group, chaired by the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists. Members include:

British Association of Perinatal Medicine

Royal College of Paediatrics and Child Health

Royal College of Anaesthetists

Obstetric Anaesthetists Association

Society of Radiographers

Care Quality Commission

The Department of Health and Social Care

Health Education England

Service user voice representatives.

Hearing from around 3,000 people via events and a survey. This included:

People who use maternity and neonatal services

National and regional service user voice representatives

Frontline professionals, including midwives, obstetricians, and neonatal colleagues

Integrated care boards

NHS England regional teams

Voluntary, community, and social enterprise organisations

National Guardian's Office

National stakeholders.

We remain committed to working closely with partners as we deliver this plan. Thank you to all the individuals and organisations who have shared their time, expertise, and experience so far.

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Three year delivery plan for maternity and neonatal services

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With this plan we aim to make care safer, more personalised, and more equitable, by: Listening to women and families with compassion which promotes safer care. Supporting our workforce to develop their skills and capacity to provide high-quality care. Developing and sustaining a culture of safety to benefit everyone.

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Nursing and Midwifery Council (NMC) guide to practising as a midwife in the UK

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Nursing and Midwifery Council (NMC) guide to practising as a midwife in the UK

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Regulating the midwives of today and the future

As the professional regulator of midwives, we support midwives to deliver safe and effective midwifery care through our regulatory processes.

Practising as a midwife in the UK outlines our approach to the regulation of midwives. It brings together in one place all of the information for midwives, women and families, and anyone else with an interest in midwifery in the UK.

The Future Midwife standards are our bespoke education and proficiency standards that set the foundations for midwives' education. They establish what we expect a new midwife to know, understand and be capable of doing, at the start of their career.

Our standards sit alongside the Code, which outlines the standards of behaviour and conduct expected of professionals on our register, and our standards for revalidation, which promote lifelong learning.

Revalidation helps make sure midwives keep up to date, and continue to develop their midwifery knowledge and expertise, to maintain excellent standards of practice.

What you can expect from your midwife

It's important that everyone feels confident about the care they can expect from the midwives on our register.

We've introduced new standards for midwifery in the UK, supporting them to deliver safe, effective, and kind care now and in the future. As a result, our midwives are at the forefront of improving people's health and wellbeing.

We've made a short animation to help you understand what you can expect from your midwife.

Midwifery as a protected function and title

Midwifery is a protected function in the UK, meaning it's a criminal offence for any person other than a registered midwife, or a registered medical practitioner, to attend on a woman in childbirth (except in emergencies or when in training as a student midwife or medical student).

It's also a criminal offence for someone to falsely represent themselves as being on our register and use the protected title of 'Midwife', or falsely represent themselves as possessing midwifery qualifications.

Our midwifery plan

We want to support midwives to deliver the best and safest care possible, and to use our influence with others who can make changes to support midwives. We can do all of these things better by ensuring the voice of midwifery is heard in every part of the NMC.

Our vision for midwifery is safe, effective and kind midwifery practice that improves the health and wellbeing of mothers, babies and their families.

Our values

We want to reflect these values in all of our work with and for midwives.

Foundations of our midwifery work

To deliver our vision, we need to be strategic, responsive, and proactive, ensuring the specific needs of the midwifery profession are articulated and visible in all our work as a regulator.

We're focused on strengthening and reinforcing a consistent approach to midwifery across all of our activities.

NMC Council

Justine Craig is a Midwife and a member of our Council. Both our Council Associates, Tracey MacCormack and Dr Gloria Rowland, are also Midwives.

The Midwifery Panel

Our Midwifery Panel plays an important role in providing advice to the Council. It meets four times a year and the discussions and debates inform Council decisions in relation to midwifery.

The midwifery unit

Two full time senior midwifery advisers provide advice and guidance across to all of our colleagues in the NMC. This ensures that the midwifery voice is considered in all aspects of our operational work.

They also collaborate with midwifery stakeholders outside the NMC - including the Royal College of Midwives - to ensure we collaborate on policies that will impact on women and families.

