Maternity Services
Literature Review
Author: Sian Ap Dewi, Principal Public Health Officer, Siobhan Jones,
Consultant in Public Health, Rob Atenstaedt, Consultant in Public Health
Medicine, Jo Charles, Associate in Public Health, Gill Richardson, Executive
Director Public Health Aneurin Bevan Health Board, Andrew Jones,
Executive Director Public Health
Date: July 2011
Version:
1 (Final)
Publication/ Distribution:
 Internet
Purpose and Summary of Document:
To answer the question: What is the current evidence base on the delivery
of safe and sustainable maternity services?
MATERNITY SERVICES LITERATURE REVIEW ................................ 1
1
SUMMARY OF KEY MESSAGES ................................................. 3
2
BACKGROUND ......................................................................... 6
2.1 Methodology ........................................................................ 7
2.2 Introduction ......................................................................... 7
2.3 Factors that impact on the health of mothers and babies ........... 9
2.4 Why is maternity care important? .......................................... 11
2.5 What do we mean by Maternity Services? ............................... 12
2.6 Access to Maternity Services ................................................. 13
2.7 Barriers to access ................................................................ 14
3
DEVELOPMENTS WITHIN MATERNITY SERVICES .................. 15
3.1 The Challenges .................................................................... 15
3.2 Maternity Dashboard ............................................................ 18
3.3 Antenatal Care .................................................................... 18
3.4 Supporting women through childbirth ..................................... 20
3.5 Role Definition ..................................................................... 20
3.6 Midwife led care................................................................... 24
3.6.1 Midwifery led Units (MLU) ..................................................... 26
3.6.2 Home Births ........................................................................ 28
3.7 Evidence from the Netherlands .............................................. 30
4
SAFER CHILDBIRTH .............................................................. 32
4.1 What should a Birth Setting look like? .................................... 33
4.2 Guidance on decision to delivery intervals for emergency
caesarean section ................................................................ 33
5
RECOMMENDATIONS ARISING FROM THE LITERATURE ........ 35
5.1 Recommendations for the Maternity Service for Wales .............. 35
5.2 Recommendations for the New Local Health Boards from the Wales
Audit Office Maternity Services report .................................... 36
6
APPENDIX: SEARCH STRATEGY ............................................. 38
7
REFERENCE LIST ................................................................... 45
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1
Summary of Key Messages
Prevention and Early Intervention

Strengthening maternity services will benefit entire health care
systems. Maternal and newborn care services are the cornerstone of
public health services. Care of pregnant women can be the entry
point for health services to the family and community (World Health
Organisation)

Future maternity services must be planned to ensure safe and high
quality maternity services are provided that meet the needs of the
population. Services should seek to reduce inequalities and
inequities and improve outcomes

Current policy documents highlight the current risks to maternal and
child health from preventable factors such as maternal smoking and
maternal obesity. The important role that maternity services can
play in improving the health and well being of individuals and
communities is identified (Strategic Vision for Maternity Services in
Wales & Midwifery 2020)
Challenges

Maternal age has
Wales appears to
maternal age and
does the risk of
treatment). All of
service need

The key challenges for medical cover of secondary care maternity
services across Wales have been identified as;
-
The effect of the European Working Time directive on the provision
of junior and senior medical service
-
Training and continuing professional development, shorter medical
training periods requiring more organised training opportunities and
supervised clinical experience
-
Recruitment difficulties in nearly all the professions involved
-
The
geographical
Date: July 2011
risen in many areas of the western world and
be following this trend. Fertility decreases with
the rate of chromosomal anomalies increases as
multiple births (as a consequence of infertility
these factors have the possibility of increasing
challenges
to
Version: 1
achieving
consistent
clinical
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standards of care including access/travel times
(Welsh Medical Committee ‘Maternity Service’ report)

The WMC report recommended that where service reconfiguration is
proposed, professional advice is sought from Royal Colleges and
advisory groups early in the planning stage, and that any impacts on
medical training be considered

Staffing levels, training, access to services, information systems,
high caesarean section rates in Wales, clinical negligence claims, the
need for a common data set and increased post natal support are
key themes that emerged from the Wales Audit Office (WAO) 2009
report on Maternity Services in Wales. Recommendations in relation
to these areas were made by WAO
Midwifery led care

To achieve the vision set out in the Midwifery 2020 strategy,
midwives should be the lead professional for healthy women with
straightforward pregnancies. For women with more complex
pregnancies they should act as the key coordinator of care
(Midwifery 2020)

Women classified as low or mixed risk, receiving midwife–led
models of care were found to have: reduction in regional analgesia,
fewer episiotomies and instrumental births, less likely to experience
antenatal hospitalisation, less likely to lose babies before 24 weeks
gestation and shorter length of hospital stay. Midwife-led care
increased the chance of having a spontaneous vaginal birth and
initiating breastfeeding. There were no statistically significant
differences in Caesarean birth rates. (Cochrane review).

The new Maternity Services Strategy for Wales currently out for
consultation, supports a greater focus on midwifery led births, and
proposes that this care is delivered in a range of settings including
home, hospital or midwife led units appropriate to the needs of the
mother and family
Midwifery led units

A structured review of birth centres (term used interchangeably
with midwifery led units for purpose of this report) found that due
to the limitations of the available data, there was no reliable
evidence about either clear benefit or harm associated with birth
centres compared with any other type of intrapartum care offered
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in the NHS. (National Perinatal Epidemiology Unit: Structured
Review of birth centre outcomes)

There was substantial support for the service from women
accessing care, their families and maternity care health
professionals as the service is clearly differentiated from an
obstetric-led maternity service. There are also benefits to the NHS
in having a tiered service for deliveries reserving expensive
obstetric care for those that really need it (National Perinatal
Epidemiology Unit: Structured Review of birth centre outcomes)

Women were transferred from midwifery led units (MLU) to
obstetric led maternity units (OLMU) in 14-16% of cases and
neonates were transferred in up to 4% of cases in one UK
evaluation (24)

More high quality evidence is needed on whether there are
important differences in experiences and outcomes for women and
babies between alternative locations and systems of care

The Evaluation of Maternity Units in England (EMU), due to report in
March 2011, is a programme of research designed to examine the
role of midwifery led units and generate high quality evidence.
Home Births

The Royal College of Midwives (RCM) and the Royal College of
Obstetricians and Gynaecologists (RCOG) support home birth for
women with uncomplicated pregnancies provided the appropriate
local infrastructures and risk assessment framework are in place to
support such a system
A Cochrane Collaboration review of home versus hospital births
concluded as follows:

There is no strong evidence to favour either planned hospital birth or
planned home birth for low risk pregnant women

The change to planned hospital birth for low risk pregnant women in
many countries during this century was not supported by good
evidence

Planned hospital birth may even increase unnecessary interventions
and complications without any benefit for low risk women
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Several studies have been conducted to evaluate the obstetric system in
Netherlands, which has a different system of maternity care to the UK.
Low risk women give birth at home or in primary care under supervision of
midwives. There is conflicting evidence from these studies on outcomes
and perinatal mortality in relation to place of birth and travel times to
hospital.
Organisation and delivery of care in Labour

-

2
The Safer Childbirth report (2007) gives detailed advice of staffing
roles within maternity services. In particular they advise:
Increase in appropriately trained maternity support workers to
support role of midwife
Availability of Supervisor of midwives 24/7, with a ratio of 1
supervisor to every 15 midwives.
Labour ward shift coordinator should be supernumerary
40 hour consultant cover on labour ward for units with <2500
births/year. 60 hour consultant cover for units with 2500-4000
births
Guidance exists in relation to decision to delivery intervals for
emergency caesarean section. A decision to delivery interval
describes the time between an obstetrician in a consultant led unit
deciding that a caesarean section should be undertaken, and the
delivery. A decision to delivery interval of less than 30 minutes is
not in itself critical in influencing baby outcome but remains an audit
standard for response to emergencies within maternity services
(NICE Clinical Guideline)
Background
The purpose of this report is to provide information to support the North
Wales Review of Maternity, Neonatal, and Gynaecology and Child Health
services. The aim of the review is to describe the optimum service delivery
model that will ensure safe, sustainable and efficient maternity, neonatal
and paediatric health services are provided for the population of North
Wales. The future model of service delivery will seek to improve
population health and optimise health and well-being outcomes for women
and children.
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In order to ensure that discussion and debate are as well-informed as
possible, this paper seeks to provide:

