World Patient Safety Day

Published 17 September 2021

This year the theme of the WHO’s World Patient Safety Day is dedicated to the need to prioritise and address safety in maternal and newborn care, particularly around the time of childbirth.  Professor James Walker, the Clinical Director of Maternity Investigation at the Healthcare Safety Investigation Branch, has welcomed this theme, saying that safety in maternal and newborn care “is fundamental for the health and wellbeing of all societies.  A healthy mother and child are the centre of the family group and the future of the nation.  The death or damage that result from unsafe maternity care leads to lifetime health and emotional effects on the extended family group and society as a whole.  Getting it right first time and reducing the risk of damage or death is a reflection on the nation’s desire to advance and improve the life of all”.

In this article, we look back at some of the key reports published in this area over the past year, and Dr Sarah Winfield, Consultant Obstetrician at Leeds Teaching Hospitals NHS Trust and Regional Lead Obstetrician for the North East and Yorkshire and the Humber, also provides some of her own reflections on developments in maternity safety over the past year and looks to the future.

Key Publications In 2020/2021

• Donna Ockenden, who is conducting a review into maternity services at the Shrewsbury & Telford Hospital NHS Trust, published a report of her emerging findings and recommendations in December 2020. It not only set out learning points for Shrewsbury & Telford Hospital NHS Trust, but also seven areas of essential action that all maternity services across the NHS should implement in order to improve patient safety.  Her recommendations included that there should be collaboration between neighbouring Trusts in order to ensure that local serious incident investigations have regional oversight, that there should be better multidisciplinary training of maternity staff, and that agreement should be reached in relation to the criteria for referral of mothers with complex pregnancies to tertiary centres.  A link to the report can be found here.

• In February 2021 the Healthcare Safety Investigation Branch published a National Learning Report on severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia. The report advocated the use of three tools to try to minimise the risk of shoulder dystocia: (i) the Cochrane review by Boulvain et al regarding induction of labour at or near term for suspected fetal macrosomia, (ii) IDECIDE (a digital tool that is being developed by NHS England and Improvement to help frontline staff with communication, decision-making and consent processes when obstetric interventions and recommended) and (iii) the BRAIN acronym (i.e. benefits, risks, alternatives, implications, intuition and nothing) as a useful mnemonic for clinicians to use when having discussions with mothers regarding their options for birth.  A link to the report can be found here.

• Group B Strep Support published a report entitled “Preventing Group B Strep infections in babies: failure to turn national recommendations into local guidelines”, which identified a widespread lack of compliance with the RCOG guideline relating to this common type of infection. It recommended that the 19% of Trusts who had not yet updated their local guidelines to comply with the RCOG guideline should do so, and it also recommended that all pregnant women should be provided with an information leaflet on Group B Strep and that all Trust should routinely collect data on Group B Strep infection in babies locally (amongst other recommendations).  A link to the report can be found here.

• In July 2021 the House of Commons Health and Social Care Committee published a wide-ranging report on the safety of maternity services in England. The report sought to address what it described as “worrying variation in the quality of maternity care which means that the safe delivery of a healthy baby is not experienced by all mothers”.  It made recommendations in three categories to try to correct this longstanding problem, i.e. supporting maternity services and staff to deliver safe maternity care, learning from patient safety incidents (including reform of the clinical negligence system), and providing safe and personalised care for all mothers and babies.  A link to the report can be found here.

• NICE published a new guideline on antenatal care (NG201) in August 2021. It set out recommendations in relation to the organisation and delivery of antenatal care, routine antenatal clinical care, information and support for pregnant women and their partners, and interventions for common problems during pregnancy.  The guideline particularly highlights the risks of venous thromboembolism, gestational diabetes, pre-eclampsia and hypertension in pregnancy (and the steps that can be taken to mitigate those risks) and it makes several recommendations relating to the monitoring of fetal growth and wellbeing and also breech presentation.   A link to the guideline can be found here.

