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Showing results for tags 'Maternity'.
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Event
Black Maternal Health APPG Meeting
Patient Safety Learning posted an event in Community Calendar
untilThe Black Maternal Health All Party Parliamentary Group (APPG) is having a meeting to discuss various updates and new improvements that have been made in the maternity world. The meeting will be hosted and chaired by Bell Ribeiro-Addy MP, Chair of the APPG and the Secretariat of the APPG is provided by Five X More CIC The E8 Group and Mimosa Midwives. The APPG aims to raise awareness of the issue of racial disparities within maternal healthcare and offer solutions to end this. Register -
News Article
Herpes deaths: NHS trust lied about virus links, inquest hears
Patient Safety Learning posted a news article in News
The mother of a young woman who died with herpes said she was "disgusted" with an NHS trust which "lied" about the potential cause of the virus. Kim Sampson and Samantha Mulcahy died with herpes after the same obstetrician at the East Kent Hospitals University NHS Trust carried out their caesareans. Yvette Sampson's daughter had been "fit and healthy" until she gave birth on 3 May 2018, an inquest has heard. She said the trust had lied about links between the two mothers' deaths. They were treated by the same surgeon and midwife six weeks apart, neither of whom were tested for herpes, the inquest in Maidstone was told. Ms Sampson said her daughter had been "in agony" from 3 May when she gave birth to her second child, until she died on 22 May. She told the inquest she had received "poor treatment" by midwives at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, which she felt also "contributed" to her daughter's death. Ms Sampson was initially denied a Caesarean and instead told to push for almost three hours, despite repeatedly telling midwives that "something wasn't right" and "clinging to the bed in agony", her mother said. Read full story Source: BBC News, 20 April 2023 -
News Article
‘They didn’t believe I was in labour’ says Black mother ‘ignored’ by midwives
Patient Safety Learning posted a news article in News
The Women and Equalities Committee in a recent report has challenged the government over failures to address inequalities in maternity care which have led to Black women dying at four times the rate of white women. Tinuke Awe, 31, was left ‘traumatised’ and forced to go without pain relief after midwives didn’t believe she was in labour. Ms Awe, was induced after experiencing late pre-eclampsia while pregnant with her first child in 2017. She said: “Pre-eclampsia can be life-threatening for mum and baby, and it could’ve been fatal if I wasn’t treated. I was told I couldn’t leave the hospital and had to be induced". “They said the hormones could take 24 hours to work, but my labour happened really quickly and when I told the midwife she didn’t even believe I was in labour.” “I felt so overlooked and it was horrible how nobody listened to me,” she added. “I ended up having to have an assisted delivery which isn’t what I wanted, but it could’ve been avoided if someone had acknowledged I was in labour rather than ignore me. I just felt so unimportant.” Ms Aew alongside Clotilde Abe set up the charity Five X More. The organisation helps give advice and empower Black women to make informed choices during pregnancy and after childbirth. Five X More hope that the testimonials of the women they support can be used to show that better outcomes are possible with their ‘five steps for self-advocacy‘ being used to encourage women to ask for things like a second opinion. Read full story Source: The Independent, 18 April 2023 Read our interview with Tinuke Awe on the hub: Five X More campaign: Improving maternal mortality rates and health outcomes for black women -
News Article
Northern Ireland new model of care for pregnant women launching
Patient Safety Learning posted a news article in News
Anew model of care which the Public Health Agency (PHA) say will 'improve maternity services for women and babies in Northern Ireland' is being launched. The new model, which will see women receive support from the same midwifery team during pregnancy, birth and in the early days after birth, is being rolled out across all Health and Social Care (HSC) Trusts in the coming months. ‘Continuity of Midwifery Carer’ (CoMC) is a new model of care for women throughout their childbirth journey "that will provide positive clinical outcomes and higher care satisfaction", the PHA said. Chief Nursing Officer for Northern Ireland, Maria McIlgorm said: “This is a very positive development for maternity services in Northern Ireland. There is a clear evidence base behind the Continuity of Midwifery Carer model which shows that when a woman knows their midwife it can make a significant difference to their experience and outcome. “This woman and family-centred model of care will mean that women across Northern Ireland using our maternity services will receive support from the same dedicated midwifery team throughout their pregnancy, birth and postnatal period.” Read full story Source: Belfast Live, 12 April 2023 -