To get in touch with the midwifery unit, please get in touch.

Midwifery education

Lead midwives for education (LMEs) are employed by approved education institutions (AEIs) that provide pre-registration midwifery programmes.

We hold two meetings a year with the Lead Midwives for Education Strategic Reference Group (LMESRG) to discuss topics around midwifery education. Those conversations inform our work around the standards and quality assurance.

Communicating with midwives

Our quarterly newsletter highlights what we're doing to support you, and features midwives from across the UK.

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We're here to support midwives deliver the safe, kind and effective midwifery care that all women have a right to expect.

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Standards for midwives - The Nursing and Midwifery Council

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These standards represent the skills, knowledge and attributes all midwives must demonstrate.

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Self-Care Can’t Always be There (But it Needn’t be Far Away)

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Self-Care Can’t Always be There (But it Needn’t be Far Away)

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Self-Care Can't Always be There (But it Needn't be Far Away) | All4Maternity

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Self-Care Can't Always Be There (But It Needn't Be Far Away) Dr Jan Smith (she/her) -Director/Psychologist, Healthy You Ltd Instagram @drjansmithinsta Published in The Practising Midwife Volume 25 Issue 10 November 2022, Pages 19 https://doi.org/10.55975/PMZW9229 Introduction There aren't many people who would disagree that caring for ourselves is crucial, particularly when working in an emotionally [...]

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Exploring Patient Safety in Maternity and Midwifery Care

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Exploring Patient Safety in Maternity and Midwifery Care

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A Reflection on Perceptions of Safety During the Latent Phase of Labour

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A Reflection on Perceptions of Safety During the Latent Phase of Labour

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A Reflection on Perceptions of Safety During the Latent Phase of Labour | All4Maternity

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A Reflection On Perceptions Of Safety During The Latent Phase Of Labour Esther Byrne – Newly qualified midwife, Birmingham City University Instagram @estherjoy95 Published in The Practising Midwife Volume 26 Issue 03 March 2023, Pages 32-34 https://doi.org/10.55975/BZWF6978 Summary This reflection w…

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Effective Midwifery Leadership: Knowing Your Roots and Finding Your Passion | All4Maternity

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Effective Midwifery Leadership: Knowing Your Roots and Finding Your Passion Caroline Homer (she/her) - Co-Program Director, Maternal, Child and Adolescent Health and Professor of Midwifery, Burnet Institute Twitter @CarolineHomer Published in The Practising Midwife Australia Volume 01 Issue 06 July 2023, Pages 08-12 https://doi.org/10.55975/WESN3331 Summary In this feature article, a...

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Revalidation for your Midwifery registration

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Revalidation for your Midwifery registration

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Revalidation - The Nursing and Midwifery Council

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Revalidation is the process that all nurses, midwives and nursing associates need to go through to renew their registration with the NMC.

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If you have any questions, please do write them below 

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If you have any questions, please do write them below 

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Options for women and families in the UK

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Options for women and families in the UK

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Choosing your birth location

You can give birth at home, in a unit run by midwives (a midwifery unit or birth centre) or in hospital.

Your options about where to have your baby will depend on your needs, risks and, to some extent, on where you live.

If you're healthy and have no complications (low risk) you could consider any of these birth locations. If you have a medical condition, it's safest to give birth in hospital, where specialists are available. This is in case you need treatment during labour.

If you give birth at home or in a unit run by midwives, you're less likely to need assistance such as forceps or ventouse (sometimes called instrumental delivery).

Wherever you choose, the place should feel right for you. You can change your mind at any point in your pregnancy.

Find out what's in your area

Your midwife will discuss the options available in your area but, if you're willing to travel, you're free to choose any maternity services.

As well as from your midwife, you can get information from:

children's centres

your GP surgery

local maternity units - find maternity services near you

Maternity Voices Partnerships (MVPs) - ask at your local hospital's maternity unit

You may also want to get advice from your friends and family.

Talk to your midwife about going to have a look around the local maternity services, and ask questions if you do not understand something or think you need to know more.

