Maternity safety
- Steve Johnson
- Feb 2
- 6 min read
I was lucky enough to be at an NHS meeting in the last week looking at learning from recommendations. There were amazing people there, doing incredible work. I was particularly impressed by work on tracking Maternity recommendations. The following tracker was presented:
It really spoke to me because it seems to have done for maternity what I have been trying to do across inquiries. Make recommendations accessible and easier to manage and use. You can even download a spreadsheet of the recommendations from each report. I know from experience that no matter how many tools you use, that ends up being very manual. Its a lot of hard work and praiseworthy.
It also links to the reports, from which the recommendations came. This is a tricky space, and another driver behind my site. 18 of the report links from about 80 were broken. It is good practice to link to an original page, but sadly the way in which HMG departments, Arms length bodies etc. manage their websites is not great. Reports are moved, sites rebranded or dropped. This inadvertently creates work for other agencies who may not realise till someone reports it.
What can you do? Well you can check backlinks and send those sites a note, or you can set up a redirect for important pages. As I always say, when people have died for these lessons, they are probably worth a bit of effort to keep the reports accessible.
Back to the Maternity recommendations register.....
Lovely work and (to help you) I have checked all the links and created a download of the reports that are still live on their site here
I also trained the Google LLM against 60 reports and asked it to create a discussion between two podcasters about:
What does this mean for a non-medical professional?
Are things getting better?
What are the trends?
Very interested to hear from medical professionals about the AI analysis, was it useful, any new insights or just a nice summary?
It also created this timeline and list of stakeholders:
Timeline of Main Events & Issues
This timeline combines information from various reports spanning several years, focusing on trends and key issues rather than a chronological day-by-day account.
1985-2011:
Maternal mortality rates are tracked, showing fluctuations over time, with direct and indirect causes considered.
Specific causes of maternal death include hemorrhage, anesthesia complications, psychiatric issues (including suicides), and malignancy.
Indirect causes also include cardiac disease, neurological conditions, and malignancy.
2003-2018:
Ongoing monitoring of maternal mortality rates in three-year rolling averages using the ICD-MM classification system.
Rates of both direct and indirect maternal deaths are tracked, showing a fluctuating trend.
2014:
The Perinatal Confidential Enquiry examines cases of congenital diaphragmatic hernia (CDH), assessing care quality and identifying areas for improvement.
Analysis of risk factors and management during pregnancies.
2015:
MBRRACE-UK publishes its Perinatal Report analyzing stillbirths, neonatal deaths, and overall perinatal mortality across different regions.
Data collection and analysis are refined, adjusting for patient-level and organisational-level risk factors.
Focus on the quality of antenatal care, delivery, and baby characteristics in relation to stillbirths and neonatal deaths.
A range of maternity units across the UK are assessed.
Review of maternal deaths and serious incidents.
The Perinatal Mortality Review Tool (PMRT) is introduced to improve data collection and review processes after perinatal deaths.
Data collection regarding parents' experiences of care following perinatal deaths is investigated.
2016:
The MBRRACE-UK Maternal Report details rates of maternal mortality and examines factors including direct and indirect causes, with a shift to ICD-MM classification.
Examination of maternal mortality trends by cause, with direct causes including hypertensive disorders, haemorrhage, and pregnancy-related infections.
Indirect causes include cardiac and neurological conditions, suicide, and drug/alcohol issues.
The NHS initiates the Saving Babies' Lives care bundle aimed at reducing stillbirths.
National Maternity and Perinatal Audit (NMPA) clinical report shows variation across different hospital trusts and health boards in areas like mode of delivery, breastmilk feeding and smoking cessation advice.
MBRRACE-UK Perinatal Report highlights regional variations in perinatal mortality rates across the UK.
Emphasis on quality of data, collection, and analysis.
Focus on continuity of carer as part of improvement.
2017:
MBRRACE-UK Intrapartum Confidential Enquiry Report details cases of suboptimal care, with communication failures, lack of supervision, and human resource shortages as key contributing factors.
NMPA Report highlights the quality of data collection and variation across maternity services.
Issues around data quality, smoking cessation, breastfeeding, and skin-to-skin contact.
2018:
MBRRACE-UK Maternal Report examines maternal mortality, highlighting suicide as a significant cause of indirect death.
