The power of two: what the national maternity team need to know....

Blog post number four of my 'What the national maternity review team needs to know' #MatExp action, gives us a sobering nudge. The national maternity review team are offered a perspective on how to reduce perinatal deaths. 

Victoria Morgan is currently on sabbatical, developing the 'Every Birth a Safe Birth' methodology. Here she reflects on the MBRRACE-UK Perinatal Deaths and the London Maternity Strategic Clinical Network conferences:  and asks if they shed light on a way forward for clinical quality improvement in maternity care. 

Perinatal deaths in the UK

The Perinatal Mortality Surveillance Report was recently published by MBRRACE-UK (which runs the Maternal, Newborn and Infant Clinical Outcome Review Programme).  At the launch event, hosted by the Royal College of Obstetricians & Gynaecologists, two key findings struck me.

Key finding 1:  the UK mortality rate for babies is 6 stillbirths and neonatal deaths per 1,000 births

“Between 2003 and 2013, the rate and the number of stillbirths and neonatal deaths fell in the UK.  The fall equates to more than 1,000 fewer deaths, despite the fact that the birth rate has risen by 12% in the same period.”

But is this good enough?  The report went on to say:  “If the UK could match mortality rates achieved in Sweden and Norway…the lives of at least 1,000 babies could be saved every year.”

Key finding 2:  local rates vary from 5.4 – 7.1 stillbirths and neonatal deaths per 1,000 births

This variation is not explained by differences in the poverty, ethnicity or age of the mother – the rates have been adjusted to account for that.

This variation is not the variation which is part of any process – the rates have been stabilised.

When reviewing statistics, it is tempting to say the variation is due to factors outside our control – the demography of the population or normal variation.  However, the MBRRACE-UK team has addressed this in their analysis.

A call to improve the quality of maternity care

The MBRRACE team called for trusts with rates that are 10% higher than the UK average to “review both their data quality and the care they provide”.  Trusts were encouraged to get an outside person to help them look at clinical practice by David Field, Professor of Neonatal Medicine and the Perinatal Programme co-lead for MBRRACE-UK, at the University of Leicester.

However, as no organisation had rates matching the lowest mortality rates in Europe – in the Nordic countries (Norway, Sweden, Denmark, Finland and Iceland) of 4.3 extended perinatal deaths per 1,000 births – Prof. Field encouraged all trusts to consider if they were happy with the present situation and whether they had a desire for further improvement.  He asked if we were willing to aim at the Nordic countries’ rates.

London Maternity Strategic Clinical Network

On the same day, the London Maternity Strategic Clinical Network of midwives, general managers, commissioners, GPs, obstetricians, service users and those from education and quality improvement organisations met to learn from one another’s experience about how to improve maternity care.

In 2013, two months after the Network was formed, the CQC maternity services survey results revealed 6 of the 13 worst performing trusts were in London.  Network members chose to believe that improvement was both desirable and possible and have set about making it happen.

User experience

Florence Wilcock, consultant obstetrician and Chair of the Network’s Maternity User Experience Sub Group, is a driving force in improving maternity user experience and has a very personal take on the difference to wellbeing that compassionate care makes to mothers (see her on YouTube).

The Whose Shoes? approach is one Florence champions.  Five trusts have held user experience Whose Shoes? workshops.  The workshops bring together a wide range of maternity service users and staff from all disciplines (including CEOs, heads of midwifery, obstetricians, support staff and parents).  The benefits of the workshops were broad:

• Spending time on reflection helped clinicians and service users understand one another’s perspectives; common themes emerged.
• It helped staff to bond after a recent merger.
• Gave added impetus to change underway.
• The format of hand held notes was reviewed to make them more user friendly for mothers and clinicians.
• A service was provided for women with a previous traumatic birth experience.

You can read more about Flo and Gill's work here! 

The power of two

So what if we could bring the two approaches together?

• The approach to data exemplified by the MBRRACE-UK report, sharing outcomes data in rate form, so that comparisons – in this case, between Clinical Commissioning Groups - can be made; and
• the approach to quality improvement of the London Maternity Strategic Clinical Network - the meeting of multi-disciplinary teams from discrete geographical areas to examine other approaches and implement change to improve quality.

The Northern New England Cardiovascular Disease Study Group are a case in point.  The group saw a 24% improvement in six hospitals’ mortality rates for coronary artery bypass surgery (Peck 2005).    Improvements came through 'examining other systems of care and questioning your own system' (Malenka and Connor, 1998).  In my next blog I shall look at the lessons learnt from this Group and how they might help us answer the question:  how can we improve the quality of maternity care?

Thank you Victoria....

Victoria morgan

You can find Victoria on Twitter @VictoriaRM6