An understanding of the background to the current situation

A summary of key guidance and recommendations made by national
bodies and authorities

Findings from a targeted review of key sources

An indication of the key aspects of safety, quality and sustainability
against which proposed options generated within the review process
may be viewed.
2.1
Methodology
Due to the short timescales involved in undertaking this review, a method
drawn from an approach known as Rapid Appraisal has been used.
Searches were undertaken of core databases, topic specific databases and
meta search engines for recently-published (since 2000) evidenceinformed material. Here the phrase “evidence-informed” is used
purposefully to distinguish it from the more familiar term “evidencebased”. Use of the term evidence-based would imply
1. a systematic review approach to ensuring all relevant literature is
identified;
2. reference to a “hierarchy of evidence”; and
3. structured critical appraisal of the individual pieces of literature.
This review has used a structured approach to identify relevant reports
and papers, many of which are summaries of available evidence with
recommendations for good practice. The most important sets of
recommendations are reproduced in full in the penultimate section. The
initial searches were undertaken by the Public Health Wales Library and
Knowledge Management Services Team, and their full search strategy is
listed as an Appendix.
2.2
Introduction
The priority for modern maternity services as identified in the “Maternity
Matters” report prepared by the Department of Health is to provide a
choice of safe and high quality maternity care for all women and their
partners. This is to enable pregnancy and birth to be a safe and satisfying
process for both mother and baby and to support and enable new parents
to have a confident start to family life (2).
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The “Towards better births” review of maternity services in England
highlighted that the National Service Framework emphasised the need for
woman centred, individualised care (3). The report recognised that a
women’s reaction to her birth experience can influence her emotional well
being, her relationship with her baby and future parenting. Women should
have a good experience and positive view of the support provided to them
during the three stages of maternity care: pregnancy, labour and birth
and the post natal period.
Women their partners and their families should, according to the NICE
guidelines on Antenatal Care, always be treated with kindness, respect
and dignity (4). The views, beliefs and values of the woman, her partner
and her family, in relation to the care of her baby, should be sought and
respected at all times. Good communication between healthcare
professionals and women is essential. This should be supported by
evidence based, written information tailored to the woman’s needs. Care
and information provided should be culturally appropriate, and all
information should also be accessible to women with additional needs such
as physical, sensory or learning disabilities, and to women who do not
speak or read English (4).
The Wales Audit Office report on maternity services stated that maternity
services need to be planned in such a way that they meet the needs of the
local population. The report also suggested that it is important that
services meet national standards to help ensure consistency in the quality
of maternity services provided across Wales. The Wales Audit Office report
noted that the Welsh Assembly Government had not set any national
performance targets for maternity services and whilst the office was not
recommending the implementation of targets, it did note that the absence
of national performance targets for maternity services had resulted in
other service areas being given higher priority (5).
Infant mortality rates are higher in more deprived areas of the country
and in more vulnerable and disadvantaged groups (2). The “Why Mothers
Die” report found a higher risk of maternal death in women from minority
ethnic groups, women who were socially disadvantaged, poor attenders
and women with a history of psychiatric illness (6).
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Future maternity services must therefore be planned to reduce inequalities
and inequities and improve outcomes for the most disadvantaged and
vulnerable families. The challenges of the reduction in working hours of
doctors as a result of the introduction of the working time directive needs
to be addressed, as do the changes brought on by demographic and
lifestyle changes. However the principle should remain that pregnancy and
birth are natural events which should be supported by midwives (2).
2.3
Factors that impact on the health of mothers and
babies
Research work undertaken in Great Britain has shown that more deprived
families are likely to have overall higher levels of the following:

Perinatal and infant mortality, including sudden infant death

Low birth weight babies (less than 2500g)

Teenage pregnancy.
Conversely mothers in less deprived circumstances are more likely to start
their families at a later age, have more babies with a higher birth weight
than 4000g, and have teenage pregnancies ending in a termination (7).
There is a strong association in Wales between the proportion of low birth
weight babies and the relative social deprivation of the area in which they
live. The more deprived the area then the higher the proportion of low
birth weight babies. Teenage pregnancy rates also tend to be higher in the
more deprived areas of Wales (7).
Babies born with low birth weight (less than 2500g) are more likely to die
in the first few weeks of life or to develop certain chronic diseases in
childhood. Very low birth weight (‹1500g) is associated with significant
disability. Poorer survival and the association with deprivation can be
demonstrated in Wales (7).
In recent years maternal age has risen in many areas of the western world
and Wales appears to be following this trend. A woman giving birth at an
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older age is associated with relative affluence and better maternal
educational achievement. There is some evidence of this in Wales (7).
However fertility decreases with maternal age and the rate of
chromosomal anomalies increases as does the risk of multiple births
(probably as a consequence of infertility treatment). All of these factors
have the potential to increase service need (7). The most recent annual
report by the Congenital Anomaly Register and Information Service
highlights high rates of Isolated Cleft Palate in North West Wales.
Although detailed analysis of the data has not identified a reason for this
increase, there are some important public health messages to
communicate around risks of congenital anomalies. In particular, the risks
in relation to smoking, alcohol, substance misuse and obesity in
pregnancy. The use of folic acid and the importance of preconceptual care
are also highlighted (49).
Improved care for serious childhood illness, including cancer and
congenital heart conditions has permitted increasing numbers of women to
reach their childbearing years after surviving major health problems; and
these women are more likely than other women to need additional support
during pregnancy and labour. Less common conditions like tuberculosis
are also on the rise and can pose a threat to women in pregnancy (8).
There are a number of groups within society who although small in
number carry an increased vulnerability to social exclusion and economic
disadvantage. People within these groups have a greater risk of adverse
health outcomes. Groups include those with learning disabilities or
physical disabilities, people with mental health problems, young adults
who are leaving care, victims of domestic abuse, people who are
homeless, travelling families, refugees, people with substance misuse
problems or people leaving prison (7). For women in such groups
pregnancy might bring with it particular challenges, however at present no
comprehensive data exists to describe the health status of women and
their babies in these groups across Wales.
WHO note the benefits of strengthening maternity services (9) and the
importance of ensuring the availability of high quality safe universal
services for the whole population that can also be flexible to meet the
specific needs of vulnerable groups. Current policy documents highlight
the important role of maternity services in improving the health and well
being of individuals and families (53, 54). The public health role of the
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midwife is also highlighted as vital, needing to be protected and
strengthened (53,54)
2.4
Why is maternity care important?
The World Health Organisation identified in their strategic approach
document for making pregnancy safer (2008) that women and babies in
European countries are still dying an unfair and unnecessary death, and
suffering unnecessary illness and disabilities (9).
The report argued that although evidence based interventions are well
known, many European countries have stagnated and regressed in their
efforts to reduce maternal and perinatal mortality (9).
Obtaining the highest attainable standards of health is a human right and
all women and newborns regardless of their socio – economic status,
culture, race or origin have the rights to these standards of health (9).
Women play an irreplaceable role as citizens, mothers, and caretakers and
are frequently the family’s breadwinners. Therefore if a woman dies from
complications of pregnancy, or becomes ill or disabled, then the well being
of the whole family is severely affected (9). Investing in maternal health is
a powerful way of improving the lives of poor and marginalized women.
The “Making Pregnancy Safer” Regional strategy for Europe argued that no
single intervention on its own was sufficient. Maternal and newborn deaths
can, however, be reduced significantly using low cost and effective
interventions (9). The regional strategy stressed the importance of
strengthening capacity within health systems in order to identify best
practice for programme development. Emphasis needs to be placed on
planning implementing and evaluating interventions, including the
identification of subpopulations with higher levels of needs (9). The health
of the newborn is directly linked to the health of the mother and avoiding
complications that affect the mother will improve perinatal outcomes (9).
The World Health Organisation argue that strengthening maternity
services will benefit entire health care systems as maternal and newborn
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care services are a cornerstone of public health services. The care of
pregnant women can be the entry point for health services to the family
and community to prevent and treat for example STIs, HIV, and introduce
family planning, ensure immunizations, provide nutritional advice or act as
a conduit to the introduction of other health programmes (9).
2.5
What do we mean by Maternity Services?
Maternity services were defined by a multi professional maternity services
group in 2010 in the document A Maternity Service for Wales (10), as
those services delivered chiefly by Midwives, Obstetricians, Anaesthetists,
Paediatricians and Neonatologists. The Maternity Service aims to be a
cohesive service providing care for women at both high and low risk of
complications. The medical specialities are also a part of the core service
specialities. The role of GPs in the provision of mainstream maternity
services has diminished considerably within the last decade, but continues
usually at a lower level most often in the period before pregnancy and
after delivery.
Midwives are involved in the care of all pregnant women irrespective of
their risk status and their involvement in the Maternity Service is
ubiquitous (10). A recent policy document recommends that midwives
should be the lead professional for healthy women with straightforward
pregnancies. For women with more complex pregnancies they should act
as the key coordinator of care within the multidisciplinary team (53)
Much of the care provided to women is provided in the home or
community. When a women’s risk status changes from one of low risk to a
higher risk during pregnancy then it becomes necessary to involve one or
more of the medical specialities in addition to midwifery care. This higher
level of care is provided in hospital consultant or obstetric units with the
majority forming part of the secondary sector, with the midwife remaining
as the coordinator of care (53). The Royal Colleges have set out the
requirements for providing obstetric led care and obstetric anaesthesia,
while the British Association of Perinatal Medicine (BAPM) sets out the
standard of care for newborn babies.
The Maternity Services also represent an interdependent network across
Wales; especially where more advanced care at tertiary centres is required
for critically ill babies or their mothers. It was noted within A Maternity
Service for Wales that the Welsh maternity services network is a virtual
one, and as such has never been subject to formal organisation (10).
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Access to Maternity Services
The “Access to Maternity Services” research report highlighted inequalities
in access to maternity services and identified a number of groups who
were less likely to access ante and post natal services. The report found
that women’s attitudes towards managing their health and accessing
maternity services often reflected their circumstances (11). Some women
from minority ethnic groups and communities preferred to use expertise
and support that was available within their community groups, and only
used general health services when necessary (11).
Other “hard to reach” groups, such as those individuals dependant on
drugs or alcohol and homeless women, found it difficult to access health
services as a result of the complexity of their problems, limited
understanding of the health service and issues relating to their transient
lifestyle (11).
The NICE guidelines relating to Pregnancy and Complex Social Factors
note that pregnant women who misuse substances may be overwhelmed
by the involvement of multiple agencies and that those women need
supportive and coordinated care during their pregnancy (12). Although
teenagers and women with learning difficulties were more likely to access
services, along with other groups they often lacked the confidence to
engage fully with services as they feared that they would be labelled or
would face discrimination (11).
As well as attitudes towards pregnancy, other barriers, such as those
relating to practical access, cultural relevance and understanding of the
role and value of the services meant that none of these “hard to reach”
groups used maternity services to their full extent (11). Attendance at
antenatal classes was limited and most care focused on scans and check
ups. Many were late receiving antenatal care and consequently felt ill
prepared for motherhood. Patterns of post natal care were more
consistent as contact was relatively easy for health visitors to follow up
after the birth (11).
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Barriers to access
The Access to Maternity Services report found that women from “hard to
reach” groups found it difficult to access maternity services targeted at the
general population for the following reasons (11):