Home birth

If you have a straightforward pregnancy, and both you and the baby are well, you might choose to give birth at home.

Giving birth is generally safe wherever you choose to have your baby.

But if you're having your first baby, home birth slightly increases the risk of serious problems for the baby - including death or issues that might affect the baby's quality of life - from 5 in 1,000 for a hospital birth to 9 in 1,000 for a home birth.

If you're having your second baby, a planned home birth is as safe as having your baby in hospital or a midwife-led unit.

It's rare but, if something goes seriously wrong during your labour at home, it could be worse for you or your baby than if you were in hospital with access to specialised care.

If you give birth at home, you'll be supported by a midwife who will be with you while you're in labour. If you need any help or your labour is not progressing as well as it should, your midwife will make arrangements for you to go to hospital.

Advantages of home birth

The advantages of giving birth at home include:

being in familiar surroundings, where you may feel more relaxed and better able to cope

not having to interrupt your labour to go into hospital

not needing to leave your other children, if you have any

not having to be separated from your partner after the birth

increased likelihood of being looked after by a midwife you have got to know during your pregnancy

lower likelihood of having an intervention, such as forceps or ventouse, than giving birth in hospital

Considerations

There are some things you should think about if you're considering a home birth.

You may need to transfer to a hospital if there are complications.

Epidurals are not available at home, but you can use gas and air, a warm bath, a birth pool, TENS and any relaxation techniques you've learned. Find out about pain relief in labour.

Your doctor or midwife may recommend you give birth in hospital - for example, if you're expecting twins or if your baby is lying feet first (breech). Your midwife or doctor will explain why they think a hospital birth is safer for you and your baby.

If you choose to give birth at home or in a unit run by midwives, you should be given information by your midwife or GP about what would happen if you had to be transferred to hospital during labour and how long this would take.

Planning a home birth

Ask your midwife whether a home birth is suitable for you and your baby.

If it is, your midwife will arrange for members of the midwifery team to help and support you. Here are some questions you might want to ask:

how long would it take if I needed to be transferred to hospital?

which hospital would I be transferred to?

would a midwife be with me all the time?

how do I obtain a birthing pool?

Midwifery units or birth centres

Midwifery units or birth centres are more comfortable and homely than a maternity unit in a hospital. They can be:

part of a hospital maternity unit, where pregnancy (obstetric), newborn (neonatal) and anaesthetic care is available

separate from a hospital, and without immediate obstetric, neonatal or anaesthetic care

Advantages of a midwifery unit or birth centre

The advantages of giving birth at a midwifery unit include:

being in surroundings where you may feel more relaxed and better able to cope with labour

being more likely to be looked after by a midwife you have got to know during your pregnancy

the unit potentially being much nearer your home

lower likelihood of having an intervention such as forceps or ventouse than giving birth in hospital

Considerations

There are some things to think about if you're considering giving birth in a midwifery unit or birth centre.

You may need to be transferred to a hospital if there are any complications.

In a unit that's completely separate from a hospital, you won't be able to have certain kinds of pain relief, such as an epidural. Ask your midwife whether the unit or centre is part of a hospital or completely separate.

Your doctor or midwife may feel it's safer for you to give birth in hospital

Planning a birth in a midwifery unit or birth centre

Ask your midwife if there are any midwifery units or birth centres in your area. There may be others you can use if you're prepared to travel.

Hospital birth

Most births happen in an NHS hospital maternity unit. If you choose to give birth in hospital, you'll be looked after by midwives, but doctors will be available if you need their help.

You'll still have choices about the kind of care you want. Your midwives and doctors will provide information about what your hospital can offer.

Advantages of hospital birth

The advantages of giving birth in hospital include:

direct access to obstetricians if your labour becomes complicated

direct access to anaesthetists, who give epidurals and general anaesthetics

there will be specialists in newborn care (neonatologists) and a special care baby unit if there are any problems with your baby

Considerations

There are some things you should think about if you're considering a hospital birth:

you may go home directly from the labour ward or you may be moved to a postnatal ward

in hospital, you may be looked after by a different midwife from the one who looked after you during your pregnancy

you're more likely to have an epidural, episiotomy, or a forceps or ventouse delivery in hospital

Planning a hospital birth

Your midwife can help you decide which hospital feels right for you. If there's more than one hospital in your area, you can choose which one to go to. Find out more about the care provided in each so you can decide which will suit you best.

