Written evidence submitted by The Royal College of Physicians (MSE0009)

 

The Safety of Maternity Services in England Inquiry

 

The Royal College of Physicians (RCP) welcomes this opportunity to respond to the Safety of Maternity Services in England Inquiry. This submission is based on the experience of the obstetric physicians working across the country, who are Fellows of the RCP.

 

Executive Summary

  1. Causes of maternal mortality and morbidity in the UK are often related to underlying medical conditions
  2. Development of Obstetric Medicine specialists and national networked maternal medicine services aim to contribute to a reduction in maternal mortality and morbidity and improve patient safety
  3. All health professionals who may encounter pregnant women need specialist bespoke training and education in obstetric medicine. This includes every level of training (undergraduate, postgraduate or following training completion) and those working in physician specialities as well as maternity.
  4. The RCP has been instrumental in the growth in this area in recent years with:
    1. The development of post-CCT and higher specialist training (HST) credentialing in Obstetric Medicine (2020)
    2. The publication of recommendations for the management of pregnant women in an acute medical setting (in conjunction with the Society of Acute Medicine) - Acute care toolkit 15: Management of acute medical problems in pregnancy [1].

 

Remit

This document will focus on maternal death and morbidity and care of women with medical conditions before, during and after pregnancy.

 

Explanation of terms

‘Obstetric Medicine’ and ‘Maternal Medicine’ are used interchangeably in this document to describe the same work in this field.

 

 

What the impact has been of the work which has already taken place aimed at improving maternity safety, and the extent to which the recommendations of past work on maternity safety by Trusts, Government and its arm’s-length bodies, and reviews of previous maternity safety incidents, are being consistently and rigorously implemented across the country

MBRRACE-UK

MBRRACE-UK (Mothers and Babies: reducing risk through audit and confidential enquiry) is a nationally mandated, world-renowned resource collecting anonymised information about women who die during or up to 12 months following pregnancy, in order to provide information about trends and overall lessons that can be learnt about the care provided to pregnant women [2]. This data collection has occurred since the 1950s and has been a major contributor to the understanding of trends in mortality and morbidity. It is a valuable resource for those working in Maternity services. Annual reports are published and these lessons are then circulated to improve delivery of maternity services both on a service and individual level. The rate of maternal death in the UK has been steadily falling over the last few decades, driven by changes in practice as a result of these enquiries, but reached a plateau in 2011, as shown by the mortality figures reported by MBRRACE-UK. The most common reason a woman dies during pregnancy is cardiac disease accounting for 23% of deaths in the last report.

The programme undertakes invaluable and unparalleled work. However we are concerned that recent reductions in funding, as well as NHS England’s restriction on the number of recommendations which can now be made in the report (as well as their requirement that they must be ‘cost neutral’) in combination with the lack of a mandated requirement for hospitals to implement said recommendations, risks limiting the impact this programme will have in the longer term.

UKOSS

The UK Obstetric Surveillance System (UKOSS) has been in place for the past 15 years to describe the epidemiology of uncommon disorders of pregnancy [3]. The aim was to enable the conduct of parallel cohort or case-control as well as descriptive epidemiological studies. There is no national funding of this scheme though, instead it is entirely reliant on research funding. Through this work guidelines have been developed in maternity for rarer conditions. The knowledge gained has resulted in practical improvements in the management of these conditions. During the COVID pandemic a study was rapidly initiated to collect data on COVID-19 in pregnancy, a result of an established reporting structure and a study protocol already prepared for infections of pandemic potential. The results to each study are published and lessons can therefore be learnt at both local and national level.

Consultants in Obstetric Medicine

National statistics show an increase in the average age of pregnant women, as well as increasing rates of obesity [4]. These factors contribute to the risk of developing medical complications in pregnancy, such as hypertension, diabetes, venous thromboembolism and heart disease. Moreover, the long-term survival of individuals with previously life-limiting conditions such as cystic fibrosis, is increasing. More women are therefore reaching childbearing age with conditions causing significant alterations to their baseline physiology, yet services are becoming more focused on the care of the low risk mother. As pregnancy is a significant physiological stressor, these women can decompensate in pregnancy increasing the risk of complications for both mother and baby.

In 2019 data were collected through the Society for Acute Medicine Benchmarking Audit, a national audit of service delivery and patient care in acute medicine over a 24 hour period [5]. 130 hospitals participated: 5.5% had an acute medicine consultant trained in obstetric medicine, and 38% of hospitals had a named lead for maternal medicine. 64 units had local guidelines for medical problems in pregnancy; 43% had a local guideline for venous thromboembolism in pregnancy. Centres with a named lead had more guidelines (p = 0.019).

Pre-pregnancy counselling is helpful to women and health care professionals, and essential in women with complex medical conditions, but is inconsistently provided across the UK.  This is the result of both financial restrictions (it is not universally agreed which hospital department should be providing and funding this service) and a lack of appropriately-trained individuals to provide it.