News Article
End racial disparities in maternal deaths
Patient Safety Learning posted a news article in News
An MPs' report is calling for faster progress to tackle "appalling" higher death rates for black women and those from poorer areas in childbirth. The Women and Equalities Committee report says racism has played a key role in creating health disparities. But the many complex causes are "still not fully understood" and more funding and maternity staff are also needed. The NHS in England said it was committed to making maternity care safer for all women. The government said it had invested £165m in the maternity workforce and was promoting careers in midwifery, with an extra 3,650 training places a year. Black women are nearly four times more likely than white women to die within six weeks of giving birth, with Asian women 1.8 times more likely, according to UK figures for 2018-20. And women from the poorest areas of the country, where a higher proportion of babies belonging to ethnic minorities are born, the report says, are two and a half times more likely to die than those from the richest. Caroline Nokes, who chairs the committee, said births on the NHS "are among the safest in the world" but black women's raised risk was "shocking" and improvements in disparities between different groups were too slow. "It is frankly shameful that we have known about these disparities for at least 20 years - it cannot take another 20 to resolve," she added. -
Content ArticleIn the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
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Content ArticleA doula, according to Doula UK (2022), provides ‘support in pregnancy, birth and in the postnatal period by providing information, advocacy, and practical and emotional support to the whole family’. This blog by the Healthcare Safety Investigation Branch (HSIB) maternity team outlines why HSIB decided to investigate the role of doulas in maternity safety and the results of their investigation. It highlights discrepancies in doula training and several cases where doulas stepped outside of the boundaries of their role. HSIB argues that there is a need for further work to understand how families view the role of doulas during pregnancy and birth.
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Event
SEIPS masterclass in maternity
Patient-Safety-Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place -
Content ArticleThis paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
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News Article
Trusts given five years to achieve safe midwife staffing
Patient Safety Learning posted a news article in News
NHS trusts have been given until 2027-28 to employ enough midwives to meet safe staffing requirements, NHS England’s new maternity delivery plan has said. The three-year delivery plan for maternity and neonatal services sets out to “make maternity and neonatal care safer, more personalised and more equitable for women, babies and families”. It says: “Trusts will meet establishment [requirements] set by midwifery staffing tools and achieve fill rates by 2027-28, with new tools to guide safe staffing for other professions from 2023-24.” The plan follows a series of high-profile maternity scandals in the NHS at Shrewsbury and Telford, East Kent, Morecambe Bay and an ongoing independent review by Donna Ockenden into Nottingham University Hospitals Trust. The Care Quality Commission has highlighted a string of other concerns across the NHS. Read full story Source: HSJ, 31 March 2023 -
Content ArticleThis plan from NHS England sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. NHS England has engaged a wide range of stakeholders who supported the development of this plan. This includes women and families who have used or are using maternity and neonatal services, members of the maternity and neonatal workforce, leaders and commissioners of services, NHS systems and regional teams, and representatives from Royal Colleges, charities and other organisations.
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Content ArticlePoster presentation from Dr Felicity Brokke and Ken Spearpoint at the recent GOSH Patient Safety and Human Factors Conference.