Birth questions to ask

Here are some questions you might want to ask if you're considering having your baby in a midwifery unit or birth centre, or in hospital:

Are tours of the maternity facilities available before the birth?

When can I discuss my birth plan?

Are TENS machines available for pain relief or do I need to hire one?

What equipment is available - for example mats, a birthing chair or bean bags?

Are there birthing pools?

Are fathers, close relatives or friends welcome in the delivery room?

Are they ever asked to leave the room - if so, why?

Can I move around in labour and find my own position for the birth?

What is the policy on induction, pain relief and routine monitoring?

Are epidurals available?

How soon can I go home after the birth?

What services are provided for premature or sick babies?

Who will help me if I choose to formula feed?

Will my baby be with me all the time or is there a separate nursery?

Are there any special rules about visiting?

How long would it take if I needed to be transferred to hospital from a birth centre?

Which hospital would I be transferred to?

Would a midwife be with me all the time?

Wherever you decide to give birth, you can change your mind at any stage of pregnancy. Talk to your midwife if there's anything you're not sure or want to know more about.

For more information visit birthrights.

If you are thinking about unassisted birth

You can choose to have a home birth without a midwife with you (unassisted birth). This is sometimes called freebirth.

Talk to a midwife if you are worried about your care.

They can:

discuss with you the role of the midwife and help you make an informed choice

personalise your care and support so it's right for you.

If you decide to have an unassisted birth, you can change your mind at any time during your pregnancy or labour. NHS midwives will always be available to support you.

A midwife can offer you support and advice during labour, and check on the health of you and your baby. They'll know if you or your baby need help, and can arrange for medical attention if needed.

If you have an unassisted birth, you'll need to tell a GP or local maternity services about your baby's birth as soon as they've been born. This is because by law every birth in the UK needs to be recorded (notified) within 36 hours. A GP or midwife will need to see you before they can notify the birth.

When the birth has been notified, your baby will get an NHS number for their NHS care.

Further information:

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Find out about your options for where to give birth: at home, in hospital or at a midwife-led (midwifery) unit. Learn more about which pain relief methods will be available.

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Can I choose where to give birth?

Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives. It can be part of a hospital or completely separate.

Your NHS trust may automatically book you into a hospital or birth centre. You can ask to discuss this and make your own choice.

A healthcare professional may say you 'need' or 'have' to give birth in a hospital. You can ask them why they think this. What medical reasons do they have for this advice? You do not have to agree with them.

In some cases, there may be restrictions on your right to choose a hospital or birth centre. However, no-one can make you give birth away from home if you want to stay at home.

The only time someone else can decide for you about where you give birth, or your treatment, is if you lack mental capacity. This is very rare, but we describe what mental capacity is below.

Yes. You have a right to choose where you give birth. You cannot be made to go to hospital. Healthcare professionals may want to talk to you about your plans and any concerns they have. This should be an opportunity to have an open discussion and to share information. They should always respect your views and choices.

All NHS Trusts are expected to run a home birth service. This is not guaranteed in law, but the law says that your right to choose where to give birth should only be restricted when there is a good reason to do this, and where the decision is 'proportionate'.

This means that a Trust should only pause their home birth service if they have looked at all the options for keeping it going and they are still unable to.

If you are told you cannot give birth at home because of staff shortages, remind the hospital that it must make sure there are enough staff to provide the services it has promised. They should have plans for situations such as staff shortages. This could include providing an independent midwife.

Yes. The Nursing and Midwifery Council's Code says that midwives must put your interests first and make your safety their main concern. This is their professional duty.

Midwives should respect your decision to give birth outside the hospital. They should attend you at home if you ask for this, even if they don't agree with your decision.

