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The following safety issues were identified during the HSIB’s initial investigation and will form the basis for the ongoing investigation: referral from the emergency department into early pregnancy services provision of early pregnancy assessment services that allow for the timely diagnosis and optimum management of ectopic pregnancies.

Key learning points Sharing information with the multi-disciplinary team helps break down barriers and reduce anxiety. Women should have an opportunity to discuss concerns and have questions answered face-to-face rather than a written response. There is a huge benefit for women to have access to a service that supports closure and shared understanding following a poor experience whether from the birth or postnatally. Providing reassurance that their concerns are addressed and there is organisational learning from their feedback. Women are at the centre of midwifery care. Always listening to what women want/need to ensure a positive birth experience improves the quality of care delivery. Passionate patient engagement is essential. Staff working within the service must value patient feedback and be driven to use it to develop services not just resolve a complaint. It’s important to not be afraid of saying ‘sorry’, this simple word can validate someone’s feeling and has made a huge difference. Enabling parents to feel positive about their birth reduces anxieties, increase confidence and reduces mental health problems following the birth.

Home births: a woman’s choice? Maternity services are rapidly adapting the way they work in light of the pandemic. Pregnant women are being asked to attend antenatal appointments alone or remotely in order to reduce risk of infection. In some areas, the option to have a midwife-led home birth has been suspended.[2] A recent report from the BBC suggests that as many as one third of Trusts could have removed home birth as an option.[3] For those who are not considered high-risk and have given birth before, home birth is often a very positive experience and clinical outcomes are good, with transfer rates to hospital and medical intervention very low among this group.[4] There is some evidence to suggest that more women are requesting to birth at home to reduce the risk of catching COVID-19 while in hospital.[5] This will, of course, require the appropriate level of support midwives being available to enable this. Commenting on the role of midwife-led care during the pandemic, joint guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) states: “The positive impact of midwife-led birth settings is well documented, including reductions in the need for a range of medical interventions. These positive impacts remain of significant importance to prevent avoidable harm, and availability of midwife-led care settings for birth should therefore be continued as far as is possible during the pandemic.”[6] For some women though this option is now being taken off the table. Due to the pressures on services caused by the pandemic, the RCOG/RCM guidance also includes a framework to help maternity teams understand when and how they may need to suspend midwife-led services such as home births. In some areas of the UK, this is already happening and low-risk pregnant women are no longer being offered the full spectrum of birthing choices, as recommended by the National Institute of Health and Care Excellence (NICE).[7] There doesn’t seem to be publicly available information on the extent of this service suspension. The guidance recommends a staged approach in responding to emerging issues with staff shortages and other service pressures during the pandemic. It states that decisions about when to implement each stage will need to be made at a local level based on current local data including: bed occupancy in the maternity unit(s) community workload sickness rate among midwifery staff (midwives, maternity support workers and senior student midwives) available midwifery staffing (including additional midwives from the NMC emergency register, those previously in non-clinical roles or year-3 student midwives) skill mix of available midwifery staffing – including level of seniority and experience in provision of community-based care availability of ambulances and trained paramedic staff, to provide emergency transfer. COVID-19 is therefore having the direct impact of reducing birthing options available to some pregnant women. Patient Safety Learning is concerned with the safety of mums and babies with this erosion of a woman’s right to choose the birth they want. We are hearing that: Some women have serious concerns and anxiety about attending hospital during the pandemic and how they and their babies are being protected from COVID-19. Suspension of services could have a major impact on women who are frightened to birth in a hospital setting due to past trauma. Low-risk women are not being offered a home birth service in some areas. Women are unclear as to why they cannot home birth; is it because there are safety concerns where midwife-led services were critically understaffed when responding to home births? We think there are risks to patient safety and that there are significant questions that need to be answered: Are Trusts able to evidence that their decision-making around the suspension of home births is appropriate and proportionate, particularly for low-risk women where evidence indicates good clinical outcomes? Are Trusts’ decisions to suspend home births (and the basis behind these decisions) being shared publicly with the women under their care? RCOG/RCM guidance gives advice on reinstating services and recommends suspensions be regularly reviewed. How regularly are these suspensions being reviewed? Is this information publicly available? What