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Working Together Towards Safer Maternity Care

James Titcombe

About Baby Lifeline

2020 will see Baby Lifeline enter its 40th year, having been founded by Judy Ledger following the personal tragedy of losing three premature babies. Initially setting out to raise funds for just one incubator at a local neonatal unit, Baby Lifeline has gone on to raise tens of millions of pounds to provide equipment and training for maternity services across the UK and worldwide. The charity has delivered CPD training for over 25,000 healthcare professionals – 10,000 of these in the last couple of years.

Today, Baby Lifeline is proud to be hosting its inaugural National Maternity Safety Conference in Birmingham.

As we look forward to welcoming around 300 delegates to the Hilton Metropole – including parents, healthcare professionals and maternity experts from around the UK and as far afield as the US – we wanted to take the opportunity to share a little more about what today’s event is all about; and to share some reflections on maternity safety from some of today’s key speakers.

The Need for Action in Maternity Safety

As we start 2020, maternity safety is being prioritised by national bodies, charities, the Royal Colleges, healthcare organisations, and maternity professionals across the country – all working towards achieving the national ambition of reducing stillbirths, neonatal and maternal deaths, and brain injuries in babies that occur during or soon after birth by 50 per cent by 2025.

Although there is a considerable amount of positive national work ongoing, the need for action towards safety maternity care remains as pressing as ever.

In 2018, the Royal College of Obstetricians and Gynaecologists’ (RCOG’s) Each Baby Counts programme published its second major report looking at the care of term babies who were either stillborn, died shortly after birth or were at risk of brain damage in England in 2016. The review found that 674 babies (71%) might have had a different outcome with different care.

The latest report from MBRRACE, Saving Lives, Improving Mothers’ Care, highlights alarming  inequalities in outcomes for pregnant women. These include:

  • Black women are 5 times more likely to die as a result of complications in their pregnancy than white women.
  • Risk for women of mixed ethnicity is 3 times more than white women.
  • Risk for Asian women is twice as much as white women.

Latest figures from NHS Resolution show that the value of clinical negligence claims in maternity (2018/19) was £2,465.5 million.

Although adverse outcomes in our maternity services remain rare, the impact on parents, family and healthcare professionals when they do occur are often devastating and life changing. We owe it to them to ensure that every effort in made to learn from avoidable harm and make changes to ensure future care is safer.

About the Conference

The theme of today’s conference is ‘Working Together Towards Safer Maternity Care’ – a mission that all of us at Baby Lifeline are passionate about, and which runs as a golden thread through all aspects of the work we do.

The conference programme comprises speakers from a wide range of backgrounds – parents, experts and professionals from all corners of country; all of whom are performing important and impactful work towards supporting this national ambition.

There will be presentations and discussions about the latest findings from national maternity work and shared insights from leading national experts. Topics covered will include CTG interpretation, culture and quality improvement approaches, and learning from adverse events whilst supporting staff and families. We also hope to motivate and inspire ambassadors of change with locally led success stories and information about the latest objectives from leaders of national maternity transformation work.

We are delighted to welcome Rt Hon. Jeremy Hunt MP to open the conference today. Mr Hunt became the longest serving Health Secretary in British political history and made improving patient safety – with a particular focus on maternity care – a national priority during his tenure, and he continues to be a passionate advocate for patient safety today.

We will close the day with a joint talk from Professor Dame Lesley Regan – immediate past President of the RCOG – and Gill Walton – Chief Executive of the Royal College of Midwives (RCM). The talk will focus on the importance of working together and speaking with one voice.

Ahead of today’s event we asked some of our key speakers to share their thoughts about why maternity safety matter to them and what they see as the main priorities ahead. We hope you find these reflections interesting and that they help get the conversations started.

If you are not attending todays conference, we hope that you will you follow the event on social media and join in the with discussions using the hashtag #MatSafety2020. You can find us on Facebook, LinkedIn, Twitter and Instagram.

Mr Edward Morris – President of the RCOG

Why is maternity safety important to you?

As leader of the professional body representing obstetricians, I share the aspiration of the RCOG that no term, healthy baby should suffer death either during or shortly after birth, or suffer a severe disability as a result of an event in labour.

The death of a baby is an extremely devastating experience for parents, families and healthcare professionals involved and we owe it to all of them to ensure every death is properly investigated, so that lessons can be learned, and future tragedies can be prevented.

What do you see as the main priorities for maternity safety moving forward?