Fear of discrimination or prejudice and referral to either social
services or immigration agencies

Cultural sensitivities relating to the need to be treated by a female
and with discretion

Personal circumstances that made it difficult to acknowledge and
accept their pregnancy

Practical difficulties relating to low levels of literacy, transient
lifestyle (which meant that they were not always registered with a
G.P) cost of travel, fixed appointment times and language
difficulties.

Misconceptions about their eligibility for the service and its
elements.
These barriers demonstrate the need for maternity services to cater more
effectively to the needs of specific, vulnerable groups through a more
tailored service. Active steps are needed to counter misconceptions and
build a better understanding of the service offered.
The importance of sensitivity when dealing with women from hard to reach
and vulnerable groups was highlighted within the report as was the need
to provide information and guidance in order to prevent confusion (11).
These recommendations are also repeated within the NICE guidelines
relating to Pregnancy and complex social factors (12) which recommended
that

Women should be told why and when information may need to be
shared with other agencies

To allow for discussion of sensitive issues each woman should be
provided with a one to one consultation without partners, family
members or legal guardians present on at least one occasion

Hand-held Maternity Notes should be kept up to date with a full
record of care received and contain all test results (12)
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Post natal services were appreciated for the practical strategies provided
but women from these “hard to reach” groups often felt that the services
failed to provide them with much needed emotional support and
reassurance (11).
Successful engagement with maternity services usually resulted from
flexible provision, targeted information, and continuity of staff who were
experienced or familiar with working with specialist audiences (11).
3
Developments within Maternity Services
There have been many changes in maternity services over the last twenty
years. Some of these changes are the result of technical advances while
others are the result of the application of the findings of sound scientific
studies. The introduction of screening for aneuploidy (which identify one
or more chromosomes above or below the normal chromosome number),
better ultra sound imaging and the creation of the sub-specialty of fetal
medicine are all examples of this (13).
Another development has been that of senior clinicians specializing in
obstetrics alone. This is recognised by the Royal College of Obstetricians in
their report The Future role of the Consultant (14).
3.1
The Challenges
There have been a number of challenges identified to providing a safe
coordinated Maternity Service in Wales:
The Welsh Medical Committee’s “Maternity Service” (10) report noted that
the risk of potential collapse of the medical elements of the service within
one or two years were identified through

The effect of the European Working Time directive on the provision
of junior and senior medical service, training and continuing
professional development.

Shorter medical training periods requiring more organised training
opportunities and supervised clinical experience to achieve
completion of competence- based training.
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
Recruitment difficulties in nearly all the professions involved, with
unplanned pressure to replace junior services provision 24/7 but
without a suitable source of suitably trained practitioners

Attempts to deal locally with the difficulties of ad hoc mergers for
example, without a broader view of the effect on neighbouring and
centralised (tertiary) services.