steps are being put in place to preserve midwife-led services for women and their babies, whose health outcomes may be adversely affected by these changes? Are the health outcomes of these women and babies being monitored and reported on? How are women being reassured and informed of their safety from COVID-19 in hospital maternity care? High-risk pregnancies Some pregnancies are deemed as ‘high-risk’ and these women often fall under the care of a consultant. High-risk women and their babies are more likely to need extra medical support that is unavailable in a midwife-led birth setting. They would usually be advised by to go to a hospital labour ward to have their baby where that clinical support is available if needed. We are hearing that there is the potential for the number of high-risk women requesting to have their baby at home to rise, due to fears around coronavirus. This has serious safety implications and raises further questions around the number of experienced staff (and home birth equipment) available to support these labours. Where home births have been suspended there is also the frightening potential for high-risk women who choose not to go to hospital, to labour without clinical support. The RCM has highlighted there is anecdotal evidence that more women are choosing to birth at home unassisted due to reduced birth options and midwives are becoming increasingly concerned at the safety implications of this.[8] Maria Booker, Programmes Director from Birthrights, a charity that protects human rights in childbirth, explained their concerns around restricted services: "We are concerned that more women will have an unassisted birth that they have not actively chosen to have, due to the withdrawal of home births and midwifery led birth centres in some areas, which may put themselves and their babies at risk. Trusts need to be very clear that they can justify these restrictions on services as a proportionate response to their current situation and to review these decisions frequently as circumstances change."[9] We think there are risks to patient safety and that there are significant questions need to be answered: Has there been an increase in high-risk women deciding to birth at home against clinical advice? Where home birth has been suspended, and a high-risk woman decides to birth at home against clinical advice, will she give birth without clinical assistance? Where there is an increase in women requesting to have their baby at home, are midwives (including those returning to the profession) receiving the right support? Do they have an adequate supply of home birth kit and PPE? Are there enough staff experienced and confident in supporting both low and high-risk women to labour at home? Safe births during the pandemic Maternity services are faced with the challenge of adapting within unfamiliar and unpredictable territory. However, it is important that pregnant women and their babies continue to access the safest care options. There may not be a one-size-fits-all solution and the safety implications of blanket suspensions of home births, combined with a rising fear of hospitals, need due attention in order to protect mums and babies from suffering avoidable harm. Where Trusts take the decision to reduce birth options, these must be evidenced, proportionate and justifications must be made publicly available. References [1] BBC News, Coronavirus: Social restrictions ‘to remain for rest of year’, 22 April 2020. https://www.bbc.co.uk/news/uk-politics-52389285 [2] The Guardian, NHS trusts begin suspending home births due to coronavirus, 27 March 2020. https://www.theguardian.com/world/2020/mar/27/nhs-trusts-suspending-home-births-coronavirus; NHS Lanarkshire, NHS Lanarkshire restricts neonatal visiting and suspends home births, Friday 27 March 2020. https://www.nhslanarkshire.scot.nhs.uk/restricted-neonatal-visiting-suspended-home-births/; The Hillingdon Hospitals NHS Foundation Trust, Covid-19 virus infection and pregnancy, Last Accessed 24 April 2020. http://thh.nhs.uk/services/women_babies/COVID-19_infection_pregnancy.php [3] BBC News, Coronavirus: Uncertainty over maternity care causing distress, 24 April 2020. https://www.bbc.co.uk/news/health-52356067 [4] Birthplace in England Collaborative Group, Perinatal and maternal outcomes by planned place of birth for healthy women with low-risk pregnancies: the Birthplace in England national prospective cohort study, BMJ, 2011; 343. https://www.bmj.com/content/343/bmj.d7400; National Institute for Health and Care Excellence, Intrapartum care for healthy women and babies: Clinical guideline [CG190], Last Updated 21 February 2017. https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#place-of-birth [5] Anonymous, Midwifery during COVID-19: A personal account, Patient Safety Learning the hub, 21 April 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/midwifery-during-covid-19-a-personal-account-r2095/ [6] The Royal College of Midwifes and Royal College of Obstetricians & Gynaecologists, Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic, 9 April 2020. https://www.rcm.org.uk/media/3875/midiwfe-led-settings-and-guidance.pdf [7] National Institute for Health and Care Excellence, Intrapartum care: Quality Standard [QS105], Last Updated 28 February 2017. https://www.nice.org.uk/guidance/qs105/chapter/quality-statement-1-choosing-birth-setting [8] The Royal College of Midwifes and Royal College of Obstetricians & Gynaecologists, Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic, 9 April 2020. https://www.rcm.org.uk/media/3875/midiwfe-led-settings-and-guidance.pdf [9] National Institute for Health and Care Excellence, Intrapartum care: Quality Standard [QS105], Last Updated 28 February 2017. https://www.nice.org.uk/guidance/qs105/chapter/quality-statement-1-choosing-birth-setting