Networked Maternal Medicine Services

The development of Networked Maternal Medicine Services (NMMS) has been recognised as an important component of Government policy to improve maternal safety, with the aim of contributing to the achievement of the Government’s target to reduce maternal and neonatal mortality by 50% by 2030 [6]. Currently there are consultant obstetric physicians working in London, Oxford, Bristol and Wolverhampton.  The training of more obstetric physicians and the development of the NMMS will reduce the current geographical variations in the delivery of specialist care to women with high risk medical conditions during pregnancy.

At the heart of the NMMS are Maternal Medicine Centres (MMC), each staffed by an appropriately experienced multidisciplinary team including at least one obstetrician with sub-specialty training in Maternal Medicine (or equivalent), and an Obstetric Physician (or equivalent) with appropriate training, along with input from all relevant specialties and support from specialist midwives. The vision is that the MMCs will deliver high quality care to complex patients in their region while driving training for all levels in all related specialties and therefore knowledge and care of women with medical problems in pregnancy will improve. Funding has been made available from NHS England to enable 12 post-CCT doctors to be trained in this specialty in one of four recognised centres, and then return to their area to lead the local network.

The development of obstetric medicine services will clearly benefit maternal mortality and morbidity, but what is often not recognised is the reduction in neonatal morbidity and mortality that will occur alongside this, as a result of the reduction of preterm delivery and early recognition of the unwell mother.

 

Production of national guidance

In 2015 an electronic learning module on medical problems in pregnancy on the e-LFH website, partly funded by the RCP was released [7]. More recently, an RCP and Society of Acute Medicine initiative enabled the development of the Acute Care Toolkit 15: Management of acute medical problems in pregnancy [1]. This provides practical guidance for health professionals on the frontline, managing women with acute medical problems in pregnancy, based around learning identified within the MBRRACE-UK reports. Other guidelines to which Obstetric Physicians have contributed include the NICE guidelines for intrapartum care for women with existing medical conditions or obstetric complications and their babies, guidelines written by the Renal Association for Pregnancy and Renal Disease, RCOG Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk (Green-top Guideline No. 37a), multiple sclerosis in pregnancy, myasthenia gravis in pregnancy, the pregnancy section of the SIGN asthma guideline, and BSR/ EULAR guidelines on medications for rheumatic disease in pregnancy [8-14].

There has also been development of specialist societies including the British Maternal and Fetal Medicine Society, Macdonald Obstetric Medicine Society and the UK Maternal Cardiology Society. These societies provide opportunities for training and knowledge sharing amongst their members and the wider NHS.

 

The contribution of clinical negligence and litigation processes to maternity safety and what changes could be made to clinical negligence and litigation processes to improve the safety of maternity services

The RCP have no specific comments about clinical negligence and litigation processes.

 

Advice, guidance and practice on the choices available to pregnant women about natural births, home births and interventions such as C-sections, and the extent to which medical advice and decision-making is affected by a fear of the “blame culture”

A very common question from both women with medical conditions as well as the clinicians caring for them is about the ‘safest’ mode of delivery.  There is often a supposition by others who do not encounter pregnant women frequently in their area of specialist practice that a caesarean section must be the preferred option.  This is, however, frequently not the case. The development of networked maternal medicine services will result in a specialist multidisciplinary team which works effectively together to deliver holistic care to the pregnant woman, supporting her to achieve her chosen birth plan as far as possible and providing consistent messages if adjustments to this delivery plan are required.

The development of robust multidisciplinary teams will also address the issue of the fear of the “blame culture” as all parties will have been involved in the decision-making process.

 

How effective the training and support offered to maternity staff is, and what improvements could be made to them to improve the safety of maternity services

There are a wide range of educational needs relating to the care of women with high-risk pregnancies for health care professionals working in Maternity. In recent years a multitude of training opportunities have been developed to address aspects of this, at both local and national level, including lecture courses about medical complications in pregnancy, simulation courses for junior doctors and practical courses such as PROMPT (PRactical Obstetric Multi-Professional Teaching) and Medical Emergencies in Obstetrics (MEmO)[15].

With respect to specific Obstetric Medicine training, there has also been the development of a curriculum, Obstetric Medicine has been recognised as a special skill for those training in Acute Medicine, as well as the development of the Post-Certificate of Completion of Training and Higher Speciality Training Credential in Obstetric Medicine via the Royal College of Physicians in 2020.

In the future, it is imperative that systematic improvements in Obstetric Medicine education are made at every level to improve maternal safety.  In medical training, this means ensuring high-risk pregnancy and common complications that can occur in pregnancy are addressed in every undergraduate curriculum, as well as being a key component for postgraduate training in Internal Medicine, Acute Medicine and related medical specialties.  Data from MBRRACE-UK show that 20% of pregnant women who die are in the community or accident and emergency setting, so that education of health care professionals working in these areas is also required. At present this specialist knowledge is often solely acquired by attendance at lecture-based teaching, but would be improved by a requirement for trainees to attend specialist clinics and gain first-hand experience of care for these women, and ideally attendance at simulation courses. Inclusion of Obstetric Medicine as an option for trainees in their Internal Medicine Training year 3 (IMT3) would also be a valuable and popular opportunity.