If you are in labour and the hospital tells you there is no midwife to attend you, (and that they will send an ambulance), you cannot be made to attend hospital if you do not want to. You or your birth partner can ask to speak to the Head of Midwifery and ask them to provide a midwife.

If a midwife - or any healthcare professional - has breached their duty of care, you can complain. Duty of care means that they must care for you and keep you safe. They can be referred to their regulatory body, which will investigate.

Yes. Only you have the right to decide where you give birth. No one can overturn the decision you have made. This is the law.

The only time that someone else can make decisions about your healthcare is if you lack mental capacity to make those decisions. This is very rare.

Even if healthcare professionals advise you not to give birth at home, no one can make you go to hospital.

Your midwife and hospital consultant (if you have one) should work with you to make a care plan for giving birth at home.

When professionals give you advice and information about where to give birth, it should be based on facts, not personal opinions.

Healthcare professionals must not put pressure on you, or threaten you, when you are deciding where to give birth. They must not threaten to involve social services. If you feel this has happened, you may not have given consent to the treatment you received. This could mean that the healthcare professional can be taken to court for failing to obtain your consent.

Yes. All people in the UK have a right to maternity care in hospital.

Your GP will tell you which hospitals have maternity services in your area, and you can choose which one to use.

You can ask to use a different hospital. If your GP will not refer you to the hospital you choose, you can refer yourself. Look on the hospital's website or ask its maternity team for the self-referral form.

Yes. The government says everyone in the UK should be able to choose between giving birth in hospital, in a birth centre, or at home. You should be offered a full discussion of the risks and benefits of the options you are considering.

If there is no birth centre in your area, or you want to use a different birth centre, you can ask your GP to refer you or you can refer yourself.

Birth centres often have rules, called admissions criteria, that say people with 'high risk' pregnancies cannot use the centre.

These are not legal rules and they cannot be applied in a blanket way. The centre should use them only to guide them when making a decision about who can use the centre.

The birth centre must only refuse to allow you to use the centre if they feel they cannot provide you with safe care. The centre must have a good evidence-based reason that shows you or your baby are at high risk of harm when giving birth without the support of a hospital obstetric ward. The centre must be able to show that it cannot safely manage that risk. They should consider the risk on a case-by-case basis, looking at what the risks are in your personal situation.
For example, a birth centre might say you cannot use the centre if your labour is being induced and where medical advice strongly recommends the monitoring of your contractions.
Or the birth centre's rules might say that you cannot use the centre if your body mass index (BMI) is above a certain level. However, they should look at what the specific risks are in your case and whether they can be safely managed. They need to have evidence for what they say. They need to discuss it with you, and if they think they cannot safely care for you in the birth centre they need to discuss what alternatives they can suggest (for example, offering similar support such as a birth pool on the labour ward).

Both hospitals and birth centres must make 'reasonable adjustments' so that anyone with a long-term health condition or disability has equal access to their services. This is law, under the Equality Act 2010.

These adjustments could be in the way the hospital or birth centre provides care, accessing and navigating the buildings, providing equipment, or providing services such as British Sign Language interpreters or extra support.

The Equality Act 2010 says the midwifery team should talk to you about what adjustments you need. Your midwife can also ask for help from other teams in the hospital, such as Occupational Therapy, if necessary.

They should talk to you from the start of your pregnancy so that together you can work out the best way they can support you throughout your pregnancy, in labour, and during your post-natal care.

Having a long-term health condition, disability or sensory impairment does not take away your right to choose where you give birth.
For example, a woman who uses a wheelchair should be given a room that she can access in her wheelchair as well as a bathroom that she can comfortably access. She should also be provided with appropriate aids such as a shower stool and toilet frame. An autistic person may ask for a familiarisation tour of the ward or have sensory considerations in their birth plan to make the environment accessible.
If you need help to communicate with healthcare professionals, ask as early in your pregnancy as possible so that you can make informed choices from the beginning.

This might be support with British Sign Language interpreters, large print materials or materials in a form that is suitable for your screen reader.

