RCM responds to report on factors affecting the delivery of safe care in midwifery units’

on 08 May 2024 Maternity Services Safety Maternity Safety Midwifery Midwives Midwife Training Electronic fetal monitoring RCM RCM Member

The Royal College of Midwives (RCM) has warned that staffing levels and access to training remain the key factors that prohibit the delivery of safe maternity care, following the publication of a new report on safe care in midwifery-led units in England.

The report from The Maternity and Newborn Safety Investigations programme (MNSI) which reviewed the findings of 92 MNSI investigations in England itself has highlighted work demands and staff capacity as a key prohibitors to the delivery of safe care.

Commenting, RCM’s Executive Director Midwife, Birte Harlev-lam said:

“Learning lessons from both failed and successful maternity services is crucial to ensure mistakes are not repeated and good practice is shared so the RCM really welcomes this report. Sadly, it underlines what the RCM and our members have been long saying that staffing shortages drastically impacts safety and quality of care that can be delivered. Also given the rise in more complex pregnancies, having the right skill mix of staff on shift is key. Access to appropriate training has also been flagged in this report as an issue in in the delivery of safe care. When there aren’t enough midwives, crucial training is often postponed and this undoubtedly impacts how prepared staff can be for not only emergency situations, but how day to day clinical practice improvements and safety risks could be mitigated.”

More training to improve telephone triage processes and intermittent auscultation (fetal monitoring) have also been identified as key area that requires improvement. The RCM says again this is something that requires investment, promises of investment, must be met with actual investment where its needed most.

Importantly the RCM says for each theme highlighted in this report, there is also a set of safety prompts to be used alongside clinical guidance by staff working in and leading maternity services.

The RCM’s own Solution Series published in response to the Ockenden Review in 2022 included guidance on how to develop systems for thorough investigation following adverse events so lessons can be learned, and future incidents avoided. The series also includes guidance for RCM members on interpreting electronic fetal monitoring, leadership and creating a positive work culture.

Birte added:

“Let’s not forget maternity staff who feel supported and valued provide better care. We also know that when there is a positive working culture between teams the quality of the care improves. Poor organisational culture has been identified as a key factor in recent investigations and reports on maternity safety and there is a growing body of evidence clearly linking culture with safety. Improving the culture and working environment in maternity services must be a shared endeavour between all members of the maternity team. Safety needs to be everyone’s business.”


For interview requests and to contact the RCM Media Office call 020 7312 3456, or email [email protected]



  • At the time of carrying out the investigations in the report, the MNSI programme was still part of the Healthcare Safety Investigation Branch (HSIB). In October 2023, MNSI moved to be hosted by the Care Quality Commission (CQC).


The Royal College of Midwives (RCM) is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team.  We provide workplace advice and support, professional and clinical guidance, and information, and learning opportunities with our broad range of events, conferences, and online resources. For more information visit the RCM | A professional organisation and trade union dedicated to serving the whole midwifery team