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News ArticleMothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
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Content ArticleWomen should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
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EventBaby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
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News Article
Birmingham hospital apologises after delays leave baby disabled
Patient Safety Learning posted a news article in News
Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023 -
News Article
Specialist NHS centres aim to halve maternity deaths in England
Patient Safety Learning posted a news article in News
Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths. For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy. Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women. The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof. GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures. Read full story (paywalled) Source: The Times, 20 March 2023 -
News Article
Conference highlights racial disparity in UK maternal healthcare
Patient Safety Learning posted a news article in News
Unconscious bias in the UK healthcare system is contributing to the stark racial disparity in maternal healthcare outcomes, a conference has heard. The Black Maternal Health Conference UK, also heard that black women not being listened to by healthcare professionals was also a contributing factor. The conference, organised by The Motherhood Group, was arranged to highlight the racial inequality in maternal healthcare and the disparity in maternal mortality between white, ethnic minority and black women in the UK. Black women in the UK are four times more likely to die in pregnancy and childbirth than white women, according to a report published by MBRRACE-UK. Asian women are twice as likely to die in pregnancy or childbirth. Sandra Igwe, who founded the NGO The Motherhood Group in 2016 after the traumatic birth of her daughter, told the PA Media that the event was an opportunity to “bridge the community, stakeholders, professionals, [and] government”, de-stigmatise mental health and bring about change to improve black maternal health. “There are so many stats – so why wouldn’t we have a whole day’s conference dedicated to addressing these, just scratching the surface of some of the stats?” Charities and activists have been raising alarm bells about the dangerous consequences of unconscious bias in maternal healthcare for many years. Igwe co-chaired the Birthrights inquiry, a year-long investigation into racial injustice in the UK maternity services, which heard testimony from women, birthing people, healthcare professionals and lawyers and concluded that “systemic racism exists in the UK and in public services”. Read full story Source: The Guardian, 20 March 2023 Sandra Igwe is our hub topic lead for Black Maternal Health. Read our recent interview with Sandra. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety. -
News Article
Why US mothers are more likely to die in childbirth
Patient Safety Learning posted a news article in News
The United States remains one of the most dangerous wealthy nations for a woman to give birth. Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention. In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC. Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank. "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US." Read full story Source: BBC News, 18 March 2023 -
Content ArticleIn this Guardian article, Sarah Kendell describes her experience of maternity care in Australia, highlighting the stark difference in care offered before and after a woman has given birth. She says "at the most difficult transition of our lives–after childbirth–the healthcare system leaves us to fend for ourselves," and argues that the impact this can have on the health and wellbeing of women and their babies needs to be considered. She asks whether reallocating some resource from antenatal care to postnatal care would produce health benefits for new mothers and babies.
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News Article
Family campaigns to prevent breech birth deaths
Patient Safety Learning posted a news article in News
A couple whose baby died after he was starved of oxygen during a home birth are campaigning for risky breech deliveries to be spotted earlier. Arthur Trott was an undiagnosed breech baby, born after a planned home birth in Burgess Hill on 24 May 2021. A breech delivery is when a baby's bottom or feet will emerge first. An inquest into his death found a delay in transfer to hospital "materially contributed" to his brain injury. The South East Coast Ambulance Service Trust said it welcomed "any changes to national breech birth guidance". Arthur's parents believe a breakdown in communication between the paramedics who attended and their control room meant Mrs Trott was kept at home too long. Arthur's father, Matt Trott, said: "You could hear the panic and confusion in everyone's voices. One minute they were told to go to hospital, the next minute to stay." As a result of Arthur's death, all planned home births in Sussex are being offered a presentation scan at 38 weeks. Read full story Source: BBC News, 14 March 2023 -
Content ArticleIn this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
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Content ArticleAt least 1 in 5 mothers experience a perinatal mental health (PMH) problem, making mental illness the most common serious health problem that a woman might experience in the perinatal period. This resource was produced by the Institute of Health Visiting (iHV) in partnership with the Maternal Mental Health Alliance (MMHA). It draws together principles collated from a comprehensive desktop evidence review of current policy, research, reports and literature on what good PMH care looks like. It aims to support individuals, services, pathways, multiagency groups and networks across health, public health, social care and non statutory services to consider: Where are we now? Is the care we currently provide good enough? What do families want mental health care in the perinatal period to look like?
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News ArticleBereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned. Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives. "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'. "People are lying, they're not being open and they're concealing what's happening. "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else." Read full story Source: Mail Online, 10 March 2023