This might be access to an interpreter for your appointments and care.

Yes. A birth plan lets you tell healthcare professionals about the kind of treatment and care you want.

Your midwife or doctor should help you to make a birth plan (this may be called a personalised care and support plan) that will be included within your maternity records (your digital or handheld notes). If you choose care that is 'out of guidelines' then you may find it helpful to make your birth plan with a consultant midwife or doctor. Your plan should be recorded so that any doctors or midwives who care for you can find it. You might also want to print a copy so that you can give it to your doctor or midwife when you are in labour.

This can include where you want to give birth, so thinking about your birth plan will help you to explore the options and decisions you might make.

You may find it useful to think about what is important to you before you make your birth plan. This can help you to think of the questions you want to ask the healthcare professionals who are supporting you. It can help you have a clear and respectful discussion with them about where you want to give birth and what care you want during and after the birth. You can read more about birth plans on our factsheet Consenting to treatment.

Your midwife and doctor should provide you with information and personalised discussions to help you make informed choices about your care.

When you make your decision, your midwife should support you. They should listen to you and respect what you say. They should help you to get the maternity care you choose.

If you are struggling to find this support, contact the Director or Head of Midwifery at your hospital. If you don't know the details for the Head of Midwifery, you can ask your midwife and/or the Patient Advice and Liaison service (PALS) (in England and Wales) to put you in touch. The Trust website will have a page with PALS details on it. If you are worried, you can look these details up in case you need them.

The Nursing and Midwifery Code says that all midwives must treat people as individuals and respect and uphold their rights. Your midwife is your advocate. They should support you even if your decision doesn't fit the hospital or birth centre's guidelines.

You may want to choose a hospital or birth centre in another area, for example to be near family support. Or you may need to change to a Trust if your circumstances change, for example if you move to a new area during your pregnancy.

If you move, you can book with a hospital or birth centre in your new area for care. You can do this directly by looking on the hospital's website or asking its maternity team for the self-referral form. Alternatively, your GP in your new area can help. You should be able to do this even if you are very late in your pregnancy. You can also ask to book with the home birth team, although they may have a limit on numbers of people they can book or how late they can accept bookings, depending on how they are staffed.

If you are having trouble booking for care after a move, you can contact us for support.

If you are told that you cannot choose the hospital or birth centre you want because you do not live in the right area, you can ask for an exception to be made. Ask:

Even if their policy says you cannot use the services you have asked for, you can ask them to look at the reasons why you want this hospital or birth centre. They need to give you a good reason if they say no.

Wherever you give birth, your postnatal care will be provided in your home area.

Many NHS Trusts now offer only online video tours, photographs or leaflets about their maternity wards and birth centres. These can help you familiarise yourself with the maternity unit. You do not have a right to an in-person tour.

However, if you have a disability or health condition that means you may need reasonable adjustments, ask to visit the hospital or birth centre so that you and the healthcare professionals working with you can plan ahead.

You might want to look at physical adjustments that will be needed, such as a hoist. If you have a visual impairment, the position and nature of the lighting could be important. Autistic people often want to visit ahead so that they know what to expect and can ask for changes that will make their birth experience easier. The key is that everyone is different so you need to visit in order that you and the healthcare team can plan your individual care.

You have the right to ask for a water birth. The hospital or birth centre may have rules about who can have a water birth but these are not legal rules. You can ask how many rooms have a pool in the birth centre or hospital.

If your care team has concerns about whether a water birth is safe, they should offer you a respectful discussion on the risks and benefits in your situation so that you can make an informed decision.

The hospital or birth centre should only say that you cannot access a water birth if they have a good reason based on clinical evidence.

Your midwife and doctor should also help you consider other options, such as using water for pain relief in labour but not for the birth itself.

If you choose a water birth at the birth centre or hospital, you may not be able to access a pool if there is not one free when you arrive. If you are unsure whether a pool will be available, some people decide to hire their own pool for use at home and then transfer when they are ready. If you have a home birth, you can buy or hire a pool to use at home.

