CQC Maternity Services Survey – 6 trusts worse or much worse than expected
The CQC have published the result of their latest survey which looked into the experiences of women receiving care from maternity services.
The survey included 17611 women who gave birth in February 2018 across NHS trusts in England reporting that overall women had positive experiences. Questions were asked on antenatal care, labour and delivery and postnatal care.
Some positive areas include:
There were some areas where improvements can be made:
The results provide a breakdown as to how individual trusts performed against each question and details any outliers.
There were 9 trusts identified as performing better than expected, 5 categorised as worse than expected and 1 trust performing much worse than expected. Those trust that have been identified as worse than expected have been asked to outline the actions they will take to address the areas in which they are underperforming.
Full details of the study and results is available here.
Maternity and newborn services user guide – Safer Care Victoria
This Week in Maternity - New studies; Unplanned Caesarean links to depression, Incentive programme for safety reporting and Operator experience linked to OASIS
Unplanned caesarean sections linked to postnatal depression
A study titled ‘Mother’s mental health after childbirth: Does the delivery method matter?’ has been published looking into the effects of caesarean section on a mothers mental health specifically focusing on caesareans that are unplanned. It used data from across the UK collected through the UK Millenium Cohort Study.
The result of the study indicate that women who had an unplanned caesarean delivery were more vulnerable to depression. They were 15% more likely to experience postnatal depression.
The author highlights the implications for service provision summarising:
‘From a policy perspective, this study highlights the importance of accounting for the psychological costs of unplanned caesarean deliveries when evaluating the costs and benefits of this procedure….. Additionally, it suggests the importance of providing appropriate services, such as professionally-based home visits and peer-based telephone support, to prevent the development of postnatal depression (Royal College of Obstetricians and Gynaecologists, 2017).’
The study is available here.
Incentive programme improved reporting of safety events
An article ‘Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program’ has outlined the success of a programme aimed at improving trainee safety event reporting.
The programme provided financial incentives to trainees reporting 2 or more events with the objective to increase safety event reporting and improve patient safety. An education module was also provided to outline the importance of reporting and how to do so.
The article reported an increase in reporting from 0.5% of reports being submitted by trainees to 7% following the incentive programme. The types of events being reported by trainees differed to that of other health professionals contributing to a wider view of safety events. Following the financial incentive scheme report remained high in the year following.
Read the full article here.
Operator experience affects the risk of obstetric anal sphincter injury in vacuum extraction deliveries
A study conducted in Sweden has looked at the risk factors for obstetric anal sphincter injuries (OASIS) with a focus on operator related factors.
The study looked at data from one hospital over a 1 year period with 323 nulliparous women included. The results showed OASIS occurred in 17.6% of those women with 11.5% of deliveries performed by an obstetrician, 13.5% by a gynaecologist and 26.9% by residents. Risk of OASIS was 5 times higher when vacuum extraction was performed by residents.
The study highlights that it is the number of years’ experience as opposed to the number of procedures completed that impact the risk of OASIS suggesting that more training and supervision is required.
The study can be accessed here.
This Week in Maternity....Safer Care Victoria Report & New US Maternity Laws & 8 Steps to Reduce Maternal Health Disparities
Eight steps for narrowing the maternal health disparity gap
An article from Contemporary OBGYN titled ‘Eight steps for narrowing the maternal health disparity gap’ has been written providing 8 steps they recommend taking to reduce the inequalities being seen in maternity care.
Within the US approximately 700 women die each year due to pregnancy related causes with 50,000 women experiencing a life-threatening childbirth related complication. There are significant racial differences in the rates of both maternal mortality and morbidity. Black women are 3-4 times more likely to die from pregnancy related causes compared to white women. Native American, Latina and Asian women also experience increased rates of maternal morbidity. Many pregnancy related deaths, up to 60%, could be preventable.
The article details 8 steps to narrow the disparities across care:
The article concludes that implementing the above will not just improve care for those belonging to racial and ethnic communities but for all women during childbirth.
The full article can be read here.
Safer Care Victoria - Supporting Patient Safety Report
Safer Care Victoria has published its annual report for 2017-18. The report provides information about serious adverse events reported with the aim to understand what has been learnt and how care has been improved.
The report highlights events that resulted in the death of an unborn or a new-born baby including:
Safer Care Victoria has a number of projected focused on improving the quality and safety of maternity care including:
Looking forward the Safer Care Victoria is aiming to deliver clinical governance training to all Victoria public health boards, promote medication safety and utilise learning from the Coroners court of Victoria.
Access the full report here.
US laws passed for maternity safety
NHS Long Term Plan - Maternity Provisions
The NHS has recently released their plan for the Health Service for the next 5 years with details on progress towards a new service model, prevention of health inequalities, improving care and quality outcomes, tackling workforce pressures and enabling digital progress. Within the plans are provisions for maternity and neonatal care.
