In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent.
Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience.
Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups.
This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships.
The report highlights the next steps that maternity services and the CQC need to take:
For maternity services and local maternity systems
- Leadership: In line with essential action 2 of the first Ockenden review, Boards must take effective ownership of the safety of maternity services. This includes ensuring that they have high quality, multidisciplinary leadership and positive learning cultures. They must seek assurance that staff feel free to raise concerns, that their concerns and adverse events lead to learning and improvement and that individual maternity staff competencies are assured.
- Voices and choices: In line with the Cumberlege review ‘First do no harm’, maternity services must ensure that all women and their families have information and support that allows them to make choices about their care. This includes listening to individual women and fully explaining choices, in an accessible way throughout the pregnancy journey. This includes, for example, working effectively with interpreters.
- Engagement: As supported by the findings of 'Better Births' and 'First do no harm', local maternity systems need to improve how they engage with, learn from and listen to the needs of women, particularly women from Black and minority ethnic groups. They also need to make sure that targeted engagement work is appropriately resourced.
- Data and risk: Services and systems should use ethnicity data they collect to review safety outcomes for women from Black and minority ethnic groups, and take action in response to risk factors. This includes working with Black and minority ethnic women to personalise care and reduce inequality of outcomes.
The CQC will continue to:
- focus on the quality of maternity leadership teams, ensuring they understand the day-to-day running of the service, are listening to staff and ensuring they feel free to speak up, and that they foster a culture that drives continuous improvements in safety.
- look at how leadership teams ensure multidisciplinary staff who work together are training and learning together without barriers, and that staff are supported to develop and maintain individual core competencies and to work effectively as a team at all times.
- assess the transparency of services, ensuring that they embrace learning and reporting cultures and that there is accountability and trust.
Tackling health inequalities is a core ambition of CQC's new strategy. As part of this the CQC will:
- continue to ask maternity services about work on maternity equity and engagement during inspection and monitoring activity
- continue to learn from women who use services and who face inequality
- apply what we have learned to other core services and areas of our work
- consider equity and engagement as issues that impact on safety
- expect services to use people’s experiences and equality data to review and act on outcomes and respond to the needs of their local population
- continue to improve how we work with equality data to assess safety and quality of people’s care and work with others to do this.