 

 

The role and work of the Healthcare Safety Investigation Branch in improving the safety of maternity services, and the adequacy and appropriateness of the collection and analysis of data on maternity safety

 

For maternal deaths, the role of HSIB has a somewhat different focus and remit to that of MBRRACE-UK.  The feedback to the centre that follows an HSIB investigation provides an external assessment of events and how the factors that led to a maternal death could be mitigated to reduce the chance of a similar event in the future, which is fed back to the unit at local level. HSIB does not have a remit to produce national level reports and draw together wide national learning including areas outside maternity such as acute medicine. MBRRACE-UK, in contrast, feeds back recommendations at national level, and due to the anonymised nature of the analysis of each maternal death there is no blame involved, so this does not contribute to a ‘blame culture’. The family of the deceased are also involved in an HSIB investigation directly which gives them an opportunity to raise their concerns and questions independent of the Trust in question.   The nature of the HSIB investigation, however, often means that much time passes between maternal death and feedback to the centre. Whilst the HSIB investigation is ongoing, a local investigation is put on hold.  There is therefore potentially a risk of delay in local learning from the case in question, and a lack of timely closure for both family and staff involved in these distressing cases. Furthermore, HSIB do not cover all maternal deaths, and although their investigations can include a variety of specialists, may not always include obstetric physicians, whereas MBRRACE-UK include as part of standard practice a wide range of specialist clinicians, including not only obstetric physicians but also other specialist physicians such as cardiologists. This recognises the, often complex, care required for pregnant women with medical conditions, and therefore the extremely nuanced expert reviews required to learn lessons to prevent deaths in the future.

More recently, for maternal deaths occurring during the COVID pandemic, a joint report was developed by MBRRACE with HSIB clinical leads contributing to the chapter writing. This minimized duplication and maximized the benefits of HSIB (ensuring the facts around each death were independently established at local level) and the strengths of MBRRACE-UK (bringing together national learning points to drive system changes), which in the future could be a mutually-beneficial model.

 


References

  1. Acute Care Toolkit 15: Managing acute medical problems in pregnancy. Royal College of Physicians, London, UK, 2019. https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-15-managing-acute-medical-problems-pregnancy [accessed August 2020]
  2. Mothers and babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–16. MBRRACE-UK, 2018. www.npeu.ox.ac.uk/mbrrace-uk/reports [accessed August 2020]
  3. UK Obstetric Surveillance System https://www.npeu.ox.ac.uk/ukoss [accessed August 2020]
  4. National Maternity and Perinatal Audit, UK. https://maternityaudit.org.uk/pages/home [Accessed August 2020]
  5. Atkin C, Prinja P, Banerjee A, Holland M, Lasserson D. Provision of acute medicine services for pregnant patients in UK hospitals: data from the Society for Acute Medicine Benchmarking Audit. Obstetric Medicine, published online June 2020. https://doi.org/10.1177/1753495X20929502
  6. Department of Health. Safer maternity care – the national maternity safety strategy – progress and next steps, 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/662969/Safer_maternity_care_-_progress_and_next_steps.pdf [accessed August 2020]
  7. Medical Problems in Pregnancy, series of electronic modules. https://www.e-lfh.org.uk/programmes/medical-problems-in-pregnancy/ [Accessed August 2020]
  8. NICE guideline [NG121} Intrapartum care for women with existing medical conditions or obstetric complications and their babies. 2019. https://www.nice.org.uk/guidance/ng121 [Accessed August 2020]
  9. Clinical Practice Guideline: Pregnancy and renal disease. Renal Association, 2019. https://renal.org/wp-content/uploads/2019/09/FINAL-Pregnancy-Guideline-September-2019.pdf [Accessed August 2020]
  10. Royal Colleges of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. Green-top guideline No. 37b , 2015. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg37a/ [accessed August 2020]
  11. Dobson R, Dassan P, Roberts M, Giovannoni G, Nelson-Piercy C, Brex PA. UK consensus on pregnancy in multiple sclerosis: 'Association of British Neurologists' guidelines. Pract Neurol. 2019;19(2):106-114.
  12. Norwood F, Dhanjal M, Hill M, et al. Myasthenia in pregnancy: best practice guidelines from a U.K. multispecialty working group. J Neurol Neurosurg Psychiatry. 2014;85(5):538-543.
  13. SIGN 158: British guideline on the management of asthma.  Revised 2019. https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma [accessed August 2020]
  14. Gotestam Skorpen C, Hoeltzenbein M, Tincani A et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Annals of the Rheumatic Diseases 2016; 75:795-810.
  15. https://www.promptmaternity.org/ [accessed August 2020]

 

 

7 September 2020