Mental capacity means that you can understand the choice you need to make about treatment and can make a decision.

In law, everyone has mental capacity unless it can be shown that you do not.

Very rarely, someone may not be able to give consent to treatment because they are unable to make a decision that they need to make, even when it is very clearly explained and they are given lots of support.

It is very rare to not have mental capacity.

The people caring for you cannot say you do not have mental capacity simply because you do not agree with them.

Most people do not have to pay for their care. The NHS provides free care to those who are 'ordinarily resident' in the UK. If you are not 'ordinarily resident' then you may have to pay for your care. If this applies to you, then this includes maternity care in hospital, in the community and at home. Your NHS Trust must tell you if you will be charged for your care.

Even if you have to pay for your care and cannot afford to do so, you must still be given maternity care. You cannot be told that you have to wait until you can pay.

The rules about who has to pay for care, and how charging works are very complicated.
Guidance giving you the choice of where to give birth
The 2016 Better Births report for NHS England set out that women should be able to decide where they want to give birth; whether this is at home, in a midwifery unit or in an obstetric unit. This also applies to birthing people who do not identify as women.

The other nations of the UK have the same expectations of maternity services in their areas. Here is their guidance:
Guidance on home births
The legal position is that you have the right under Article 8 of the Human Rights Act to a private and family life which includes the right to choose where you give birth and who is present.

However, this is a qualified right which means that the rights can be restricted where there is a legitimate aim such as protecting the health of others, and the restriction is 'proportionate'.

This means that the Trust should only suspend their home birth service if they have looked at all the options for keeping it going including using local Independent Midwives or bringing back retired midwives to supplement their team, and looking at alternative ways to transfer into hospital if the ambulance service is under pressure (this last realistically applies only in times of severe crisis such as a pandemic).

The UK's guidance is set out in:

In 2016 the NHS Ombudsman accepted that an NHS Trust that suspended its home birth services and refused to make contingency plans was acting unreasonably. They were told to start providing the service again and to work with other Trusts to provide support for home birth in the meantime.
The Nursing and Midwifery Council Code
The Nursing and Midwifery Council Code sets out professional standards of behaviour for nurses, midwives and nursing associates in the UK. It says that midwives need to put the interests of people using maternity care first.
About Birthrights
Birthrights factsheets give you information about your human rights when you are pregnant and giving birth.

Birthrights champions respectful care during pregnancy and childbirth by protecting human rights. We provide advice and information to women and birthing people, train doctors and midwives, and campaign to change maternity policy and systems.

We are a charity, independent of the government and the NHS.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
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Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Can I choose where to give birth? Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives.

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Part One: Taking Hold of the Opportunity to Move into Education

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Part One: Taking Hold of the Opportunity to Move into Education

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Taking Hold of an Opportunity to Move into Education | All4Maternity

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Taking hold of an opportunity to move into education Rebecca Baker - Midwife, and Associate Lecturer in Midwifery at University of Suffolk Published in The Practising Midwife Volume 22 Issue 3 March 2019 Following qualifying as a midwife in 2015, I worked within my local trust for three years as a rotational midwife.

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Taking Hold of an Opportunity to Move into Education

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Taking Hold of an Opportunity to Move into Education

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Taking Hold of an Opportunity to Move into Education | All4Maternity

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Taking hold of an opportunity to move into education Rebecca Baker – Midwife, and Associate Lecturer in Midwifery at University of Suffolk Published in The Practising Midwife Volume 22 Issue 3 March 2019 Following qualifying as a midwife in 2015, I worked within my local trust for three years as a r…

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Understanding and addressing root causes is important to promoting safety

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Understanding and addressing root causes is important to promoting safety

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"Normal birth at any cost" - Understanding and addressing root causes is important to promote safety in UK maternity services | All4Maternity

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"Normal birth at all costs" - Understanding and addressing root causes is important to promote safety in UK maternity services Ms Florence Darling Midwife/Researcher City University, London Practices underpinned by "normal birth as all cost" are reported as a contributory factor in the failings in two UK maternity services.