The NMPA Clinical Report is published showing variations in maternity care across hospital trusts and health boards.
Analysis of the data relating to vaginal births after cesarean sections (VBAC).
NHS Resolution report analyses of Serious incidents using incident forms, internal root cause analysis and multi disciplinary meetings
PMRT data collection covers serious incidents and deaths in maternity.
2019:
The MBRRACE-UK Maternal Report shows increasing suicide rates and other indirect deaths.
NMPA Clinical report recommends using the NMPA technical specification as a guide to data collection to improve data quality.
NMPA Organisational Report highlights variations in midwifery staffing numbers, access to records for women and GPs, continuity of carer models, and the provision of FGM services.
Emphasis on the need to implement the "Saving Babies' Lives" care bundle and improve identification of risk factors.
PMRT highlights the role of social factors, mental health issues and communication challenges in maternal and perinatal deaths.
Parents perspectives of care is a key part of perinatal review tools.
2019-2020:
PMRT data identifies key issues such as smoking, lack of appropriate referrals for social issues, inadequate antenatal screening and management, and issues relating to care in labor.
Emphasis on the need for resourcing and appropriate staffing in maternity services.
Review of the environmental quality of care and family support during admissions.
PMRT data review includes analysis of the type of perinatal mortality, including stillbirth, neonatal death and late miscarriage and what level of neonatal unit the review came from.
2020-2022:
Continued tracking of direct and indirect maternal deaths, including those due to suicide.
MBRRACE-UK reports show that maternal death rates remain high among certain groups.
Child Death Review data indicates that mortality rate increased across all age groups.
Data is presented by region, and indicates deaths in 2021-22 were notably higher in the 15-17 age group
NNAP report analyses variations in neonatal care provision and outcomes across the UK.
Variations in breast milk feeding, use of breastmilk at discharge and use of formula.
2022-2023:
MBRRACE-UK publishes a maternal mortality compiled report with updated data, continuing to emphasize the need for improvements in care.
Cast of Characters
This section provides brief bios of the principle people (or types of people) mentioned in the sources. It should be noted that the sources are reports and not a narrative so specific personal information for all individuals listed is limited.
Mothers/Women: The central subjects of these reports. They are the recipients of maternity care, and their outcomes are the focus of the analysis. Many of the reports focus on those who experienced adverse outcomes, such as serious complications, stillbirths, or death. Reports highlight diverse demographics and risk factors and the challenges in providing effective care to each individual.
Babies/Infants: A significant focus of these reports, especially concerning stillbirths, neonatal deaths, and perinatal mortality. These reports assess the care they received and identify areas of improvement in their care.
Parents: Reports highlight the need for parental engagement with care reviews and taking parents' feedback into account.
Midwives: Key healthcare professionals involved in providing care during pregnancy, labor, and postpartum. Reports note the need for one-to-one care during established labor, and explore models of care like case loading.
Obstetricians: Specialist doctors responsible for managing complex pregnancies and deliveries. Their involvement is highlighted in cases where specific medical interventions are needed.
Anaesthetists: Professionals providing pain management during childbirth. Anesthesia-related complications are cited as a cause of maternal death in some reports.
Neonatal Nurses: Provide specialized care to newborns, particularly those born prematurely or with health complications. Their role in neonatal care and the provision of transitional care is highlighted.
GPs (General Practitioners): Involved in the early stages of pregnancy care and some reports refer to their role in accessing patient records.
Risk Managers: Involved in the analysis of serious incidents and mortality reviews.
Pathologists: Perform post mortems and examine tissue in perinatal mortality cases.
Service managers and Management Teams: These teams are involved in reviewing and addressing the findings of mortality reviews.
Administrative Support Staff: Assist with the logistical elements of care, review and data management.
Researchers: Those behind the MBRRACE-UK and NMPA reports. Responsible for data collection, analysis, and generating recommendations for improvements.
National and Regional Transformation and Improvement Initiatives: Organisations and groups who use the findings from these reports to improve services.
Commissioners: Highlighted in the NMPA reports, those who have financial oversight and planning authority for NHS services.
This detailed breakdown of the timeline and cast should provide a good understanding of the main events and people mentioned in your sources. Let me know if you need anything else!
Comments