National review of maternity services in England 2022 to 2024

Our national review of maternity services in England, 2022 to 2024.

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Summary

The quality and safety of maternity services have remained under scrutiny in recent years. While a series of high-profile investigations identified key failings at specific NHS trusts, our National maternity inspection programme – an inspection of all hospital maternity locations that had not been inspected since before March 2021 – has shown many of the issues raised are widespread across England.

While we identified pockets of excellent practice, we are concerned that too many women and babies are not receiving the high-quality maternity care they deserve. Of the 131 locations we inspected between August 2022 and December 2023, almost half were rated as requires improvement (36%) or inadequate (12%). Only 4% of services were rated as outstanding and 48% were rated as good. At 12 locations, ratings for being well-led dropped by 2 ratings levels and at 11 locations, ratings for being safe dropped by 2 levels.

The safety of maternity services remains a key concern, with no services inspected as part of our inspection programme rated as outstanding for being safe. Almost half (47%) were rated as requires improvement for the safe key question, while 35% were rated as good and 18% were rated as inadequate. Where we had the most concerns, we used our enforcement powers to require trusts to make significant improvements to protect people from risk of harm.

While many of the issues we highlight in this report are systemic, with the right culture, services can improve and learn from one another. Alongside this report, we have worked with providers, maternity staff and stakeholder organisations to develop some additional resource materials which can be implemented at trust-level. These resources are available on our website and are aimed at maternity service staff at all levels to help support their efforts to deliver high-quality care and make improvements where needed.

In this report we refer to ‘women’, but we recognise that some transgender men, non-binary people and people with variations in sex characteristics or who are intersex may also use maternity services and experience some of the same issues.

Responding and learning from incidents

More work is needed to improve the way services report, learn and communicate with women following patient safety incidents. Although most services managed patient safety incidents well, we are concerned about the potential normalising of serious harm in maternity. For maternity staff, well recognised complications such as postpartum haemorrhages may be common and do not always constitute a patient safety event. However, the impact on women can be significant. We are concerned that women do not always receive the information they need to process what has happened to them and make informed decisions about future pregnancies.

Risk assessment and triage

We found significant variation for maternity triage as there are no national targets or standards for this area, and many of our inspections were carried out before the Royal College of Obstetricians and Gynaecologists (RCOG) released its Good Practice Paper on Maternity Triage in December 2023. Research by the Sands and Tommy’s Joint Policy Unit supports this, showing that “guidance on how and when to contact triage is not clear and consistent between services”. While a ‘one size fits all approach’ may not be appropriate across all services, we are concerned that not everyone received a safe and timely assessment. We found instances where the triage phone went unanswered and when people arrived at hospital, issues with staffing and the triage environment meant some women were not assessed in a timely way. In some cases, delays in triage were so severe that women discharged themselves before being seen by a midwife or doctor

Recruitment and retention of staff

Our programme identified chronic issues around recruitment and retention of the maternity workforce as a key issue affecting the quality of care that women receive. It is vital that maternity services can recruit to maintain safe staffing levels in line with national standards. Staff should then be supported to carry out their roles with the appropriate levels of training. With high numbers of midwives being driven away from the profession by current pressures, leaders must prioritise the wellbeing of staff to foster an open and supportive culture. There is also work to be done to future-proof the workforce and attract students to a career in midwifery, as data from UCAS shows midwifery applications for June 2024 were at their lowest for more than 6 years.

Estates and environment

Unsuitable maternity estates emerged as another key barrier to high-quality care. We found some maternity units were not fit for purpose, as they lacked space and facilities and, in a small number of cases, appropriate levels of potentially life-saving equipment. Additional capital investment is needed to ensure women receive safe, timely care in an environment that meets their needs.

Inequalities and racism

We found significant differences in the way trusts collect and use demographic data to address health inequalities in their local populations. Reducing inequalities is imperative in saving lives and preventing harm to people with protected characteristics.  Without national guidelines, we are concerned that trusts have no way of effectively evaluating whether initiatives to make maternity care more equitable are driving much-needed change. This is unacceptable given that, according to MBRRACE-UK data published in January 2024, Black women are still 2.8 times more likely to die during or up to 6 weeks after pregnancy compared with women in White ethnic groups. The data also showed that Asian women are 1.7 more times likely to die during the same period. Concerningly, we also found some trusts where both staff and people who were using the service experienced discrimination because of their ethnic background, or issues associated with having English as a second language or not their preferred language.

Communication with women and families

Communication with women and their families is not always good enough, particularly for those with protected equality characteristics. This affects their ability to consent to treatment and can perpetuate levels of fear and anxiety. Through our Give feedback on care service, many women told us that a lack of communication negatively affected their birth experiences. A cultural shift is needed so that all women are given the information they need, in a way they understand it, to make informed decisions and consent to treatment.