National Learning Report Released Today Highlights Persistent Failures in Maternity Care.

The Maternity and Newborn Safety Investigations (MNSI) has today released a national learning report that highlights key factors needed to ensure safe care in maternity units.

The Maternity and Newborn Safety Investigations (MNSI) has today released a national learning report that highlights key factors needed to ensure safe care in maternity units .

The MNSI reviewed 92 of their own investigations and has found the following four themes:

1. The work demands exceed capacity;
2. Intermittent auscultation is not being carried out in line with national guidance;
3. There is a lack of organisational preparedness for predictable safety-critical scenarios; and
4. There are failures in the telephone triage systems leading to a variation in advice given.

By highlighting these four themes and providing “safety prompts” on how improvements might be made, the MNSI “aims to help trusts do all they can to ensure the safest possible care is provided”.

Whilst this report acts as a helpful reminder of some of the issues with the current maternity provision, these themes have been highlighted multiple times before. In fact, the report itself recognises that these issues are not new. As an example, the lack of organisational preparedness for predictable safety-critical scenarios was flagged in the National Maternity Review in 2016, by Rowe et al in 2020 and by Donna Ockenden in 2022.

What this means is that, despite a blueprint for improvement being given to maternity units in 2016, 2020 and 2022, there is still limited evidence that unit-level risk assessments are happening to identify and address weaknesses in the systems and processes that the units rely on. These aren’t risk assessments and plans for “never events”, there is a lack of preparation for predictable events such as a low risk mother experiencing a complication and needing to be transferred to the obstetric-led unit or a baby unexpectedly needing resuscitation.

Whilst the MNSI report highlights some positive developments, it does not seem to be happening quickly enough. An example lies with the issues identified with Intermittent Auscultation (IA- the technique of listening to and counting the fetal heartbeats for short periods of time during active labour. It is usually performed using a Pinard stethoscope or a hand-held Doppler device, with the uterine contractions palpated by hand). It has been known for years that IA is not carried out in line with national guidance and the guidance is difficult to achieve in practice. Despite this being a known issue and a toolkit being developed by the National Perinatal Epidemiology Unit, this study is not due to finish until 2025 and the roll-out time thereafter is unknown. More needs to be done in the meantime to ensure this fundamental task of listening to changes in a baby’s heart rate is being done properly on UK maternity wards.

We have the reports, the blueprints for change and the Government knows the level of funding needed (and has done since 2021 when the Commons Health Committee recognised £350 million investment in maternity care was urgently needed ). Now is the time to take action and implement real change.