Birth choices Our pregnant women are still being offered good choices in their birth experience such as homebirth and water birth, so long as they are well. I did two lovely home births this week. We are definitely seeing a rise in people transferring to our homebirth service. I do think there is a concern nationally about high risk women choosing to homebirth unassisted, in areas where maternity services have suspended homebirth as an option. Because women in my area still have the option of a homebirth, it’s not something we’re experiencing. Birthing partners and limited visits Partners are allowed at births including cesarean sections. Also, we’ve had lots of very positive feedback from the women to say that not having their partners or visitors on the wards hadn’t been as bad as they thought, as they have talked and bonded more with other new mums and made new friends. It’s difficult for them without the support of family in the postnatal period but with encouragement they can usually see it as a positive, a time for them to bond as a family and get to know their little ones. Dads are actually very positive realising that it means they get to spend much more time with their partners and new baby. Appointments and new ways of working My Trust are doing just as many face to face antenatal visits. We do virtual appointments at booking and 16 weeks in the vast majority of cases but GPs locally are refusing to see women at 25 and 31 weeks, so we have changed the schedule to include these in midwifery care. We are using well midwives, who are isolating at home for whatever reason, to do phone clinics for booking and 16 week appointments which lifts the pressure off those of us working clinically. They also ring around all of the women due to be seen to make sure they’re well and understand that they need to attend appointments alone. I’m a case loading midwife so I know my mums to be/new mums well and do feel I’ve been able to support and reassure them effectively. I know that sadly not everyone is in this position though. Staff levels and wellbeing Annual leave has been cancelled. Nobody has complained about this though (or at least nobody that I’m aware of). We were expecting it and realise it’s vital. Lots of staff are also picking up extra shifts. If staffing levels drop though the pressure will be enormous. My trust have been very proactive regarding training and we are all being supported in terms of wellbeing. Accommodation has been provided for staff unable to go home and wellness packages and mental health support is in place. We’ve even been provided with a pop-up supermarket. Our local community are also amazing. Most staff could access a free hot meal most days if they chose to from various donations, school, restaurants and local sports teams. Hand cream, treats, snacks etc are always coming in. We feel so appreciated and loved One of our biggest issues is PPE Even for confirmed COVID-positive women we are given less protection than we are normally given when caring for women with flu. Working in community, this has its own issues. Statistically we know that the chances are that viral loads in homes are likely to be high due to the number of people present in small spaces, more soft furnishings, less stringent cleaning routines etc. The apron and mask we are given are unlikely to offer us any real protection. When we leave the houses we then have to transport the contaminated personal protective equipment (PPE) in our own vehicles, we’re wearing uniform that is likely to be contaminated and we are stood on pavements trying to clean the equipment we have used because that too will be contaminated. We’re not protected in the same way that hospital staff are. We are walking in to homes where there may be 4 or 5 people in the same room that we need to be in, as everyone is at home. We keep being told effective hand washing is key but we’re doing that in environments which are often less than clean, and in cases of COVID-confirmed women we can’t wash our hands at all as we’re unable to remove our PPE until we’ve left the house. It all feels very unsafe both in terms of staff contracting COVID-19 and cross contamination to other women, colleagues and our family. The support we are lacking comes from Public Health England and the Government. PPE guidance and availability is pitiful and dangerous and I believe is based on availability rather than need or any scientific basis. Do you work in maternity services? Or perhaps you are expecting a baby? Does this midwife's account reflect the maternity services in your area at the moment, or are you seeing different positives and challenges? We want to hear from patients and staff, so please sign up to comment below or contact us directly (content@pslhub.org) to share your story.

Key learning points Always consider individual benefits and risks when making decisions about pregnancy. Continuing medication or preventing illness with vaccination may be the best way to keep both mother and baby healthy - ask a specialist. Black and Asian women have a higher risk of dying in pregnancy. Older women are at greater risk of dying Be body aware - some symptoms are normal in pregnancy but know the red flags and always seek specialist advice if symptoms persist. Overweight or obese women are at higher risk of blood clots including in early pregnancy.

The WHO Safe Childbirth Checklist is a tool intended to improve the quality of care for women and babies at the time of childbirth. The Checklist is an organised list of evidence-based essential birth practices targeting major causes of maternal deaths, intrapartum-related stillbirths and neonatal deaths that occur in facilities around the world.