Today, we published a report identifying the main factors affecting the delivery of safe care in NHS hospital midwifery units.

The report – ‘Factors affecting the delivery of safe care in midwifery units’ – looks at the findings from 92 of our investigations where safety recommendations were made to midwife led units in NHS hospital trusts in England. It highlights key learnings and prompts to help trusts to consider how safety risks can be mitigated and drive improvements in care.

Based on an analysis of 92 MNSI investigations completed on or before 14 June 2022*, the report identifies the following four common themes as issues impacting on maternity safety:

  • Work demands and capacity to respond – the number of tasks needed to be done and whether there are enough (and suitable) staff, and appropriate physical space, to do them.
  • Intermittent auscultation – a method used to assess a baby’s heart rate as an indicator of their wellbeing.
  • How prepared an organisation is for predictable safety-critical scenarios, and the role played by in situ simulation (a training method that involves staff rehearsing scenarios in the workplace).
  • Telephone triage – the assessment a midwife carries out when a pregnant woman telephones because they have gone into labour or have a concern about their pregnancy.

These themes are illustrated by excerpts from the investigations analysed. For each theme, there is also a set of safety prompts to be used alongside clinical guidance by staff working in and leading maternity services. Our aim is to promote and support learning discussions within midwifery units and staff in other birth settings, and to influence the development of systems and processes to improve safety.

Sandy Lewis, MNSI Director said: “Today’s report shares important safety observations from our investigations in midwifery units and aims to help trusts do all they can to ensure the safest possible care is provided. Our investigations have demonstrated very clearly how supporting staff through appropriate training, ensuring consistent and robust triage processes are in place, and implementing an effective fetal heart monitoring approach are all critically important.

“While the report draws on analysis of incidents specifically involving midwife led units, all maternity services must prioritise actions to mitigate safety risks regardless of the setting or mode of birth. As such, the learning we highlight is equally as relevant to other birth settings, including hospital obstetric units, and we hope the report will prompt discussion and reflection among professionals across the sector.

“MNSI has a responsibility to families who have received care and may use maternity services in the future, to understand what happened and why, and to share learning to support service improvements. I am incredibly grateful to the families whose experiences are included in this report and to the healthcare staff who participated in the investigations.”

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