• At NHS Resolution, the Early Notification Scheme increased its collaboration with the Healthcare Safety Investigation Branch in relation to the investigation of birth injuries, and it also initiated a new “outcome first” approach to its investigations. You can listen to a podcast with Sangita Bodalia, the Head of Legal at the Early Notification Scheme team, about these initiatives here.

Reflections of Dr Sarah Winfield

"With all of my colleagues in maternity services, I am delighted that the focus of World Patient Safety day 2021 is the care of mothers and their babies.

The global call to action should be loud and clear; it is encouraging to see a decline in global maternal mortality of 38% between 2000 and 2017 (Unicef), but we need to do better. It is not acceptable that a woman having her baby in sub-Saharan Africa is more likely than a woman in the UK to die during pregnancy, childbirth and the postnatal period.  Access to safe maternity services makes a huge difference to outcomes for women and their babies and the ‘safety net’ needs to be cast wide. Even in the UK, maternal mortality rates (2016-20218 MBRRACE-UK 2020) demonstrated that black women in the UK are 80-83% more likely to experience a ‘near miss’ during pregnancy and childbirth, and are up to 4 times more likely to die during this time. The #BlackMaternalHealthDebate is now being highlighted through movements like the @fivemore campaign, campaigning to change black women’s maternal health outcomes in the UK. This movement has gained traction through social media and TV coverage, and this is excellent. People are listening and long may this continue.

Looking at maternity services in the UK, these have continued to run during the COVID-19 pandemic and this has been a challenging time. The patient journey has changed, with more telephone appointments, anxiety about catching COVID through hospital attendance, partners having initially restricted access and other factors that have affected the experience of parents having a baby. All staff and keyworkers in the NHS and other areas have worked hard during the pandemic to keep the country going through very challenging circumstances, but maternity staff in particular have delivered care safely during  these difficult times, with many people now suffering from exhaustion and ‘burnout’, as well as many frontline staff having been directly affected by COVID.

Publication of the Ockenden report in December 2020 shone light directly onto maternity safety in all units, and asked teams to demonstrate that they were providing safe maternity care but also fostering a culture of kindness, learning together, and really listening to women and their families.

Women with complex medical problems that are known about before pregnancy or that develop during the course of pregnancy are at high risk of poor outcomes, but the implementation of maternal medicine networks with Obstetric Physicians as part of the maternity team, aims to ensure that a pregnant woman/birthing person receives optimal care wherever they attend, be it a midwife clinic or hospital admissions unit. Other great achievements in maternity safety, include raising the profile and work of Maternity Voices Partnerships, the work of the Maternity and Neonatal Safety Improvement Program and the Health and Safety Investigation Branch (HSIB), plus the National Maternity Transformation Program overseeing the delivery of the ambitions of Better Births through local maternity systems, clinical networks and regional maternity teams. 

Also the development of a regional Chief Midwife and Chief Obstetrician in each of the 7 regions in England lends a multidisciplinary approach to supporting and strengthening the oversight and expertise required to help us to make the best experiences and outcomes possible for women/birthing people and their families. We all need to work together and there is an appetite to do this, not just on the frontline but also with leaders who are engaged and genuinely want make a difference to ensure that pregnancy, childbirth and the postnatal period is safe for all women. There is a lot to do, but these are busy and exciting times and women and their babies are at the heart of this work."

As Dr Winfield says, there is now an increasing and very welcome focus on safety in maternity and neonatal services, as reflected in the plethora of reports and initiatives that have been launched in the past year, and in the decision of the WHO to make safety in maternal and newborn care the theme of this year’s World Patient Safety Day.  It is to be hoped that, by the time World Patient Safety Day 2022 comes around, there will be substantial implementation of the recommendations made in the various reports, and that we can get closer to a world in which harm to mothers and babies around the time of delivery is on the way to being eradicated.