Safety and improvement projects and initiatives
The RCM Professional team influence, support and promote a number of national initiatives within maternity services, with the overall ambition of improving maternity care in the UK. In response to the interim Ockenden report the RCM published a series of four publications called the ‘Solution Series’ throughout 2021. These focus on how to learn from service reviews, creating positive workplace cultures, supporting positive leadership and focussing on human factors to improve safety in maternity services. You can access the Solution series here.
The RCM has representation on several national steering groups and is a stakeholder on a vast range of projects and programmes; this varies from representation on high level boards and committees such as the RCOG Patient Safety Board and Clinical Quality Assurance Group to representation on national workstreams and steering groups. The list below provides information on some of the Q&S projects the RCM is currently involved with:
The Tommy’s National Centre for Maternity Improvement was formed in 2019 by Tommy’s, in partnership with the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG), with the aim of reducing the number of babies who are stillborn or born prematurely.
By working with women, midwives, doctors, NHS trusts and academic experts from the University of Bristol, the University of Sheffield, St George’s University of London, King’s College London and the PROMPT Maternity Foundation, the centre is driving an innovative programme of improvement to maternity services in the UK.
The central vision is to make the UK the safest place in the world to give birth by making it easier for every woman to receive the right care at the right time and by reducing health inequalities across the country. The team is developing and implementing The Tommy’s App – an online medical tool that will help healthcare providers work out which pregnant women are most likely to give birth prematurely or are most likely to develop pregnancy complications that can lead to stillbirth.
The app will use information routinely gathered by midwives and doctors to provide a personalised risk score and treatment recommendations for every pregnant woman, ensuring that every woman receives the best support possible throughout pregnancy. The approach will also help to support engagement of the woman in decision making about her care.
There are four early-adopter sites in England currently implementing the Tommy’s App: Sheffield Teaching Hospitals NHS Foundation Trust, Ashford and St Peters’ NHS Foundation Trust, Lewisham and Greenwich NHS Trust and Royal Bolton Hospital. The evaluation of those sites will inform national scale-up.
The ABC programme is a collaboration of the Royal College of Midwives (RCM), the Royal College of Obstetricians and Gynaecologists (RCOG)and THIS Institute at the University of Cambridge. It is funded by the Department of Health and Social Care in response to the national drive to reduce preventable intrapartum brain injury by 50% by 2024.
The programme Thiscovery platform can be accessed here.
ABC focuses on two overall workstreams:
- Intrapartum fetal surveillance (IFS)
- Management impacted fetal head at Caesarean Birth (IFH).
Intrapartum fetal surveillance (IFS)
Sub-optimal detection and response to suspected fetal deterioration during labour can cause avoidable brain injury that can be catastrophic for babies and their families, and the staff involved, as well as being significant contributors to litigation claims and costs. An emerging view is that current practice for detection and response to suspected fetal deterioration are based too narrowly on fetal heart rate monitoring as the main source of information about fetal wellbeing, and that this is too limited to be effective. Risks can accumulate as labour progresses and may not be adequately detected using current fetal monitoring guidelines, which do not adequately integrate the fetal heart rate and clinical risk factors.
The programme is seeking to address deficits in relation to current practices for detecting and responding to fetal deterioration by developing new tools, processes and systems.
The interpretation and response to suspected fetal deterioration involves a series of complex socio-technical processes with many potential points of failure. Midwives and obstetricians caring for those in labour therefore need an approach with a robust evidence base to support clinical decision-making about whether deterioration is occurring, when concerns should be escalated and whether further action should be taken. A similarly robust system is needed for communication between all participants in intrapartum care – including women and birth partners as well as members of the intrapartum care team.
Initially tools were developed through expert clinical consensus, review of the evidence and consultation with maternity staff and families. The tools were then optimised further through evidence-based multidisciplinary consultation, development, testing, and refinement. The collaboration has brought together inputs from clinicians working on the shop floor, women and birth partners, social scientists, human factors specialists, and information scientists into a fetal surveillance protocol and associated tools that will inform a national package that will be implemented later this year.
Management impacted fetal head at Caesaren Birth (IFH)
Maternity staff increasingly encounter impacted fetal head (IFH) at caesarean section (CS). Recent UK studies estimate that IFH may complicate as many as one in ten emergency caesarean births (1.5% of all births).These births are technically challenging and associated with significant risks to both mother and baby. Difficulty in disimpacting the fetal head can result in injury to the mother’s womb and neighbouring organs, excessive bleeding and longer hospital stay. Babies experiencing this complication are at increased risk of birth trauma including skull fracture, brain haemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit, and even death.
