Maternity improvements are too slow

In most cases pregnancy and birth are a positive and safe experience for women and their families. But when things go wrong the results can be devastating; in some cases leading to the death of babies or mothers, and/or causing serious, long-term disability.

Our ratings data shows that the improvement in the safety of maternity services is too slow. In our report ‘The state of care in NHS acute hospitals 2014 to 2016’, published in April 2018, we raised our concerns that half of all maternity services were rated as requires improvement or inadequate for the key question ‘are maternity services safe?’. Our Getting Safer Faster briefing in March 2020 showed that this had improved slightly to 39%. Our latest report, Safety, equity and engagement in maternity services, highlighted that that as of July 2021, 41% of services are rated as requires improvement or inadequate.

In July 2021, the Health and Social Care Committee published its report on 'Safety of maternity services in England'. In this, it highlighted “the worrying variation in the quality of maternity care which means that the safe delivery of a healthy baby is not experienced by all mothers”.

To explore issues around safety in more depth, we visited nine maternity services where we had concerns between March 2021 and June 2021. As part of these inspections, we looked at the safety, teamwork and culture of services, as well as how they worked with their local Maternity Voices Partnerships (MVPs) to engage women in their local area. We also looked at what they were doing to address inequalities for women and babies from Black and minority ethnic groups and deprived communities.

While our review was focused on services with potential risks to safety and was not therefore a national picture, we are concerned that many of the issues we found may be occurring in other maternity services.

The culture of services varied across the nine trusts we visited, with evidence of poor working relationships between obstetric and midwifery teams, and between hospital and community-based midwifery teams in some services. Poor teamwork was also characterised by staff feeling unsupported, not feeling confident to seek support from senior colleagues or being afraid to challenge decision-making.

While we saw some evidence of multidisciplinary team training taking place, there were concerns that not all staff were engaged with training. The quality of training and support for staff to maintain and develop their individual capabilities and core competencies also varied between the trusts we looked at. Leaders of maternity services must tailor the training requirements for individuals to ensure that they are ‘fit for purpose’.

From our visits, we found limited evidence of how services were ensuring that women from Black and minority ethnic groups had equal access to care in order promote equitable outcomes. The majority of services we visited had carried out some work to implement the four actions from the Chief Midwifery Officer to support maternity equity for women from Black and minority ethnic groups. However, we were concerned that in many cases the actions had been interpreted narrowly, rather than considering what further actions were needed to make services truly equitable and safer for all women, and ensuring that all women felt informed and supported.

One of these four actions was to ensure that the importance of vitamins, supplements, and nutrition in pregnancy is discussed with all women. It is well known that, due to low sunshine levels, people living in the northern hemisphere may not get enough vitamin D. Women from Black and minority ethnic groups who have melanin pigmented (darker) skin or who cover their skin when outside may be particularly at risk. We found that recording of discussions about vitamin D was often inconsistent or absent in the services we visited. This creates the risk that vitamin D is not being discussed and/or offered to women who need it.

Another area we looked at was around continuity of carer teams. Studies have shown that continuity of care has been linked to improved outcomes for women and their babies, particularly women from Black and minority ethnic groups. The NHS Long Term Plan set out a target that by March 2021, most women would receive continuity of the person caring for them during pregnancy, during birth and postnatally. It also set out the target that for women from Black and minority ethnic groups, and women from deprived groups, 75% should receive continuity of care by 2024.

At the time of our inspections, just over half of the services we visited had active continuity of carer teams providing support to small numbers of women identified as higher risk. Where services did not have these teams in place, we heard that they had been put on hold or disbanded, primarily due to staffing issues in the pandemic.

We found that engagement by maternity services was often generic, rather than being targeted towards women from Black and minority ethnic groups. This was echoed by MVP chairs who told us that they were concerned MVPs were not fully representative of their local area, and that engaging with women from Black and minority ethnic groups to understand their views and experiences was an area for improvement. MVP chairs described a lack of funding as a major challenge to meaningful engagement with women from Black and minority ethnic groups, and that greater remuneration for their time would also encourage more women from deprived areas to be involved.

The pandemic had also had an effect on the ability of MVPs to engage with women. MVP chairs told us that not being able to meet face-to-face during the pandemic had been a major barrier to engagement. Before this, events such as ‘walking the patch’ to talk to mothers on the ward and visiting children’s centres and baby groups presented opportunities to connect with women who may not have otherwise contacted their MVP.

The use of digital technology had created some new opportunities for better engagement. One MVP chair noted that attendance of their meetings had increased, possibly because women who are less mobile when they have a newborn baby or lack transport may find it easier to attend online MVP meetings. Online meetings also enabled professionals from the maternity service to attend, as well as increased representation from community groups and other professional stakeholders.

While this is positive, we also heard that reliance on digital technology during the pandemic made it harder for women without the access to, or skills to use, digital technology to keep informed and have their voices heard.

Tackling health inequalities is a core ambition of our new strategy. In line with this, we will continue to monitor maternity services’ work on equity and engagement, including how they are using people’s experiences and equality data to review and act on outcomes and respond to the needs of their local population. We will also continue to learn from women who use services and face inequity, and apply what we have learned to other core services and areas of our work.

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