Geographical challenges to reaching clinical standards of care
including access/travel times
Reorganisation of the health service in Wales presents excellent
opportunities to address these concerns but there is also the potential to
overlook them or for deterioration in quality of service if these challenges
are not addressed.
The Wales Audit Office 2009 report on Maternity Services in Wales (5)
identified a number of key themes that needed to be addressed;-
Staffing levels in some trusts were not always adequate. Some trusts
were identified as failing to meet recommended midwifery staffing levels,
and whilst some of the data related to consultant staffing was unclear, in
some trusts there was insufficient consultant obstetrician presence on the
delivery suite.
Training provided for maternity staff varied considerably within Wales,
with some trusts having very low levels particularly in areas such as skills
for handling emergencies and in monitoring the progress of labour. The
Wales Audit report (5) noted that not all obstetricians had received core
training within the recommended timescales.
Accessing Services- Most women accessed ante natal services within the
initial 12 weeks of pregnancy in line with recommended timescales.
However it was noted in the report that although the National Service
Framework promotes the midwife as the appropriate first point of contact
for pregnant women, 69% of those surveyed for the Wales Audit Office
report first went to their GP. This is because although some midwives
have clinics in GP surgeries most are only accessed via the GP (5).
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Information The Wales Audit report noted that in some trusts the
information provided to pregnant women was not effective in informing
them of what they could expect from maternity services, thus enabling the
women to make informed choices about their care. The example of ante
natal classes was cited as they provide a unique opportunity for health
professionals to engage with women and provide information. The
proportion of women who said they had wanted to attend antenatal
classes and were then able to do so vary considerably between trusts,
with low attendance rates in a number of trusts.
Caesarean Sections- There were a higher level of Caesarean sections
within Wales than in England and there were inconsistencies in the
practices that trusts employ to prevent unnecessary Caesareans (5). The
typical rate of normal births in Wales was 40 percent which is considerably
lower than the recommended level. There was variation identified in the
rates of intervention (i.e. induction, ventouse or forceps delivery) between
trusts (5).
Clinical negligence claims for obstetrics had more than doubled between
2003-4 and 2007-8 with £28.4 million paid out by the Welsh Risk Pool in
2007-8 (5). However the Wales Audit office report suggested that the
culture in some trusts may not be conducive to learning from such
incidents.
Common data set -the lack of a common data set for maternity services
in Wales prevents meaningful benchmarking of performance amongst
trusts in Wales. It was also identified that maternity services have a range
of groups for gathering feedback on performance but that there could be
improvements in how these were used to drive forward service
improvement (5).
Recommendations from the “Maternity Services in Wales” (5) report are
that maternity services should seek to achieve high levels of satisfaction
as well as providing high quality care that meets prescribed standards of
good practice.
Post natal support -the importance of the NHS maintaining contact with
mothers for a short period of time after they return home from hospital in
order to monitor the progress of both mother and baby was identified. It
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was noted that wide variation exists within Wales in the number of visits
that are made, which suggested a lack of consistency in the way that
trusts provided post natal support.
3.2
Maternity Dashboard
The Maternity Dashboard is a tool recommended by the Royal College of
Obstetricians and Gynaecologists that can be employed to monitor the
implementation of principles of clinical governance “on the ground”. It can
be used as a means of benchmarking activity and can help monitor
performance against locally agreed standards for the maternity unit on a
monthly basis (18). The maternity dashboard can help identify patient
safety issues in advance so that an appropriate course of action can be
undertaken.
It follows the principle of a car dashboard which provides contemporary
information about the fuel in the tank, speed, state of the battery, and
temperature of the engine so that that appropriate action can be taken if
the car breaks down.
Similarly the maternity dashboard will provide contemporary information
about resources, clinical management issues, risk management issues and
user views (18).
In any unit the various parameters of clinical
performance and the workforce delivering should be known and should be
constantly monitored and the maternity dashboard assists this process.
This tool has now been adopted by health boards across Wales as part of
performance monitoring processes.
3.3
Antenatal Care
The updated NICE guidelines relating to Antenatal care identified a
number of new key priority areas for implementation (4).
Antenatal information should be offered to women on the basis of
current available evidence and should include where they will be seen, and
who will undertake their care.
Screening for haematological conditions such as sickle cell and
thalassaemia should be offered to all women as early as possible in
pregnancy and ideally by 10 weeks.
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Screening for foetal anomalies and the participation in regional congenital
anomaly registers and /or UK National screening approved audit systems
is strongly recommended in the NICE guidelines to facilitate the audit of
detection rates (4). Screening for Down’s syndrome using the combined
test (nuchal translucency, beta human chorionic gonadotrophin,
pregnancy- associated plasma protein-A) should be offered between 11
weeks 0 days and 13 weeks 6 days. For women who book later in
pregnancy the most cost effective serum screening test (triple or
quadruple test) should be offered between 15 weeks 0 days and 20 weeks
0 days.
Screening for gestational diabetes using risk factors is recommended in a
healthy population (4). Women with certain risk factors should be offered
testing for gestational diabetes.
Gestational age assessment - pregnant women should be offered an
early ultrasound scan between 10 weeks 0 days and 13 weeks 6 days to
determine gestational age and to detect multiple pregnancies. This will
ensure a consistent approach for gestational assessment and reduce the
incidence of the induction of labour for prolonged pregnancy.
Lifestyle factors and pregnancy- The NICE guideline regarding
antenatal care has an updated section relating to alcohol consumption in
pregnancy(4). At the first contact with the pregnant woman staff are
encouraged to discuss smoking status, provide information about the risks
of smoking to the unborn child and the hazards of exposure to second
hand smoke and refer to specialist services (4). This would also include
explaining the risk of giving birth to a low weight or pre term baby.
Mental health disorders- The updated NICE Antenatal guidelines also
note that in all communications (including the initial referral) with
maternity services that healthcare professional should include information
regarding any relevant history of mental disorder (4). Health professionals
should ask at their first contact about past or present severe mental
illness including schizophrenia, bipolar disorder, and psychosis in the post
natal period and severe depression. After identifying a possible mental
disorder in a woman during pregnancy or the postnatal period then further
assessments should be considered, in consultation with colleagues if
necessary.
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All Maternity Services need to have the appropriate systems in place to
provide this level of ante natal care. Because of the unique impact of
lifestyle factors on the unborn child, action to support the woman in
addressing these issues is particularly importance during pregnancy. A
failure to address lifestyle issues during pregnancy can lead to poorer
outcomes for both mother and baby which in turn lead to increased costs
to the service.
3.4
Supporting women through childbirth
Historically women have been attended and supported by other women
during labour. However in recent decades in hospitals around the world
the continuous support of women through the process of childbirth has
become the exception rather than the routine. This has raised concerns
that the process of childbirth has become dehumanized, and that modern
obstetric care frequently subjects women to institutional routines which
may have an adverse effect on the way that labour progresses. A
Cochrane collaboration review of continuous support for women during
childbirth noted that supportive care during labour may enhance normal
labour processes as well as women’s feelings of control and competence
and thus reduce the need for obstetric intervention (19).
The review included 16 trials from 11 countries, involving over 13,000
women in a wide range of different birth settings and circumstances. The
review concluded that women who received continuous labour support
were more likely to give birth “spontaneously” i.e. give birth with neither
Caesarean nor vacuum nor forceps (19). In addition women were less
likely to use pain medication, were more likely to be satisfied, and have
slightly shorter labours. In general labour support appeared to be most
effective when it was provided by women who were not part of the
hospital staff and when support commenced early in labour. The authors
of the review suggested that it may be possible to increase access to one
to one continuous labour support worldwide by encouraging women to
invite a family member or friend to commit to being present at the birth
and assume the supportive role. No adverse effects were identified within
the review (19).
3.5
Role Definition
The following section will therefore go on to clearly define the roles that
may be called upon to support a woman through the process of childbirth
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whilst seeking to define each role’s unique contribution to the birth
experience.
Midwives-it is recognised that regardless of the place of birth that women
will be cared for by midwives. The role of the midwife, her function and
scope of practice is established in statute and cannot be delegated to
anyone else. The midwife has a role in caring for all women in labour
irrespective of their risk category or the type of unit in which she is
practising (38).
Midwives expertise lies in the care of normal childbirth and in their
diagnostic skills in identifying deviations from the normal birth experience
which can lead to a referral when indicated.
When obstetric or other medical involvement is necessary the midwife
continues to be responsible for the provision of holistic support to the
expectant mother promoting pregnancy and labour as normal
physiological processes as far as is possible (38).
The role of the midwife immediately after birth encompasses the care of
the newborn, with responsibility for newborn resuscitation, the
establishment of skin to skin contact, organisation of Vitamin K
prophylaxis and the initiation of breastfeeding. Midwives are also
responsible for alerting other team members usually paediatricians, to
potentially important aspects of maternal or foetal history which may
require urgent intervention (38).
All midwives have a major public health role and have a key role in
teaching and mentoring student midwives, junior doctors and medical
students. It is essential that the midwifery establishment reflects this (38,
53).
The head of midwifery services provides strategic and organisational
leadership, and is accountable for the quality of midwifery services within
their organisation (2). The role combines the effective promotion of
professional expertise in women and children’s health, overarching
responsibility for the operational and strategic general management,
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professional leadership and being an advocate for women. Specific aspects
of the role include budgetary control, human resources, strategic planning,
clinical governance and quality of midwifery care; this should be reflected
in the organisational structure (38).
The term consultant midwife is the one which has replaced that of
clinical midwife lead and more accurately fulfils the clinical leadership role
without managerial responsibilities. The role provides clinical leadership in
conjunction with the lead consultant obstetrician and complements the
role of head of Midwifery. Consultant midwives contribute to effective
leadership, training and mentoring, as well as having specific
responsibilities such as promoting normal childbirth or reducing
inequalities. Consultant midwives are able to drive service improvement
through working with colleagues in health and other agencies to develop
effective care pathways or specific services for specific client groups (2).
Maternity Support Workers who are appropriately trained and
supervised can carry out a range of duties including clerical duties,
supporting women with breastfeeding, helping to run parent craft classes
and supporting post natal care. Wales has developed a national curriculum
for Maternity Support Workers to develop this element of the workforce
(53, 54)
Specialist Midwives include practice development midwives, lecturer
practitioners and antenatal screening coordinators, who effectively
contribute to the maternity team and can drive forward enhancements to
services (2).
The Supervisor of Midwives has a statutory role which is undertaken on
behalf of the local supervising authority. A supervisor of midwives is an
experienced midwife who has received additional training, who is able to
contribute to the development of the maternity strategy. There should be
one supervisor of midwives to every 15 midwives and their role is to
protect the public through the provision of evidence based midwifery care.
Supervisors of midwives should be represented at all local maternity
communication forums such as the maternity services liaison committee,
risk management, perinatal audit meetings and the labour ward forum and
should have a direct line of communication to the executive team. A
supervisor of midwives is to be available 24 hours a day and may be
contacted by any member of the maternity team for support and guidance
(38).
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The Labour ward manager has a crucial role to play in the smooth and
efficient management of the labour ward and in providing advice support
and guidance. This includes