A range of techniques may be employed to prevent and manage an IFH. However, there is currently no consensus on which strategy is safest and/or most effective, nor any standardised training in how to perform them. This has resulted in a lack of confidence among maternity staff, variable practice, and potentially harmful care in some circumstances.
There is an urgent need to address these uncertainties. Thus the RCM, RCOG and THIS Institute are working together to address these deficits and build consensus for management and training which will be available later this year.
Each Baby Counts + Learn and Support (EBC L&S) is a joint initiative between the RCM and the Royal College of Obstetricians and Gynaecologists (RCOG) to help improve maternity care in England. It aims to help improve maternity care by focusing on the wellbeing and working practices of the multidisciplinary team. The programme is funded by the Department of Health and Social care from 2019 until March 2022. 16 Local Development Leads (LDLs), all of whom are midwives or obstetricians, have also been appointed to help deliver the programme.
EBC L&S is working with a network of 16 NHS Trusts to:
- Build the capacity of 16 NHS maternity professionals in clinical leadership, safety thinking and quality improvement.
- Facilitate of a structured quality improvement process using behavioural science to improve clinical escalation in intrapartum settings.
- Evaluate the programme’s training and development approach and the impact of the specific co-designed intervention strategies on clinical escalation.
The programme will have three main outcomes:
- A final report outlining the findings from the evaluation of the EBC L&S programme.
- A refined version of the L&S programme within a digital learning platform that reflects the changes and content suggested by the evaluation in terms of the core components that enabled LDLs to complete the quality improvement work e.g. undertaking a behavioural approach, setting up a home team, safety II and clinical leadership.
- A clinical escalation toolkit (within the digital learning platform) incorporating the intervention strategies developed and tested as part of the L&S programme to be shared with maternity teams with recommendations for successful implementation and monitoring.
The programme Logic Model can be accessed here.
The 16 Local Development Leads’ list is available on the RCOG website.
The NMPA is a large-scale audit of NHS maternity services across England, Scotland and Wales. The audit aims to evaluate a range of care processes and outcomes in order to identify good practice and areas for improvement in the care of women and babies looked after by NHS maternity services. The NMPA is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives, the Royal College of Paediatrics and Child Health as well as the London School of Hygiene and Tropical Medicine.
The NMPA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) on behalf of NHS England, the Welsh Government and the Health Department of the Scottish Government.
The RCM is on the NMPA Clinical Reference Group as collaborating organisation.
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK)
MBRRACE-UK is the collaboration appointed by the Healthcare Quality Improvement Partnership (HQIP) to run the national Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP), which continues the national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths. The RCM's professional team have sat on expert ESMiE panels (Enhancing the Safety of Midwifery-Led Births), ensuring the midwifery voice is heard, and highlighting issues that are particular to midwife-led settings, findings from ESMiE were published on BJOG. The full-text paper is available here.
The national PMRT is a collaboration led by MBRRACE-UK, appointed by the Healthcare Quality Involvement Partnership (HQIP) to develop and establish a national standardised Perinatal Mortality Review Tool. The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units in England, Scotland and Wales. The PMRT was developed during 2017 and released in January 2018, with the latest annual report published in October 2021. The RCM has collaborated since its inception and is part of the Collaborators Group.
The PMRT is live and available for use by Trusts and Health Boards in England and Wales: https://www.npeu.ox.ac.uk/pmrt
MCQUIC is part of the Scottish Patient Safety Programme (SPSP) and part of the Healthcare Improvement Scotland ihub, which is a national initiative aiming to improve the safety and reliability of healthcare and reduce harm. The Maternity and Children Quality Improvement Collaborative is the part of the programme focusing on reducing stillbirth, neonatal mortality and severe postpartum haemorrhage as well as the implementation of a national maternity early warning chart (MEWS).
UKOSS was set up in partnership with the RCM, NPEU (National Perinatal Epidemiology Unit) and RCOG. The aim of UKOSS is to develop a UK-wide Obstetric Surveillance System to describe the epidemiology of a variety of uncommon disorders of pregnancy. The aims are:
- To use this system to lessen the burden on reporting clinicians of multiple requests for information from different sources.
- To enable the conduct of parallel cohort or case-control as well as descriptive epidemiological studies.
- To use the knowledge gained to make practical improvements in prevention and treatment and allow for more effective service planning.
- To provide a system capable of responding rapidly to emerging conditions of major public health importance.
During the pandemic UKOSS has focused on the effect of COVID-19 in pregnancy, the study page is accessible here.
The RCM is an active stakeholder and nominates midwives from member networks to regional panels and forwards topics that may be of interest to these networks.
Planning birth in a midwifery-led setting (at home or in a freestanding or alongside midwifery unit) is increasingly popular. National guidance on care for healthy women and their babies during childbirth recommends that women are advised that they may choose any birth setting. Midwifery units are particularly recommended because women who plan birth in these settings are more likely to have a straightforward birth without needing medical help from a doctor.
