Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: A case note review study

Objectives Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews. DesignAnonymised case notes review. Participants All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014. Main outcome measures The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed. Results The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140). Conclusions This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014:a case note review study

ObjectivesLocal reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.DesignAnonymised case notes review.ParticipantsAll 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012–2014.Main outcome measuresThe number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.ResultsThe care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).ConclusionsThis systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

Community postnatal care delivery in England since Covid-19 : a qualitative study of midwifery leaders' perspectives and strategies.

COVID-19 impacted negatively on maternity care experiences of women and staff. Understanding the emergency response is key to inform future plans. Before the COVID-19 pandemic, experts highlighted concerns about UK community postnatal care, and its impact on long-term health, wellbeing, and inequalities. These appear to have been exacerbated by the pandemic. To explore community postnatal care provision during and since the pandemic across a large diverse UK region. A descriptive qualitative approach. Virtual semi-structured interviews conducted November 2022-February 2023. All regional midwifery community postnatal care leaders were invited to participate. 11/13 midwifery leaders participated. Three main themes were identified: Changes to postnatal care (strategic response, care on the ground); Impact of postnatal care changes (staff and women's experiences); and Drivers of postnatal care changes in (COVID-19, workforce issues). Changes to postnatal care during the pandemic included introduction of virtual care, increased role of Maternity Support Workers, and moving away from home visits to clinic appointments. This has largely continued without evaluation. The number of care episodes provided for low and high-risk families appears to have changed little. Those requiring additional support but not deemed highest risk appear to have been most impacted. Staffing levels influenced amount and type of care provided. There was little inter-organisation collaboration in the postnatal pandemic response. Changes to postnatal care provision introduced more efficient working practices. However, evaluation is needed to ensure ongoing safe, equitable and individualised care provision post pandemic within limited resources

Midwives’ perspectives of continuity based working in the UK: A cross-sectional survey

Objective: UK policy is advocating continuity of midwife throughout the antenatal, intrapartum and postnatal period in order to improve outcomes. We explored the working patterns that midwives are willing and able to adopt, barriers to change, and what would help midwives to work in continuity models of care.Design: A cross-sectional survey.Setting: 27 English maternity providers in the seven geographically-based ‘Early Adopter’ sites, which have been chosen to fast-track national policy implementation. Participants: All midwives working in the ‘Early Adopter’ sites were eligible to take part.Method: Anonymous online survey disseminated by local and national leaders, and social media, in October 2017. Descriptive statistics were calculated for quantitative survey responses. Qualitative free text responses were analysed thematically.Findings: 798 midwives participated (estimated response rate 20% calculated using local and national NHS workforce headcount data for participating sites). Being willing or able to work in a continuity model (caseloading and/or team)was lowest where this included intrapartum care in both hospital and home settings (35%, n = 279). Willingness to work in a continuity model of care increased as the range of intrapartum care settings covered decreased (home births only 45%, n = 359; no intrapartum care at all 54%, n = 426). A need to work on the same day each week was reported by 24% (n = 188). 31% (n = 246) were currently working 12 h shifts only, while 37% (n = 295) reported being unable to work any on-calls and/or nights. Qualitative analysis revealed multiple barriers to working in continuity models: the most prominent was caring responsibilities for children and others. Midwives suggested a range of approaches to facilitate working differently including concessions in the way midwife roles are organised, such as greater autonomy and choice in working patterns.Conclusions: Findings suggest that many midwives are not currently able or willing to work in continuity models, which includes care across antenatal, intrapartum and postnatal periods as recommended by UK policy.Implications for Practice: A range of approaches to providing continuity models should be explored as the implementation of ‘Better Births’ takes place across England. This should include studies of the impact of the different models on women, babies and midwives, along with their practical scalability and cost

Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme ‘Early Adopter’

Background: Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding ‘what works’ in large system transformation. Methods: A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper. Results: Alignment of transformation work with Best et al’s rules for ‘what works’ in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new ‘system’ limiting system leaders’ power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change. Conclusions: Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands

Women's experiences of induction of labour during the COVID-19 pandemic:a cross-sectional survey

Background/Aims: Induction of labour is an increasingly common intervention. This study's aim was to explore women's experiences of induction, in particular of decision making and choice.Methods: A cross-sectional study was carried out with women who were induced with live, term infant(s) in two urban trusts. Their experiences were assessed using a postal survey that included the birth satisfaction scale and open questions on women's experiences. Chi-squared and Fisher's exact tests were used to test for associations between aspects of the induction process and women's characteristics (age, parity, ethnic group). Qualitative data were analysed thematically.Results: Half (52.9%) of the respondents reported waiting to start induction. The majority felt sufficiently involved in decision making (62.1%) and choice (59.6%). Most reported having enough information about the reason for (82%) and process of (83%) induction. The qualitative themes were emotional response, communication, feeling unheard, quality of care and the negative impact of COVID-19 policies.Conclusions: Women's overall experiences were positive. Improvements should focus on reducing delays to induction

Induction of labour care in the UK : a cross-sectional survey of maternity units

Objectives: To explore local induction of labour pathways in the UK National Health Service to provide insight into current practice. Design: National survey. Setting: Hospital maternity services in all four nations of the UK. Sample: Convenience sample of 71 UK maternity units. Methods: An online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher’s Exact and ANOVA. Main outcome measures: Induction rates, criteria, processes, delays, incidents, safety concerns. Results: 54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported ‘often/always’ in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 ‘often/always’). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work. Conclusions: There is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care

Preferences for deinfibulation (opening) surgery and female genital mutilation service provision: A qualitative study

© 2022 The Authors. Published by Wiley. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://doi.org/10.1111/1471-0528.17358Objective To explore the views of female genital mutilation (FGM) survivors, men and healthcare professionals (HCPs) on the timing of deinfibulation surgery and NHS service provision. Design Qualitative study informed by the sound of silence framework. Setting Survivors and men were recruited from three FGM prevalent areas of England. HCPs and stakeholders were from across the UK. Sample Forty-four survivors, 13 men and 44 HCPs. Ten participants at two community workshops and 30 stakeholders at a national workshop. Methods Hybrid framework analysis of 101 interviews and three workshops. Results There was no consensus across groups on the optimal timing of deinfibulation for survivors who wished to be deinfibulated. Within group, survivors expressed a preference for deinfibulation pre-pregnancy and HCPs antenatal deinfibulation. There was no consensus for men. Participants reported that deinfibulation should take place in a hospital setting and be undertaken by a suitable HCP. Decision making around deinfibulation was complex but for those who underwent surgery it helped to mitigate FGM impacts. Although there were examples of good practice, in general, FGM service provision was suboptimal. Conclusion Deinfibulation services need to be widely advertised. Information should highlight that the procedure can be carried out at different time points, according to preference, and in a hospital by suitable HCPs. Future services should ideally be developed with survivors, to ensure that they are clinically and culturally appropriate. Guidelines would benefit from being updated to reflect the needs of survivors and to ensure consistency in provision.This study is funded by the National Institute for Health Research (NIHR) Health Technology Assessment (project reference 16/78/04)

A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality

Background Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. Methods National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified. Findings There were no major differences causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). Interpretation This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. Funding This research is funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217–21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care