the maternity services (Smith et al., 2008; Sandall et al., 2008). .... RCOG Press,. London. Lewis, G. (Ed.), 2007. Saving Mothers' Lives: Reviewing Maternal.
ARTICLE IN PRESS Midwifery (2009) 25, 1–2
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Editorial
Enhancing safety in the maternity services: a greater role for midwife-led care? There are two important papers in this month’s journal which present different perspectives of issues and potential solutions relating to safety in the maternity services (Smith et al., 2008; Sandall et al., 2008). I recommend all readers take note of their messages. Although conclusions and recommendations for practice are based on the results of a qualitative study (Smith et al., 2008) and a discussion of the findings of a Cochrane systematic review (Sandall et al., 2008), they are not dissimilar. Smith et al. (2008) undertook a study of healthcare professionals’ views of safety, as part of an inquiry into the safety of maternity services in England led by the King’s Fund, an independent charitable organisation which examines health-care policy and practice. Sandall et al. (2008) discuss implications for continuity, normality and safety arising from the recently published Cochrane systematic review of midwife-led versus other models of care for childbearing women (Hatem et al., 2008). The results of the review were based on data from 11 randomised controlled trials which recruited over 12,000 women (Hatem et al., 2008). The review authors concluded that as outcomes in several important areas were better for women cared for in a midwife-led model, all women should be offered this type of care and encouraged to ask for this option. The findings and recommendations of the King’s Fund study (Smith et al., 2008) and the Cochrane review (Hatem et al., 2008) are of relevance for midwifery practice and women’s health internationally, despite evidence being collected from different countries and different health-care systems. Many of us work in countries where policy recommendations and media commentary have shifted to focus on the safety of care. The debate in the UK has been influenced by national reports of the outcomes of maternity care which have high0266-6138/$ - see front matter & 2008 Published by Elsevier Ltd. doi:10.1016/j.midw.2008.12.001
lighted the consequences of delayed access to timely and appropriate care, the poorer health of women who become pregnant, increased social inequalities, the rising birth rate and substandard care (Lewis, 2007; Royal College of Anaesthetists et al., 2007; Mander and Smith, 2008; Bick, 2008; Healthcare Commission, 2008). We are fortunate in the UK in that our maternal mortality rates are low; however, there is concern that mortality rates reported in the most recent Confidential Enquiry did not decline during 2003–2005 from the previous triennial period (Lewis, 2004, 2007). Maternal morbidity is another indicator of the safety and quality of care. Over 60,000 maternity-related patient safety incidents were reported in England and Wales from the end of November 2003 to the end of June 2006 (National Patient Safety Agency, 2007). Many incidents were related to delays in treatment or failure to recognise complications. Enhanced awareness of the need to record and report adverse events in maternity care is likely to increase these numbers. Of note is that reports have identified the concerns of maternity care professionals who want better training and education to be able to deal with more complex maternal health needs, and more priority given to the organisation, management and planning of services, including skill mix in the clinical area. The King’s Fund report ‘Safe Births: Everybody’s Business’ (O’Neill, 2008) concluded that the majority of births in England were safe, but some births were not as safe as they should or could be. The inquiry team was tasked with addressing the myriad of complex, interrelated factors which can affect the safety of maternity care and identify obstacles and strategies for overcoming barriers to safe care. The paper in this issue by Smith et al. (2008) presents findings from around 600 maternity care professionals who
ARTICLE IN PRESS 2 responded to a call for evidence, the majority of whom were midwives (80%). Few obstetricians (3%) responded, despite intensive attempts to include the views of medical professionals. Several themes with respect to safety in the maternity services were identified, including the challenge of caring for women with complex social and medical needs, low staffing levels, poor management and lack of resources. Respondents were asked what solutions they would implement to deal with the safety problems they described. Better teamwork, more staff and improved training were proposed, as was the need to implement midwifery-led care through case loading where one midwife looks after a woman throughout her pregnancy, birth and postnatal period. Despite the limitations of the study, it is clear that the midwives who responded viewed revisions to midwife models of care as important to enhance safety. The results of the Cochrane review (Hatem et al., 2008) provide further timely support for why midwife-led models of care can offer a number of benefits. The authors of the Cochrane review compared outcomes of midwife-led models of care with medical-led care, and referred to the philosophy of midwifery-led care as normality and being cared for by a known and trusted midwife during labour (Hatem et al., 2008). Models of midwife-led care as defined in the review included team midwifery, with a number of midwives in a ‘team’ sharing the care of women, and caseload midwifery, which aims to offer continuity through the episode of care from one midwife or their practice partner. Several important benefits were found including a reduced risk of a woman losing her baby before 24 weeks of gestation, an increased chance of spontaneous vaginal birth, reduced use of epidural analgesia, and fewer episiotomies and instrumental births. Whilst it is acknowledged by the reviewers that not all countries have health systems which can support midwife-led models of care, and health service funding may be a barrier to introducing or revising models of care, the review provides important evidence that outcomes can be improved. As such, it is essential that maternity service funders, providers and policy makers take note. Future plans to revise models of care should reflect the findings of the Cochrane review (Hatem et al., 2008) as well as those of Smith et al. (2008) with respect to the need to take account of
Editorial clinician anxiety and their perspectives of safety. If revisions to care, including greater use of midwife-led models, are to be implemented, they will require the support of the whole organisation, including clinicians, managers and women who use the local service. Achieving change to enhance outcomes of maternity care is a complex undertaking. Nevertheless, it is a challenge we have to address if women are to receive safe, high-quality care associated with the best possible outcomes provided by midwives who feel confident and skilled to provide the best possible care.
References Bick, D., 2008. Maternal mortality in the UK: the impact of the increasing complexity of women’s lives. Midwifery 24, 1–2. Hatem, M., Sandall, J., Devane, D., Soltani, H., Gates, S., 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 4, CD004667. Healthcare Commission, 2008. Towards Better Births. A Review of Maternity Services in England. Healthcare Commission, London. Lewis, G. (Ed.), 2004. Why Mothers Die 2000–2002. RCOG Press, London. Lewis, G. (Ed.), 2007. Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer 2003–2005. RCOG Press, London. Mander, R., Smith, G., 2008. Saving Mothers’ Lives (formerly Why Mothers Die): reviewing maternal deaths to make motherhood safer 2003–2005. Midwifery 24 (1), 8–12. O’Neill, O., 2008. Safe Births: Everybody’s Business. An Independent Inquiry into the Safety of Maternity Services in England. King’s Fund, London. Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists and Royal College of Paediatrics and Child Health (2007). Safer Childbirth: Minimum Standards for the Oganisation and Delivery of Care in Labour. RCOG Press, London. Sandall, J., Hatem, M., Devane, D., Soltani, H., Gates, S., 2008. Discussion of findings from a Cochrane review of midwife-led versus other models of care for childbearing women: Continuity, normality and safety. Midwifery. Smith, A.H.K., Dixon, A.L., Page, L.A., 2008. Health-care professionals’ views about safety in maternity services: a qualitative study. Midwifery (XXXX).
(Editor in Chief), Dr Debra Bick Professor of Evidence Based Midwifery Practice, Health and Social Care Research Division, King’s College London, UK
