Action to ensure all women receive safe, effective, and personalised maternity care must be prioritised to prevent future tragedies

Published: 20 September 2021 Page last updated: 21 March 2022

A new report from the Care Quality Commission (CQC) highlights continued concern about the variation in the quality and safety of England’s maternity services - prompting the regulator to call for improvements to be prioritised to ensure safer care for all mothers and babies.

Published today (Tuesday 21 September) CQC’s ‘Safety, Equity and Engagement in Maternity Services’ presents an analysis of the key issues persisting in some maternity services and highlights where action is still needed to support vital improvements.

The report draws on the findings from a sample of nine focused maternity safety inspections carried out between March and June 2021, along with insight gathered from interviews and direct engagement with organisations representing women and their families, including equality campaign group Five X More and local Maternity Voices Partnerships.

While recognising that many maternity units across the country are providing good care, the report reveals ongoing concerns about leadership and oversight of risk, team working and culture, and the extent to which services are engaging with and listening to the needs of their local population. It also points to the pressing need to address the inequalities in outcomes for Black and minority ethic women and babies, which have been further exacerbated during the COVID-19 pandemic.

Last year CQC’s ‘Getting safer faster’ maternity briefing made a number of recommendations for action. It also set out CQC’s intention to retain a strong focus on the safety and quality of maternity services going forward. Following that briefing, CQC launched a programme of focused maternity safety inspections, targeting those services where monitoring of data and information from people working in and using maternity services indicated an increased safety risk.

In this latest report CQC notes a variation in the consistency and stability of leadership teams in the services they inspected and, in some services, that a shared purpose and sense of a united “maternity team” was lacking.

Inspectors saw some positive examples of multidisciplinary team training and learning. However, the extent to which staff were fully engaged with that training varied, and in some services, there was a lack of support for staff to maintain and develop their skills and individual competencies. Poor incident reporting was a further theme and staff did not always recognise what constituted an incident or how to grade incidents correctly.

Maternity Voice Partnerships (MVPs) are teams of women who use maternity services, commissioners, midwives and doctors who work together to review and contribute to the development of local maternity care. CQC interviews with MVP lay chairs highlighted inconsistency in the extent to which MVPs felt supported by their local trust. Some felt working with the trust maternity service was not always a collaborative process, or that the role of the MVP was not well understood by trust staff. There was also limited evidence that the maternity services inspected were targeting engagement towards women from Black and minority ethnic groups and women living in deprived areas. Similarly, most MVP chairs felt that engaging with women from Black and minority ethnic groups to understand their views and experiences was an area for improvement.

Poorer maternity outcomes for Black and minority ethnic women have been brought to the fore by the pandemic. In June 2020, the Chief Midwifery Officer, wrote to all NHS midwifery services calling on them to take four specific actions to minimise the additional risks faced by women and babies from Black and minority ethnic communities. The majority of services CQC inspected had carried out some work to implement these four actions, albeit to varying degrees. For example, how well maternity services used tailored communications to reach pregnant women from Black and minority ethnic groups varied. Some had worked collaboratively with their MVPs to co-produce videos to share messages around accessing care and the additional risks for certain groups, but initiatives like this were not apparent everywhere.

Ted Baker, CQC’s Chief Inspector of Hospitals, said:

“We know that there many maternity services are providing good 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.

“This report is based on a small sample of inspections carried out in response to evidence of risk so does not present a national picture. But we cannot ignore the fact that 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 and listen to the needs of local women all continue to affect the safety of some hospital maternity services today.

“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. It is essential that we have a system that is open, and that recognises, investigates, and learns when things go wrong, so that so that families get the truth, and safety continually improves.

“We also must do more to tackle the disparities in outcomes that exist for Black and minority ethnic women. Addressing inequalities 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.

“Safe, high-quality maternity care should be the minimum expectation for all women and babies, and it’s what staff working in maternity services across the country want to deliver. We have seen good progress in some services, but we must now accelerate the pace of change across all services to prevent future tragedies from occurring and ensure that women and babies get consistently safe care every time.”

James Titcombe, Patient Safety and Policy Consultant, Baby Lifeline said:

“Since the Morecambe Bay report was published in 2015, improving the quality and safety of maternity care has been a national priority. Despite this, today’s report highlights that in too many maternity units, concerns around leadership, oversight of risk, teamwork and culture are still negatively impacting the care of women and families.

“It’s particularly disappointing to see that in some services, staff weren’t fully supported to develop skills and competencies through multidisciplinary team training and learning and that a shared purpose and sense of a united “maternity team” was lacking. The report also highlights the urgent need for more action to be taken to address the inequalities in outcomes for Black and minority ethic women and babies.

“Today’s report acknowledges that good progress had been made in some areas, but it’s clear that the pace of change needs to rapidly accelerate and more needs to be done to reduce variation and spread the examples of where maternity services are getting things right.

“Avoidable harm during childbirth can have a truly devastating and life changing impact on families and staff, it’s crucial that there is now a commitment from everyone involved in delivering maternity care to come together with a shared purpose and goal – and that we work together to address the issues today’s report highlights with a renewed sense of urgency and pace.”

CQC will continue to promote and check on open and honest cultures within maternity services as part of its regulatory oversight. The Commission has also made a commitment to work together with partner organisations, maternity services and those using them to help tackle persisting health inequalities – a core ambition of the regulator’s new strategy.

In addition, CQC has set out the following recommended next steps for maternity services and wider system partners to help address the issues identified in today’s report and support improvements for those using and working in maternity services across the country.

Leadership: In line with essential action 2 of the 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. 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

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.