Resource management, ensuring that there is a supportive, positive
environment that encourages learning and development of all staff

Ensuring a quality service through evidenced based guidelines, a
robust risk management framework, safe and effective resourcing
of equipment and support systems for mentoring new and junior
midwives and students. The Safer childbirth report which provides
minimum standards for the organisation and delivery of care in
labour suggests that the minimum requirement for a labour ward
manager presence is one whole time equivalent (38).
To ensure 24 hour managerial cover each labour ward must have a rota of
senior midwives as labour ward shift coordinators supernumerary to the
staffing requirements for one to one care. Their role is a pivotal one in
facilitating clear communication between professionals and in overseeing
the appropriate use of resources (38).
Student midwives are supernumerary to the midwifery establishment
numbers. But as they provide direct care to women, under the mentorship
and support of midwives their role in contributing to the care of women
cannot be overlooked (38).
Obstetricians -The role of the consultant obstetrician on the labour ward
is to ensure a high standard of care for women and their babies with
complex medical or obstetric needs and to be available for the acute,
severe and often unpredictable life-threatening emergencies which are a
feature of obstetric practice. There is some evidence linking the absence
of consultants from labour wards in the night, with less favourable
outcomes (38).
The role of the consultant obstetrician on the labour ward is clearly
defined in the Safer Childbirth report (38) as

Providing clinical leadership and leading by example

Training and educating staff in a multi disciplinary team
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
Ensuring effective teamwork

Developing and implementing standards of obstetric practice and
having a major role in risk management

Bringing experience to clinical diagnosis

Auditing the effectiveness of practice in order to modify it if
required.
Consultants in obstetrics and gynaecology are increasingly appointed with
a special interest to complement the skills of the existing team. Maternity
units may benefit from having a person appointed with a consultant lead
role in areas such as labour ward management, early pregnancy
assessment, diabetes and prenatal diagnosis (2).
Subspecialists in feto-maternal medicine work in tertiary centres and
have the expertise to provide specialised care for more complex problems
and ensure comprehensive care within a network (2).
3.6
Midwife led care
In many parts of the world midwives are the main providers of care for
childbearing women. Elsewhere medical doctors or family physicians have
the main responsibility for care or the care of the woman may be shared
between doctors and midwives.
The new Maternity Services Strategy for Wales consultation document,
supports a greater focus on midwifery led births, and proposes that this
care is delivered in a range of settings including home, hospital or midwife
led units as appropriate to the needs of the mother and family (54).
Midwives should be the lead professional for healthy women with
straightforward pregnancies. For women with more complex pregnancies
they should act as the key coordinator of care within the multi disciplinary
team (53).
Midwife–led care has an underpinning philosophy that birth is a normal
experience with continuity of care provided to the mother. The mother is
supported and cared for by a midwife whom she knows and trusts during
labour. There is an emphasis in midwife-led care on the natural ability of
women to experience birth with minimum intervention. Some models of
midwife-led care provide a service through a team of midwives sharing a
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caseload and this is often described as “team” midwifery (20). Another
model of care is “caseload midwifery” where the aim is to provide greater
continuity of caregiver throughout the episode of care. Caseload midwifery
aims to ensure that the woman receives all her midwifery care from one
midwife or her/his practice partner (20). All models of midwife-led care
are provided in a multi disciplinary network of consultation and referral
with care providers.
A Cochrane review of midwife–led versus other models of care for child
bearing women compared models of medical led care and shared care,
and identified 11 trials involving 12,276 women (20). Midwife-led care was
associated with several benefits for women and had no identified adverse
effects.
The main benefits to women were a reduction in regional analgesia, with
fewer episiotomies and instrumental births. Midwife-led care also
increased the chance that women were cared through the birth by a
midwife that they knew. This increased the chance of feeling in control
during labour and of having a spontaneous vaginal birth and initiating
breastfeeding (20). However there were no statistically significant
differences in Caesarean birth rates.
The Cochrane review identified that women who were randomised to
receive midwife-led care were less likely to lose their baby before 24
weeks gestation, although there were no differences in the risk of losing
the baby after 24 weeks or overall. In addition the babies of women who
were randomised to receive midwife-led care were more likely to have a
shorter length of hospital stay (20).
The review concluded that most women should be offered midwife led
models of care, although caution should be exercised in applying this
advice to women with substantial medical or obstetric complications (20).
Midwifery led care during labour can be delivered through different
systems such as home, hospital or in stand alone midwifery led units. The
following sections summarise evidence around these different systems of
care.
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3.6.1
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Midwifery led Units (MLU)
During the past twenty years there has been a policy emphasis on
increasing choice in relation to the place of birth. As a result women in
England and Wales are able to make a choice between giving birth at
home or in hospital. In addition to these two options women in some parts
of England and Wales have the additional choice of giving birth in a
midwifery led unit which may be geographically separate from or adjacent
to, a hospital obstetric unit (21). Midwife led maternity units (MLMU) are
units which are organised and run by qualified midwives offering midwifery
care to women during the antenatal, intrapartum and postnatal period
(22). The units provide an alternative model of care to traditional obstetric
led care, and are aimed at women who are considered to be at low risk of
developing complications during pregnancy and childbirth. Midwife led
maternity units may be located adjacent to or integrated with obstetric led
maternity units or they may be freestanding (22).
These units are also sometimes referred to in the literature as birth
centres. This section will use the term Midwifery led unit and birth centre
interchangeably to describe the system of midwifery led care that is
delivered in a separate unit that may or may not be geographically
separate from or adjacent to, a hospital obstetric unit.
The report “Structured review of birth centre outcomes” set out in its
review to achieve an overview of the evidence base from published reports
about clinical, psychosocial and economic outcomes in developed country
settings about women who plan to give birth or had given birth in birth
centres (21).
The report noted that overall data were of poor quality and derived from
small scale observational studies. Outcomes were inconsistently defined
and reported with a high likelihood of bias. It was likely that there was a
disproportionate publication of positive or negative results (21).
The “Structured review of birth centre outcomes” concluded that birth
centre care can offer the possibility of accessible, appropriate, personal
maternity care for women and their families. There is substantial support
for this service from women accessing care, their families and maternity
care health professionals as the service is clearly differentiated from an
obstetric-led maternity service (21).
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It is important to note however that no reliable evidence about either clear
benefit or harm associated with birth centre care compared with any other
type of intrapartum care offered in the NHS was identified in the review
(21). The review recommends that a large scale pragmatic randomised
controlled trial be conducted as a matter of urgency to provide high
quality evidence in maternal and neonatal outcomes by place of birth.
Walsh and Downe (23) found in their review that women labouring on a
MLMU compared to an Obstetric Led Maternity Unit (OLMU) had higher
rates of normal vaginal birth and lower rates of caesarean section,
demonstrating that women delivering in an MLMU are ideally matched to
the remit of a MLMU in terms of risk. Intact perineum rates were found to
be high in both MLMU and in OLMU. However episiotomy rates were found
to be variable in both types of unit. Failure to progress in the first stage of
labour was found to be the main reason for intrapartum transfer to an
OLMU (23).
Muthu and Fischbacher (24) found in their study that events such as
maternal and neonatal morbidity and mortality were rare in both MLMU
and OLMU. Pethidine injection and epidural anaesthesia were less common
in a MLMU than in an OLMU. Women in a MLMU were more likely to have
an intact perineum than those women labouring in an OLMU. These
findings may be expected in a MLMU setting where births likely to be less
complex. Women were transferred from MLMU to OLMU units in 14-16%
of cases and neonates were transferred in up to 4% of cases.
Another study evaluating outcomes of the first midwife led centre in Italy
found caesarean section rates to be 6.1% (87/1438) and intrapartum
transfers were 14.1% (46). Postpartum transfers due to haemorrhage or
retained placenta were 2.4%. There were no perinatal deaths. There was
one maternal death, but there was no power to calculate a maternal
mortality rate due to the sample size of the study (n= 1438).
It is important to note that there is ongoing debate in relation to the
evidence on the different systems within which care is delivered (47, 48).
In 2005, the National Perinatal Epidemiology Unit concluded that more
high quality evidence was needed about whether there are important
differences in experiences and outcomes for women and babies in these
alternative locations and systems (47).
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In response to this, work is currently being undertaken to evaluate
maternity units in England. The Evaluation of Maternity Units in England
(EMU) is a programme of research designed to examine the role of
midwifery led units and generate high quality evidence. The publication
date for the review is anticipated to be March 2011. It is anticipated that
the findings will add to the evidence base relating to midwife led maternity
units.
3.6.2
Home Births
The Royal College of Midwives (RCM) and the Royal College of
Obstetricians and Gynaecologists (RCOG) support home birth for women
with uncomplicated pregnancies (25). Their home births joint statement
states that there is no reason why home births should not be offered to
women who have a low risk of complication and state that it may confer
considerable benefits for them and their families (25). The Royal Colleges
report suggests that there is ample evidence showing that labouring at
home increases a woman’s likelihood of a birth that is both satisfying and
safe. The National Childbirth trust in their briefing document relating to
home births (26) suggest that planned home birth is a positive choice for
many parents, particularly women who are healthy, have no history of
medical conditions or maternity complications and have had a
straightforward pregnancy and previous delivery. The National Childbirth
Trust argues that being able to access a home birth is important because
women have the greatest autonomy in their own home (26). In
comparison to the institutional environment which can limit their privacy,
intimacy and freedom (26).
A review of literature on the place of birth concluded that there is some
evidence , although not conclusive that women and their babies do better
and women are more satisfied with their care when cared for out of an
institutional setting (27).
The Department of Health Maternity Standard states that several large
studies on home birth have concluded that it appears safe for women who
have been appropriately assessed (28).
Home births should be offered within a risk management framework with
adequate local infrastructure and support (28). Van Weel described risk
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selection as “delicate” (29). One study argues that adverse events may
occur if too few or too many women are referred, or if referrals are made
too early or too late. If women are not referred in time then perinatal
outcomes may be worse in primary midwife led care compared with
obstetrician led care. On the other hand unnecessary referrals may
increase the risk of unnecessary obstetric interventions (29).
A Cochrane Collaboration review (1) of home versus hospital births
originally published in 1998 and assessed as up to date in 2006 concluded
as follows