That the RCOG and RCM are committed to speaking with one, united voice on maternity safety and ensuring every woman has a good birth, with the best possible experience and outcomes for her and her baby. Together with the RCPCH, NCT and Sands, we share a vision of a modern maternity team whose common purpose is supporting best practice, respectful relationships, strong leadership and putting women at the centre of care.

Feedback from doctors and midwives at our Each Baby Counts Clinical Engagement Forum regarding priorities for implementation were around improving human factors and the way teams work together in maternity. For this reason, we have focused our efforts on developing tools and training materials to support us all to improve care.

In the past year, with the RCM, we have expanded our work in maternity safety to include even more focus on learning, through Each Baby Counts: Learn and Support and preventing stillbirth and preterm birth through the Tommy’s Centre, strengthening our evidence base to help us deliver ever more effective care.

What are your key messages for today?

We are committed to sharing the expertise we have gained from Each Baby Counts, and our understanding of the complex interplay of factors that lead to stillbirths, neonatal deaths and brain damage during term labour.

We have a desire to work even more collaboratively with partners to make radical improvements to the delivery of high quality maternity care, for example through the Maternity Transformation Programme, the Maternal and Neonatal Safety Collaborative and with the Healthcare Safety Investigation Branch, as well as charities such as Baby Lifeline and Tommy’s.

We fully support and are working with the Government to support its maternity strategy to reduce the number of stillbirths. We want to make the NHS the safest place in the world to give birth.

We share the Government’s ambition of halving the rates of stillbirth, neonatal and maternal deaths, and brain injuries occurring during or soon after birth by 2025.

To do so, we must work together to tackle health disparities and ensure that NHS staff working in maternity services feel supported, valued and equipped to provide the best possible care to all women.

Professor Jacqueline Dunkley-Bent – Chief Midwifery Officer, NHS England and NHS Improvement

Why is maternity safety important to you?

As the Chief Midwifery Officer for the NHS in England, I support the national ambition for maternity care to be safer and more personal, to be equally accessible and consistently of high quality for all those who use it, regardless of socio-economic status, ethnicity or postcode. As a midwife, providing the very best of care for each family’s unique and special maternity experience, is at the heart of everything I do, be that clinically or when influencing maternity policy. We all have a responsibility to do what’s right for families who use maternity services and I believe that the current policy focus on maternity safety is not only timely, but essential.

What do you see as the main priorities for maternity safety moving forward?

To meet the ambition to reduce the rate of stillbirths, neonatal and maternal deaths, and brain injuries occurring during or soon after birth by 50% by 2025; and 20% by 2020, reduce pre-term birth from 8% to 6%.

Rapid learning to avoid repeated mistakes cited by MBRRACE and consistently deploying the best practice with a well equipped workforce, for those who are bereaved and or those who are hurting.

What are your key messages for the day?

  • That one of our greatest freedoms is how we react to things.
  • Asking for help is one of the bravest things you could ever say.

Gill Walton – Chief Executive, Royal College of Midwives

Why is maternity safety important to you?

Ensuring every mother has a safe birth and a good experience of maternity care is important to me personally and the RCM. The role of the midwife is to help women make choices that are right for them. The midwife helps women to understand the evidence that underpins those choices and the risks and benefits associated with them. The midwife is then an advocate for the woman to ensure her choices are known and supported. The midwife is the conductor of the maternity care ‘orchestra’ to ensure everyone is working together.

I am convinced by the evidence that midwives are the intervention that not just improves outcomes but also enhances experiences for women and families, not just in the UK but around the world. This underpins the Year of the Midwife 2020 RCM campaign ‘We Wear Red’. We believe if there are more well educated and trained midwives in the UK and around the world and easy access to them, lives will be saved.

What do you see as the main priorities for maternity safety moving forward?

The top priorities for maternity safety are ensuring that all professionals delivering maternity care respect and value the contribution they all make, with women and families at the centre of all we do. Maternity safety will improve if teams learn together, work together and foster a positive, open and transparent culture. Strong leadership development at every level of the NHS with an understanding and training for human factors is key. In particular, strengthening midwifery leadership, as documented in the RCM Leadership Manifesto (2019), is essential for clinical safety and enabling midwives to influence strategic agendas and funding streams for maternity services.

What are your key messages for the day?

I hope conference participants will understand their personal responsibilities for working together, developing their leadership skills and constantly striving to deliver woman centred evidence based care.

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