Care in a midwifery unit (or birth centre) is as safe for the woman and the baby as care in a hospital obstetric unit (or labour ward). Most births in midwifery-led settings are planned in alongside midwifery units (AMUs), which are on the same site as hospital obstetric units, and the number of AMUs is increasing.
UKMidSS is a UK-wide infrastructure which enables national studies of uncommon conditions and events, and national surveys of practice in midwifery units.
The aim of UKMiSS is to work with and support a national network of midwives who report anonymised information to facilitate national studies of uncommon events and conditions in women planning birth in midwifery units, and participate in national surveys of practice.
The RCM has been involved from the inception of UKMidSS with NPEU. The RCM is part and currently chairs the UKMidSS Steering Group providing overall strategic governance and direction.
The updates list of studies is available on the NPEU Website: https://www.npeu.ox.ac.uk/ukmidss/current-studies
The OASI2 project care has succeeded the OASIS Care Bundle Project and it focuses on the evaluation of the care bundle for perineal care in the participating units. The aim of OASI2 is to support and evaluate the sustainability of the OASI Care Bundle in maternity units that participated in the initial OASI Care Bundle project (‘OASI1’), as well as compare strategies for scaling up the care bundle in new maternity units.
The project team will evaluate several measures in all 30 participating maternity units over the course of the study.
- The primary measures are OASI rates (clinical outcome) and adoption of the care bundle into routine practice (implementation outcome).
- Secondary measures that will also be analysed include episiotomy, anterior tears and caesarean section rates, alongside women’s and healthcare professionals’ perspectives on the care bundle and the way in which it was adopted in their maternity unit.
The study protocol is available here.
You can read more about the OASI project here: The OASI Care Bundle Project (rcog.org.uk)
And about OASI 2 here: OASI2 (rcog.org.uk)
Re:Birth is a collaborative project between midwives, obstetricians, other birth workers and families, facilitated by the RCM focusing on the language surrounding birth. The study page is accessible here.
The purpose of the panel is to provide expert stakeholder input into advice and guidance to improve safety and reduce risk across the healthcare system.
This advice and guidance is generated in response to issues identified by the Patient Safety Team from a range of sources including; review of National Reporting and Learning System (NRLS) incidents, coroners’ reports, Serious Incidents and communications from patients, families, other agencies, professional bodies and frontline staff.
The RCM is an active stakeholder and contributes to all relevant discussions and advice on safety issues around pregnancy and childbirth, shaping recommendations (National alerts, never events focus group). The RCM representation also want to ensure midwives and MSWs are at the forefront of every decision.
The Maternity and Neonatal Safety Improvement Programme (MatNeoSIP), was renamed following the launch of the NHS Patient Safety Strategy in July 2019. It was previously known as the Maternal and Neonatal Health Safety Collaborative and is led by the National Patient Safety team.
The programme aims to:
- Improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England
- Contribute to the national ambition, set out in Better Births of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 50% by 2025.
The RCM has been actively involved in some of the outcomes of the programme (e.g. MEWS), reviewing and shaping tools which will be used clinically, ensuring that the voice of those in clinical settings is heard by the programme leads.
The main purpose of the committee is to
- Promote safe, high quality women’s healthcare across the healthcare system, including NHS policy and guidance, national organisations and committees, local services, ensuring womens and healthcare professional voices are heard.
- Recognise that the quality of women’s health care transcends national boundaries and cultures and respect that all systems have benefits and challenges that can be shared.
- To respond to national reports, guidance and other requests for information related to patient safety in women’s healthcare.
The RCM is an active stakeholder and contributes to all relevant discussions and advice on safety issues around pregnancy and childbirth, shaping recommendations and advice for NHS providers. The RCM has also the role of disseminating those information to midwives and MSWs.
The BMFMS aims to improve the standard of pregnancy care by dissemination knowledge, promoting and funding research, contributing to the development and implementation of high quality training, and providing a forum where issues relevant to pregnancy care are discussed.
The ultimate goal is to encourage improved standards of pregnancy care. The BMFMS provides a Maternal and Fetal Medicine input to relevant Royal College of Obstetricians and Gynaecologists (RCOG) committees and provides advice on Maternal and Fetal Medicine training to the RCOG. The BMFMS also makes representation to other Colleges and other national bodies/organisations when appropriate.
The RCM represent midwives and maternity support workers within the group, ensuring clinical and non-clinical issues around pregnancy care are based on latest evidence and disseminated amongst members. The RCM is actively involved in shaping and creating training and/or research opportunities for midwives with the BMFMS support.