That there is no strong evidence to favour either planned hospital
birth or planned home birth for low risk pregnant women.

That there is no strong evidence about the benefits and safety of
planned home birth compared to planned hospital birth for low risk
pregnant women.

The change to planned hospital birth for low risk pregnant women in
many countries during this century was not supported by good
evidence

Planned hospital birth may even increase unnecessary interventions
and complications without any benefit for low risk women (1)
The Royal College of Obstetricians and Gynaecologists do support home
births in cases of low-risk pregnancies provided the appropriate
infrastructures and resources are present to support such a system.
It is however important to note that the issue of home births remains a
contested one and the American, Australian and New Zealand colleges of
obstetricians and gynaecologists oppose home birth. However the Royal
College of Midwives in the United Kingdom, Australia New Zealand and
Canada all support home birth in uncomplicated pregnancy (32).
The rate of home births within the U.K remains low at approximately 2%
(33-35) but it is believed that if women had true choice the rate would be
around 8-10% (36).
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It has been argued that the development of maternity policies over the
last four decades combined with the regular reorganisation of service
structures have impacted on the availability of home birth to the point that
birth is now focused in hospital settings (25). The Royal College of
Obstetricians and Gynaecologists suggest that reasons for this appear to
include

Financial constraints

The values and beliefs of organisations about maternity care

A lack of staff with the appropriate competencies (25)
In any discussion about home birth it is important to distinguish between
women who plan for a home birth and those who have an unintended
home birth, as unintended home births and/or women who received no
antenatal care are linked to a higher rate of both maternal and perinatal
complications (37).
A proportion of women who plan for home birth are transferred to hospital
most commonly for slow progress or needing pain relief not available at
home, such as epidural anaesthesia (25).
The Royal College of Obstetricians and Gynaecologists state that women
need to be counselled on the unexpected emergencies (such as cord
prolapse, foetal heart rate abnormalities, undiagnosed breech, prolonged
labour and postpartum haemorrhage) which can arise during labour and
can only be managed in a maternity hospital (31). Such emergencies
would always require the woman to be transferred to a hospital by
ambulance as extra medical support is only present in hospital settings
and would not be available to them when they deliver at home (31).
3.7
Evidence from the Netherlands
Several studies have been conducted to evaluate the obstetric system in
Netherlands, which has a different system of maternity care to the UK.
Women are assessed as either high or low risk with low risk women giving
birth at home or in primary care under supervision of midwives, and high
risk women delivering in hospital under supervision of obstetricians. There
is conflicting evidence from these studies on outcomes and perinatal
mortality in relation to place of birth and travel times to hospital. This
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section summarises some of the evidence on the maternity system in the
Netherlands.
One study from the Netherlands undertook an analysis of 529,688 low risk
women who were in primary midwife led care at the onset of labour (30).
The study analysed national perinatal and neonatal registration data over
a period of seven years. This study concluded that planning a home birth
does not increase the risks of perinatal mortality and severe perinatal
morbidity among low risk women. This is provided that the maternity care
system facilitates this choice through the availability of well trained
midwives, and through a good transportation and referral system (30).
A very recent study from the Netherlands conflicts these findings (49).
The Netherlands have an obstetric system which classifies women into low
and high risk categories. Low risk women receive midwife led care in
primary care or at home and high risk women receive consultant led care
in hospital. This prospective study found that infants of pregnant women
at low risk whose labour started in primary care under the supervision of a
midwife had a higher risk of delivery related perinatal death and the same
risk of admission to the NICU compared with infants of pregnant women at
high risk whose labour started in secondary care under the supervision of
an obstetrician. The authors note the study used an aggregated large birth
registry database and could not adjust for confounders, which was a key
limitation. However they note that this was a surprising finding that
conflicts findings from other similar studies on the Netherlands’ maternity
care system and requires further evaluation.
A further recent large registry based cohort study from the Netherlands
which evaluated the effect of travel times at the start of and during labour
from home to hospital found that a travel time from home to hospital of
20 minutes or more by car is associated with an increased risk of neonatal
mortality and adverse outcomes in women at full term (50). This finding
conflicts two UK studies, which found no association between adverse
outcomes and increased travel time to the nearest or second nearest
healthcare facility (51, 52), although sample sizes in these studies were
much smaller. A strength of the Netherlands study is that a large registry
database was used (n751 926) and the study did control for some
confounders. However there were some key confounders that were not
controlled for such as body mass index and smoking, it is therefore not
possible to exclude the possibility that residual confounding could explain
some of the statistically significant results in the study. The authors note
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that further research is needed to investigate the policy implications of the
findings of this study.
When considering the evidence from the Netherlands, it is important to
note that the system of maternity care is very different to the UK and this
may limit the generalisability of the findings to the UK setting.
4
Safer Childbirth
Maternity care can range from looking after women through a very natural
birth process with little medical intervention through to highly technical
emergency care which has more in common to the services provided by
an accident or emergency department or intensive care unit. The King’s
Fund Safe Births report noted that nowhere have the negative aspects of
patient safety been more emphasised than in maternity services, which
have been subject to frequent reviews often accompanied by media
commentary.
Pregnancy and birth are normal physiological processes but the transition
from routine to emergency can occur rapidly and unexpectedly. Because
pregnancy and birth do not normally involve ill health, the expectation of
safety is particularly high and the obligation of the health system to do no
harm is an even higher imperative than normal (8).
Safety is more than focusing on recording, investigating, and analysing
failure. It also has the dimension of striving to maintain a system that is
geared to success. The King’s Fund report succinctly describes safety
being as much a matter understanding how success is achieved as of
understanding how failure happened (8). Clinical and managerial leaders
at all levels have important roles to play in ensuring patient safety. They
can be proactive in promoting safer practice, monitoring standards of care
and improving safety measures where necessary (8).
