With the approach this week of World Patient Safety Day and news of the current reviews into maternity care in England, it has made me reflect on influences that have impacted upon health and maternity care provision during my time working within the NHS. Since I commenced my nursing and midwifery training in the mid seventy’s, I have witnessed amazing and extremely fast growth in health service provision much of which as both users and health professionals, we take for granted as being part of routine NHS care today.
The 1970’s saw a decade of medical advances within the hospitals including the introduction of intensive care units, organ and bone marrow transplants, in-vitro fertilisation, CAT scans and hospitals also started coming online with computers being used whilst simultaneously primary care provision grew alongside an increase health centres. Progress continued in the 1980’s with the introduction of magnetic resonance imaging scans (MRI’s), key-hole surgery and introduction of the national routine breast screening for women over fifty, all amid fighting the global AIDS pandemic.
The 1990’s saw the addition of protection against MMR, influenzaB and Group C meningococcus to the national vaccination programme, set up of the NHS Organ Donor register and fetal in-utero laser surgery whilst the 2000’s onwards have offered local access to a range of services via NHS walk in centres, saw gene therapy successfully used in children, introduction of robotic limbs, routine bowel cancer screening for over 60’s, living donors, artificial pancreas, vaccines for school girls to prevent cervical cancer, DNA mapping, expansion of clinical trials throughout all NHS areas and the Covid-19 pandemic.
Maternity service provision was influenced by these advances which brought about changing patterns of maternity care. The medical and government swing back to recommending 100% hospital birth, introduction of technologies and interventions in the early 1970’s including fetal heart monitoring, routine induction/augmentation of labour and increased numbers of obstetricians employed in maternity services, all served to medicalise childbirth and impact on midwives roles.
By the 90’s women accessing maternity services were criticising the impersonal care they were receiving. Changing Childbirth (DOH 1993) identified the importance of women being given a voice to enable choice, continuity of carer and control of their childbirth experience and promoted the midwives role in this. In turn the focus on raising the profile of normal birth led to direct entry midwifery becoming more common at the same time as midwifery education moved away from hospital training schools and into universities.
So – have I provided safe care during my career? Well, in common with all health professionals I have the privilege of working with, I always strive to provide the absolute best care and “do no harm.” To this end I embraced cultural and intellectual shifts within midwifery including adapting new ways of learning relying more on evidence, analysis and developing a critical questioning approach to learning through undertaking BSc and MSc degrees.
Consecutively, the community midwifery support provided for new mothers in the late 90’s/early 2000’s became a skeleton service with cutbacks introduced under the umbrella of service improvement, reducing midwifery postnatal visits from a 28 day window of care for first time mums (21 days for other mums) to 10 days with an average of 3 midwifery home/clinic visits all with (in conjunction with reductions in health visitor support). In common with several of my midwifery and health visiting colleagues I sadly realised I was burnt out trying to provide a level of community midwifery care which seemed attainable only at a personal cost making me question if the care I provided was both safe and effective.
Still wanting to work towards improving maternity care provision, I moved into an operational midwifery research role. Becoming a research-based profession in conjunction with learning from confidential perinatal mortality enquiries undoubtably changed and improved standards of care for mothers and their babies.
Many previous forms of midwifery and obstetric practice are by today’s standards unsafe, for example encouraging women to rest postnatally in bed for several days in bed as opposed to current early mobilisation, obstetricians solely caring for unwell women instead of the current day multidisciplinary approach, increased use of thromboprophylaxis. I’ve seen changes in management of breech presentation and delivery, timing of elective term LSCS, a swing back to physiological management of the third stage with associated delayed cord clamping, management of breast feeding, newborn tongue-tie and the back to sleep campaign which has reduced the incidence of Sudden Infant Death Syndrome (SIDS) by over 80% since its launch in 1991. I have also seen practices go and return like external cephalic version for breech presentation with much safer practice currently now its guided by ultrasound, uterine relaxants are used, and women are no longer sedated with diazepam, brandy or sherry!!
One aspect that has remained constant and been a major influence on maternity care provision throughout my time as a Midwife however has been findings from confidential enquiries. The current system of Confidential Enquiries into Maternal Deaths (CEMD) began in 1952, initially reporting on a three yearly basis and annually since 2014. The first report in 1952 reported 90 maternal deaths per 100.000 women during pregnancy or up to 6 weeks after birth within the UK. The latest MBRRACE-UK report of 2024 describes a concerning and statistically significant increase between 2017-19 to 2020-22 to levels not seen since 2003-5 (currently 13.56 deaths per 100,000) even when deaths due to COVID-19 are excluded. Focus in the reports has steadily increased on inequalities in maternal mortality, particularly increased in risk for women of Black and Asian ethnicity, those who are disadvantaged / live in the most deprived area / aged 35 years or more and are overweight or obese, highlighting also that improvements in care might have altered the outcomes in around half of maternal deaths.
Current day maternity care provision is increasingly complex, requiring a multidisciplinary approach to provide care to an everchanging population of women of differing races, cultures, beliefs, social circumstances, with co-morbities that were previously un-survivable in childhood. One thing held in common between the women, their families and the professional’s providing care is that we all want the same outcome, a safe birth for both mum and baby with ongoing optimum health.
Considering the MBRRACE-UK reports and the increasingly complex care some women accessing maternity services were requiring there has been ongoing work since 2018 across maternity units in the Yorkshire and Humber (Y&H) region towards improving recognition and management of maternal deterioration in pregnancy and childbirth. Since 2020 to date it has been a privilege to work in the Improvement Academy with all the individuals associated with the Y&H Maternal Enhanced and Critical Care (MEaCC) project which is nationally leading the way to improving the care of seriously ill pregnant women through three elements: Training – Sharing experience and learning – Data collection.
To find out more about the MEaCC project – please watch the video of Dr Debbie Horner (Consultant in Anaesthesia and Critical Care, and Chair of both the Y&H MEaCC Steering Group and Intensive Care Society Maternal Critical Care group.
If you would like any further information regarding MEaCC, please contact:
Viv Dolby MEaCC Lead Audit Midwife via Vivien.dolby@bthft.nhs.uk
