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  • Maternity services: Evidence to support improvement – a blog from Candace Imison

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    The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement.

    In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight.



    Poor care can have a traumatising effect at any time, but the consequences in maternity care are particularly profound. The death of a baby is a devastating loss for any family. As one bereaved mother put it:

    When your baby dies, it’s like someone has shut the curtains on life, and everything moves from colour to darkness.”[1] 

    It is all the more perplexing that this area of care has seen recent declines in indicators of quality and safety. There have been repeated investigations into maternity services, with repeated recommendations for improvement. Dr Bill Kirkup reflected on this in his investigation into East Kent Hospitals, and decided not to make detailed policy recommendations:

    I do not think that making policy on the basis of extreme examples is necessarily the best approach; nor are those who carry out investigations necessarily the best to do it. More significantly, this approach has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work.[1]

    As a consequence, the report suggested four areas for action that Trusts themselves can take to drive improvement. These are:

    1. Kind and compassionate care.
    2. Teamwork with common purpose.
    3. Identifying poor performance.
    4. Organisational oversight and response to challenge.

    We took these four areas as the starting point for our recent Collection: Maternity services: evidence to support improvement. We drew together research that would give Trusts a firm evidence base for improvement. When we engaged with stakeholders, they were particularly grateful for evidence on how to identify poor performance and on organisational oversight; these are frequently taken for granted in recommendations for best practice.

    Identifying poor performance

    I was struck by the basic challenge created by the poor quality of medical certificates of stillbirth: 80% contain an error, and 56% an error that would alter its interpretation. There are opportunities to generate richer learning from data readily available. For example, from complaints. Learning could be enhanced through:

    • A reliable and meaningful coding system to classify complaints; for example, according to severity and the type of concern.
    • Guidelines and training for the staff coding complaints.
    • A centralised informatics system to capture and analyse complaints data.
    • Bringing together and comparing complaints data with other sources of patient feedback and incident reporting (triangulating).

    A repeated message was the need to triangulate data. For example, the rate of caesarean sections alone is not a meaningful indicator of the quality of a service. A combination of performance data with patient feedback and other types of feedback can help interpret the statistic.

    There was also a need to ensure that recommendations from local audits and reviews were acted upon.

    Board oversight and response to challenge

    A key finding from many investigations into failures of care is the lack of oversight and understanding by the board. Donna Ockenden in her report said:

    This meant that consistently, throughout the review period, lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result.”[2]

    A recent NIHR study of boards[3] identified five key roles for effective hospital boards:

    1. Conscience of the organisation – setting and reinforcing values.
    2. Shock-absorber – helping determine local priorities in a complex policy and regulatory environment.
    3. Diplomat – managing relationships across the local health economy.
    4. Sensor – scrutinising organisational performance to drive improvement.
    5. Coach – setting direction while providing support to staff.

    The study argues that effective boards take on all of these roles. This resonates with the findings from the East Kent and other investigations, in which the boards demonstrated weaknesses particularly in the roles of conscience, sensor and coach. Boards need to ensure that the voice and experience of both clinical staff and patients are heard and understood. Their involvement is a key factor in mature and high-quality improvement systems.


    Maternity care aims always to be safe, effective and responsive. For the great majority, pregnancy and childbirth is a positive and happy experience that culminates in a healthy mother and baby. But on the rare occasions when things go wrong, the effects are life changing. We hope the evidence we brought together in our Collection will help hospitals to drive improvement and avoid devastating outcomes. 


    1. Kirkup B. Independent report. Maternity and neonatal services in East Kent: 'Reading the signals' report. Department of Health and Social Care, October 2022.
    2. Ockenden D. Independent report. Final report of the Ockenden review. Department of Health and Social Care, March 2022.
    3. Chambers N, et al. Roles and behaviours of diligent and dynamic healthcare boards. Health Services Management Research 2020;33(2):96-108. doi:10.1177/0951484819887507.

    About the Author

    Candace is Deputy Director of Dissemination and Knowledge Mobilisation for the National Institute for Health and Care Research (NIHR). She leads the NIHR’s dissemination and knowledge mobilisation activity, including the production of accessible summaries of important NIHR research findings on NIHR Evidence (https://evidence.nihr.ac.uk/). Candace has over 30 years’ experience working in UK healthcare across all parts of the health system, including undertaking health research and developing health policy. 

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