The King’s Fund Safe Births report (8) identified that the skills required to
lead maternity teams at different levels need to be clearly defined. The
development of shared objectives and a shared understanding of roles
may offer a means of promoting effective team working within maternity
service.
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4.1
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What should a Birth Setting look like?
A good working relationship between the multidisciplinary team made up
of medical ancillary and managerial staff and the women for whom they
care is crucial to ensure optimal birth outcomes (38). The “Safer
Childbirth” report suggested this is best achieved with a team approach
based on mutual respect, a shared philosophy of care and a clear
organisational structure for both midwives and medical staff with explicit
and transparent lines of communication (38). The minimum standards for
the organisation and delivery of care in labour in relation to the senior
management of an acute unit are set out in the “Safer Childbirth” report
(38).
Safer childbirth highlights the importance of the environment in which
women give birth. Facilities in all settings should be at an appropriate
standard and take account of the woman’s needs by being less clinical,
non threatening and more like home wherever possible (38). Facilities
should be audited and reviewed every two years.
4.2
Guidance on decision to delivery intervals for
emergency caesarean section
A decision to delivery interval describes the time between an obstetrician
in a consultant led unit deciding that a caesarean section should be
undertaken and the delivery. The National Institute for Clinical Excellence
clinical guidelines relating to caesarean section (39) state that emergency
Caesarean section delivery for maternal or foetal compromise should be
accomplished as quickly as possible. This is reflected in the guidelines on
electronic foetal monitoring as cited in the report of the National
Collaborating Centre for Women’s and Children’s Health (40).
The NICE clinical guidelines for caesarean section do however take into
account that rapid delivery has the potential to do harm (39). However
the most compromised babies are most predisposed to poorer outcomes
and are also often delivered with the least delay and this confounding
needs to be taken into account when assessing the effects of a rapid
delivery (41).
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A decision to delivery interval (DDI) of less than 30 minutes is not in itself
critical in influencing baby outcome, but has been an accepted standard
for response to emergencies within maternity services (39). The evidence
on this audit standard is mixed. The National Sentinel Caesarean Section
report produced by the Royal College of Obstetricians and Gynaecologists
(42) noted that in some cases the priority of ensuring maternal safety
may conflict with concerns about the baby.
Delivery should be accomplished as far as possible without endangering
the condition of the mother. Rapid decision making has the potential to
cause adverse effects and the report acknowledges that rapid decision
making in stressful circumstances may generate anxiety for all involved
(42). Delays in delivery can possibly associate with poor outcomes. Delays
have been attributed to poor communication and the sentinel report
acknowledges that rapid and precise communication between health
professionals may reduce delays (42).
The good practice guidance developed by the Royal College of
Obstetricians and the Royal College of Anaesthetists suggested that in
certain cases such as cord prolapse a DDI of 15 minutes was feasible (43).
The guidance goes on however, to suggest that in certain circumstances,
delivery within 75 minutes does not appear to raise the risk of
compromise, while delivery within 30 minutes may not always result in a
good neonatal outcome (43). Once a decision to deliver has been made
delivery should be carried out with urgency appropriate to the risk to the
baby and the safety of the mother. Units should strive to design guidelines
that result in the shortest safely achievable DDI. Undue haste to achieve a
short DDI can introduce its own risk, both surgical and anaesthetic with
the potential to cause harm to either the mother or baby (43). It is
suggested that the speed of intervention is only one aspect to be
considered, and that the anticipation and identification of early threatening
conditions for both baby and mother were important (44).
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5
Recommendations
literature
arising
from
the
5.1
Recommendations for the Maternity Service for
Wales
The report “A Maternity Service for Wales” (10) sought to provide
maternity service planners with a consensus view from the lead
professional groups on what issues need to be taken into consideration.
The recommendations made fall under two broad headings:
Service Reconfiguration
The Multidisciplinary Professional Project Group recommended that the
ultimate goal should be the development of a sustainable, safe service
which is acceptable to the users: pregnant women and their families.
Therefore where service mergers are proposed, professional advice should
be sought at the planning stage from all the Royal Colleges and advisory
groups involved. The group also recommended that the “Standards for
Maternity Care” hosted and published in 2008 by the Royal College of
Obstetricians and Gynaecologists’ for all maternity speciality groups
should set the standard for any change in care structures (10).
When service changes have been made they should be monitored
regularly against the Joint Colleges’ standards for Maternity Care.
Training
The Maternity Service for Wales report (10) recommended that the impact
of a merger, closure, or service change to a unit on other providers be
considered with especial regard to training. The maternity service should
allow for high quality training of those medical specialists who will be
providing services in the future
The Midwifery 2020 Delivering Expectations report (45) as part of its
vision for midwifery training states that midwifery education will be rooted
in normality whilst preparing midwives to care for all women including
those with complex medical, obstetric and social needs. It will prepare and
develop midwives to be skilled and safe, empathic and trustworthy with
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increased emphasis on the principles of autonomy and accountability
within multidisciplinary and multi agency teams.
5.2
Recommendations for the New Local Health
Boards from the Wales Audit Office Maternity
Services report
The Wales Audit Office report “Maternity Services” (5) made a series of
recommendations directed at the new Local Health Boards in Wales.
Staffing

The new LHBs need to strengthen the consultant job planning
process in order to clearly identify the consultant time spent on
obstetrics as opposed to gynaecology. This improvement would help
ensure that Boards have appropriate consultant cover.

Where the presence of consultant obstetricians on delivery suites
fall below recommended levels that the new LHBs should undertake
an adequacy assessment of their consultant staffing requirements
for delivering safe and high quality services.

Where midwifery staffing levels fall below recommended levels the
new LHBs should undertake an assessment of the adequacy of their
staffing requirements for delivering safe and high quality services

That the new LHBs review whether they have sufficient numbers of
maternity support workers in order to release midwives to focus on
the more specialist care and treatment, and to support the national
training programme to ensure all support workers have all the
appropriate skills.
Training

That the new LHBs ensure that all maternity services staff are
trained to the required level.