The plan sets out the NHS aim to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025. Detailed in the plan is how this will be achieved including:
There are also several other areas of focus within the plan that effect maternity. The plan sets out increasing provisions for expectant mothers, and their partners to reduce smoking with a new smoke-free pregnancy pathway including focused sessions and treatments.
To improve equality of care there are plans to implement an enhanced and targeted continuity of carer model to help improve outcomes for the most vulnerable mothers and babies with the aim to achieve 75% of BAME women receiving continuity of care by 2024.
To help address staffing concerns a national workforce group including a chief midwifery officer will be set up to support the workforce implementation plan. Every nurse or midwife graduating will also be offered a five-year NHS job guarantee within the region where they qualify and medical school places and changes to training for doctors will be explored.
The plan also details provision to help support and retain the current workforce through skills development and career progression, promoting flexibility and wellbeing, addressing bullying and harassment and improved mental health support for doctors.
The full plan is available here with the specific Maternity and Neonatal provision starting on page 46.
ACOG Practice Bulletin: Gestational Hypertension and Preeclampsia summary
ACOG have recently released a Practice Bulletin on Gestational Hypertension and Preeclampsia covering recommendations for prenatal assessment and perinatal management, including delivery. ObGProject has provided a summary of the bulletin including:
ObGProject also provide a test on the bulletin to allow you to check your understanding of the guidance both of which are available here.
The full ACOG practice bulletin list can be found here.
The vision for maternity services in England and Wales was outlined in the report of the National Maternity Review (2016). This envisaged a service that is
‘…safer, more personalised, kinder…; where every woman has access to information to enable her to make decisions about her care…’
In 2014, the UK government published ‘Personalised Health and Care 2020. Using Data and Technology to Transform Outcomes for Patients and Citizens’. This envisaged the better use of data across health & social care and that pregnant women will use apps to access their maternity records by 2018.
Central to these reports is the harnessing of data to provide better, more personalised and more accessible & responsive services. Substantial work has been undertaken. However, as a clinician at the coalface, and a user of health and social care services, there has been very little ‘effective’ change in the last 10 years. This is puzzling given the blistering pace of digital transformation in other industries. At the heart of this puzzle is the imperative to transform health records, the primary source of data.
Electronic Vs Digital health records
The phrases ‘Electronic health records (EHRs)’ and ‘Digital health records’ are used interchangeably. At My CaPl, we make a very clear distinction between these two tools.
An electronic health record is a computerised version of paper health records. You put data in, you get same data out and the computer adds little value beyond a write-read medium. Such computerisation is a necessary first step to creating a digital health record – where the computer transforms and adds value to the data. In effect, we consider a digital health record to be an electronic health record + substantial use of algorithms, big data analysis and / or artificial intelligence (AI). This distinction is vital: the computerisation of health records has potential benefits but comes at a price.
The Medscape Electronic health records report (2016), for instance, found that erosion of the physician-patient relationship is physicians' most prominent gripe regarding EHRs. In the report, 57% of respondents said that EHRs reduce face-to-face time with patients, and 50% noted a reduction in the number of patients they can see. There is also an emerging association between the use of EHRs and physician burn-out.
This price is worth paying if there are substantial gains through ‘digitization’ and automation. Otherwise, widespread adoption of EHRs in an already stretched service could be catastrophic. It is no surprise that clinicians balk at the adoption of EHRs.
The Pregnancy CaPl digital maternity platform
An effective maternity digital records platform should have 2 components: a user-friendly, woman-owned component that is seamlessly linked to a clinical component. Computers & smart phones should be harnessed to provide automated risk assessment and care planning in order to reduce the risk of error, reduce variations in care and facilitate alternative models of care.
The platform was the subject of a Maternity Safety Innovation project funded by the UK Department of Health, which concluded that it could be integrated into existing digital systems in two different NHS Trusts.
Women will carry their full maternity records on their smart phones and have access to automated individualized clinical risk assessment, antenatal care plans and evidence-based information including animated videos. Woman-centred tools such as contraction timer, kick counter and birth plan template make the Pregnancy CaPl app a consumer product as well as a clinical record. The clinician component has been developed in collaboration with obstetricians and midwives across 4 continents with a focus on safety, simplicity and UK guidelines.
Transforming maternity care
We view digital platforms like Pregnancy CaPl as a first step in the digital transformation of maternity care. Artificial intelligence and big data analysis will be used to support emergency, intra-partum and post-natal care. Wearable devices will allow remote monitoring, moving information from the woman to her phone to hospital systems and applying algorithms and AI to support decisions. We believe that such systems can cut the cost of antenatal care by 30-50% while improving pregnancy outcomes. We remain conscious of issues like acceptability but at the very least, women will have a choice.
Dr Paul Ayuk
BSc (Hons), MB.BS (Hons), MRCOG, PhD
Consultant Obstetrician & CEO