When I heard about the new role of maternity safety champions I was so pleased. This is such a fantastic opportunity to give support and guidance in maternity units and to champion benchmarking and lead improvement activity. A wealth of information is available now for units to benchmark against - including clinical measures, inspection reports and feedback from women and families.
We now know there is large variability between units in the outcomes for women and babies, including in levels of third and fourth degree tears sustained, postpartum haemorrhage, and even in the levels of perinatal death. We also know that, for various reasons, implementation of guidelines is inconsistent and safety recommendations are not always being actioned. It is imperative that this happens.
Maternity safety champions must be at the forefront of making change happen. Why? Well, the day a baby is born is one of the most important days in a family's life. It should be one of the happiest days of our lives. However, for many, poor care means this is not the case and they suffer long-lasting effects, both physically and psychologically.
And why does it matter so much to me? In 2009 I buried my longed-for baby who was profoundly brain damaged due to hypoxia during term labour and later died due to the injuries he sustained. I believe contributing factors to his brain damage were a lack of focus on safety in the unit, poor training, poor communication/supervision and low staffing on the labour ward. These events devastate families and also have a profound impact on the staff involved.
The Royal College of Obstetricians and Gynaecologists Each Baby Counts initiative has found that 1,136 babies died or sustained suspected brain damage in 2015, equating to three term babies each and every day - so not as rare as you may think. Each Baby Counts has also shown that most of these tragedies could be prevented with different care.
Since the loss of my son I have worked closely with a group of professionals in my local clinical network on a project to reduce the levels of stillbirth in our region. Over three years the eight hospitals in the region have worked together, sharing their expertise and resources. They have produced standardised guidelines and pathways of care, information for women, held joint training events and even implemented external and parental involvement in incident reviews and dissemination of learning across the region.
By working together, professionals and regions can achieve positive improvements in care and outcomes.
So here is my challenge to all board-level maternity safety champions in this critical role...I would like to ask:
- How do you know if your unit is delivering the safest care possible? How does your unit compare to others in the MBRRACE audit and National Maternity and Perinatal Audit data?
- Is your unit following all current guidelines? Are they documented, trained, audited?
- Are you investigating all Serious Incidents robustly with external representation and parental input invited? How are you supporting the staff in the unit to implement recommendations from these reviews?
- Do you know how many stillbirths there have been in your unit? Do you know how many occurred during labour? How many Serious Incidents?
- Do you read feedback and comments from parents in the Friends & Family Test and the Care Quality Commission questionnaire? What changes have you implemented in response to this feedback?
- Have you checked the staff in the unit are receiving all the training, support and resources they need to do their job well?
- Is multidisciplinary working developed at your trust – with joint training, briefings and handovers?
- Have you briefed the board on maternity safety and the activity you would like to undertake to further improve?
These are the questions and actions that will ensure safety is a priority and these tragic incidents are kept to a minimum - let’s make each family and each baby count.
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