New report investigates factors affecting the delivery of safe care in midwifery units

On 8^th May 2024, Maternity & Newborn Safety Investigations (MNSI) published a report based on an analysis of 92 Health Services Safety Investigations Body (HSSIB reports on safety incidents that involved care in midwifery units.

The MNSI programme was established to improve maternity safety across the NHS in England through investigations into maternity-related patient safety incidents. Originally a part of the HSSIB, it is now part of the Care Quality Commission (CQC).

Midwifery units

Midwifery units, sometimes called a ‘birth centre’ or ‘midwife-led unit’, are staffed by midwives and support workers. They are often chosen by pregnant women who have been assessed as being ‘low risk’. Midwifery units do not have obstetric doctors but can be on the same site (‘alongside’) as a hospital obstetric unit, where mothers can be transferred if needed.

Some midwifery units are freestanding (i.e. away from an obstetric unit). Women who need to access an obstetric unit in those units are transferred by ambulance or car.

The likelihood of a labouring woman needing to transfer to an obstetric unit is 22.5% from a freestanding midwifery unit and 25.6% from an alongside midwifery unit. However, for first-time mothers, these figures increase to 26% for those in a freestanding midwifery unit and 40% for those in an alongside midwifery unit.

Analysis into the delivery of safe maternity care in midwifery units

The MNSI analysis found four main factors affecting the delivery of safe care in midwifery units:

1. Work demands and capacity to respond in midwifery units
2. Issues with fetal monitoring
3. Preparedness for predictable obstetric and neonatal emergencies
4. Issues with telephone triage in midwifery units

Work demands and capacity to respond in midwifery units

The review found that the outstripping of demand and capacity led to delays in care and safety-critical monitoring during labour and pointed to further evidence of the need to address midwifery staffing.

Work demand exceeding the capacity of the unit was identified as a factor in 43% of the maternity investigation reports, often resulting in delays in monitoring pregnant women and their babies or meeting other care needs.

The report noted an additional risk faced by midwifery units: they are affected not only by their own workload and capacity challenges but also by those of hospital obstetric units and ambulance trusts, which midwifery units are reliant on when urgent transfers are necessary.

Worryingly, in 27.5% of the incidents analysed, women were reportedly sent to, or remained in, midwifery units even where they were not assessed as having a low risk of complications and needed additional care that the midwifery unit could not provide. This was attributed to capacity challenges in obstetric units.

Further, case studies demonstrated that capacity pressures in the ambulance service resulted in delays in ambulances attending freestanding midwifery units and a consequent delay in transfer to an obstetric unit for care.

The report references examples where workload and staffing levels resulted in midwifery units being closed due to staff shortages. Worryingly, some families described being unaware that this was a possibility when making their choice about where to give birth.

Issues with fetal monitoring in midwifery units

Intermittent auscultation (IA) is the usual method of fetal heart monitoring in midwifery units (unlike in obstetric units where continuous monitoring is common). IA requires a midwife to count the number of heartbeats heard over one minute. The woman’s pulse should be felt and separately recorded to differentiate it from the baby’s heart rate.

The report highlights issues with the reliability and sensitivity of this method of monitoring fetal wellbeing.

A 2020 confidential inquiry into 64 deaths of babies during birth in midwifery units found that IA was used in 72% of these and issues with this method were identified in over half of those.

Issues include:

• Timing of the intermittent auscultation
• Poor, inadequate or confusing recording of the fetal heart rate
• Errors in interpretation of the baby’s heart rate
• Mistaking the fetal heart rate with the maternal pulse
• A failure or delay in recognising or acting on concerns with the fetal heart rate

The report found that difficulties with carrying out or interpreting results of intermittent auscultation were a factor in almost half of the analysed reports. It was felt that challenges with IA meant it may not always be a reliable or sensitive tool. Examples given to HSSIB included varied practices in the measurement and recording of the fetal heart rate and prolonged abnormalities which were not identified during IA.

The MNSI reported that, typically in their analysis, the baby’s heart rate was not examined as described in guidance or as frequently, and that issues were associated with a high workload. Of concern, even where carried out in line with guidance, there were instances considered where intermittent auscultation did not detect the deteriorating health of a baby. 

Preparedness of midwifery units for predictable safety-critical scenarios

The report notes that in both alongside and freestanding midwifery units, it is common for a pregnant woman or baby to need urgent transfer to hospital. The case reports analysed demonstrated that unfortunately, this process often did not go smoothly, resulting in a delay in care or treatment.

The report also found that there were issues with the facilities and access to equipment as well as inadequate training and preparation which hindered the ability of staff to respond effectively to emergencies. Examples given included the placement of emergency call bells, poor communication and staff not knowing where resuscitation equipment is kept.

The reports demonstrated the dependency on other services in the delivery of safe care in midwifery units, e.g. obstetric units and ambulance trusts. It was noted that training simulation for responding to safety-critical events needs to include staff from all services involved and does not always do so.

Issues with telephone triage in midwifery units

The report states that, in the examples, documentation of information and effectiveness of communication during triage calls was variable, particularly where the woman had spoken to different staff members across different sites using different record systems.

There was reportedly no consistency for where staff can expect to receive calls and why.

Conclusion

The MNSI programme is part of the Government’s national strategy to improve maternity safety across the NHS in England. Standalone midwifery units have long been considered a potential patient safety issue by specialist practitioners in obstetric negligence and our medical negligence solicitors welcome this highlighting of some of the most commonly occurring themes arising in a sample of patient safety incidents reported to HSSIB.

A key concern which has not been discussed in detail is the information given to pregnant women who are considering their birth choices about the important differences between a standalone midwifery unit and an alongside midwifery unit if obstetric or neonatal input is required.

NICE guidance indicates that women should have personalised discussions with their midwife in deciding where to have their baby.

It is necessary to be very clear with pregnant women about the potential delays involved in ambulance transfer in an obstetric emergency. This is of particular concern given the high percentage of women, particularly those giving birth to their first baby, who will need to be transferred to a hospital for obstetric care.

Useful resources for support

• Birth Trauma Association peer support: email support@birthtraumaassociation.org.uk
• Bliss (supporting parents/families of premature and sick babies): email hello@bliss.org.uk
• Sands (Stillbirth and Neonatal Death Society, for support following the death of a baby): call 0808 164 3332 or email helpline@sands.org.uk

Further information

If you have experienced a traumatic birth, if you or your child have suffered an injury during birth, or if you have any concerns about your maternity experience, our medical negligence solicitors may be able to help.

Call our team of obstetric negligence specialists on 0117 325 2929 or complete our enquiry form.