That the training programmes implemented by LHBs should be
reviewed in order to ensure a sufficient focus on the principles of
respect, well being, choice and dignity for women.
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The Woman’s Experience

That the new LHBs work harder to gather the views of service users
and consider the views expressed when planning services.

That the LHBs promote midwives as the most appropriate first point
of access for pregnant women, and publicise broadly the services
available locally

That the new LHBs should review their processes for deciding on the
appropriate number of ante natal check ups to ensure this is based
on need and evidence based standards.

That LHBs should explore the reasons behind low attendance at ante
natal classes, and that information gained from surveys should be
acted upon in order to give every woman an opportunity to attend
classes if they wish.

In order to improve care during labour and birth that processes are
put into place by LHBs to ensure that women’s preferences for pain
relief are formally recorded by the clinicians caring for them.

That the new LHBs should provide locally accessible community
locations that can function as antenatal drop-in centres run by
midwives.

That the new LHBs carry out local audits to assess the
appropriateness of their caesarean rates including a comparison rate
between individual consultants. Where high rates are identified that
the Caesarean toolkit developed by the NHS Institute for Innovation
and Improvement which aims to reduce section rates be
implemented

That the LHBs should ensure that the necessary support is available
to support women to breastfeed and that the advice and support
provided is consistent.
Safety

In order to improve safety the Wales Audit Report recommended
that the LHBs standardise the criteria for incident reporting by
promoting a culture of openness and by putting into place
mechanisms for learning from incidents

That the recommendations contained within the Welsh Risk Pool
Maternity Project should be implemented by LHBs as they address
the problems in the use of electronic foetal monitoring that is a
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common feature in a large number of high-value obstetric clinical
negligence claims
Acknowledgments
The authors would like to acknowledge the invaluable contribution from
Dinah Roberts and Ken Jones from the Public Health Wales’ Library
Knowledge and Management Service in the development of this report
6
Appendix: Search Strategy
Main search: maternity services
Additional searches: emergency caesarean section; transfer times; home births
Topic: Maternity services
Search question: What is the current evidence base on best practice in relation to the
delivery of safe and sustainable maternity services?
By:
Dinah Roberts
Date : 3 August 2010
Updated: 18 August 2010
Methodology
Search terms :-Keywords, Free text
Models of service
Service models
Service delivery
Service provision
Service redesign
Service reconfiguration
Service rationalisation
Models of care
Access to services
Provision of services
Maternity services
Maternity hospitals
Hospitals, maternity
Obstetric led maternity units
OLMU
Maternal health services
Maternity health services
Maternity units
Maternity wards
MMU
Date: Feb 2011
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Midwifer* –led units
Midwife-led birth centre*
MLMU
Designated midwifery unit
Local maternity care
Birthing centres
Intra-partum
Pregnancy services
Ante-natal services
MESH
HMIC BNI
Obstetric and Gynecology Department, Hospital
maternity health services/ma/og/st/tr/ut
Maternal health services
Maternal care
Maternity clinics
Maternity units
General practitioner maternity units
Obstetric clinics
Obstetric care
Midwifery services
Change management
Health provision
Health service development
Health service delivery
Health service evaluation
Health service management
Health service organisation
Health service planning
Health service utilisation
"hospital planning and design"
Models
Nursing models
Organisational change
Patient safety
Service delivery
Service demand
Service development
Service needs
Service planning
Service relocation
Service standards
Service utilisation
Staffing levels
Unit management
Ward organisation
Workforce
Workforce planning
Publication types
Database searches filter =
Systematic reviews, RCTs, Meta analysis , reviews
Limitations
 Language
Date: Feb 2011
English only
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
Maternity services literature review
Dates covered/period of
publication
2000-
Exclude
Include
Developing countries
Topic: Emergency caesarean section
Search question: What is the current evidence base on decision-to-delivery time of 30mins
in emergency caesarean section?
By: Sian King, LKMS Swansea
Date : 27/09/10
Methodology
Search terms
headings,
:-Keywords,
HMIC, BNI
MESH
Publication types
Limitations
 Language


Dates covered/period of
publication
Non UK
Date: Feb 2011
subject
Caesarean adj2 emergenc*
C$esarean adj2 emergenc*
Caesarean section
Caesarian section (BNI)
Birth delivery
Emergencies
Emergency care
Emergency surgery
Labour: complications
Labor complications (CINAHL)
Obstetric emergencies
Decision making
Clinical decision making
Medical decision making
Time
Cesarean section
Emergency care
Emergency surgery
Emergency treatment
Emergencies
Decision making
Time factors
Systematic reviews, reports, guidelines, articles
English
2000-2010
Yes
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Topic: Maternity services
Transfer times from midwifery led units to consultant led
unit in relation to obstetric emergencies and maternal/neonatal outcomes?
Search question:
By: Dinah Roberts
Date : 29 September 2010
Topic: Home births
Search question:
What are the increased risks associated with home births
compared to hospital births?
By: Sian King, LKMS Swansea
Date : 07/10/10
Methodology
Search terms :-Keywords, Free text
MESH
HMIC BNI etc
Publication types
Limitations
 Language
Date: Feb 2011
Home birth$
Home adj2 birth$
Home childbirth
Pregnancy Outcome
Pregnancy, High Risk
Risks
Risk factors
Patient transfer
Home confinement
Home delivery
Confinement: Place (BNI)
Birth delivery
Fetus risk
Risks
Adverse outcome
Clinical outcomes
Fetal outcomes
Health outcomes
Outcomes and prognoses
Outcomes
Pregnancy outcome
Pregnancy: complications
Labour: complications
Labor complication(s)
Patient safety
Systematic reviews, reports, guidelines, articles
English
Version: 0j
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

Maternity services literature review
Dates covered/period of
publication
Other limitations
2000-2010
Exclude
Include
Developing countries
Personal experience stories
2. Sources
(i.) Core
databases/sources
BNI
CINAHL
Clinical Evidence
Pre 2000 included
Cochrane Library
√
EMBASE
HMIC
MEDLINE
NICE
√
Library catalogue & knowledge base
√
PsycINFO
X
(ii.)
Topic
specific
databases, sources
Databases
Child data
MIDIRS
X
POPLINE
Map of medicine
Department of Health (inc:
Children, Young People &
Services)
NSF for
Maternity
Department for Health & Children [Ireland]
Department of Health, Social Services &
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(ii.)
Topic
specific
databases, sources
Public Safety [NI]
NHS
Institute
Improvement
for
Innovation
and
NHS Quality Improvement Scotland (inc.
Findings – CH & Maternity Services &
Reproductive health)
NHS Scotland
NHS Quality Improvement
Scottish
Government
(for
Services Action Group reports)
Maternity
Welsh Assembly Government (inc: NSF for
Children, Young People & Maternity
Services)
CMACE (Centre for Maternal and Child
Enquiries)
√
NPSA
NIHR-SDO
√
Health select Committee
√
Welsh Audit Office
√
National Audit Office
National Perinatal Epidemiology Unit
Maternity
Evidence
Birmingham]
√
[University
of
√
King’s Fund – maternity topic
National Collaborating Centre for Women's
and Children's Health
NHS Evidence (specialist collections)
- health management – Maternity
services
√
Royal College of Midwives
Royal College of Paediatrics & Child Health
Royal
College
Gynaecologists
of
Obstetricians
&
√
Royal College of Surgeons
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(ii.)
Topic
specific
databases, sources
AIMS (Association for Improvements in the
Maternity Services)
European Foundation
Newborn Infants
for
the
Care
of
MARCH (Centre for Maternal Reproductive
and Child Health)
Maternity Action
National Childbirth Trust
National Maternity Support Foundation
Independent Midwives Association
Warwick Infant and Family Wellbeing Unit
Child
Health and Maternity Partnership
CHAMP
***
ChiMat
√
Maternity Liaison Committees
International
Gyn.
(iii) Meta search engines
Federation of Obstetrics and
Google/Google Scholar
√
√
Intute
SUMsearch
TRIP
Date: Feb 2011
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7
Maternity services literature review
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