Making childbirth safer – the results of the ESMiE enquiry

Thanks to the amazing work of our National Health Service, baby deaths during childbirth are uncommon, occurring in around 1 in every 3500 births(ii), and national policy aims to improve this further and halve the rates of stillbirth and neonatal death by 2025(iii).

In the UK most women give birth in hospital units led by obstetricians. However, it seems that more women are now giving birth in midwifery led settings.

In 2007, just 5% of babies were born in midwifery led units in England, yet by 2015, this percentage had risen to 15%(iv). Midwifery-led settings come in different forms – some are attached to hospital units led by doctors, others are standalone units; it also applies to births at home, though.

Enquiry into enhancing the safety of midwifery-led births

The Enhancing the Safety of Midwifery-led births Enquiry (ESMiE) investigated the care received when babies had died following a planned birth in a midwifery led setting. Each death was reviewed by a panel of two midwives; two obstetricians; two neonatologists; and one pathologist.

A number of similar investigations have been carried out in the past to identify areas of improvement for care within a hospital setting. However, births planned in midwifery-led settings are important to investigate because the nature of any issues with care may be different compared with births planned in obstetric-led units.

Findings and recommendations of the ESMiE enquiry

In total, 64 deaths were reviewed and in 48 cases (75%), the panel identified improvements in care which may have saved the baby’s life.

Several themes emerged from the enquiry, highlighting areas where best practice could be made even better:

Deciding on the best place to give birth

When deciding where to give birth, a mother’s individual risk factors need to be considered. This might include considering a mother’s age and medical history to determine whether there might be an increased risk of difficulties, such as fetal growth concerns or a more complicated birth.

The enquiry found that in 34% of women, the decision, discussion and documentation for planning the place of birth was really good. However, for 12 women there was an identified lack of consideration given to risk assessing the place of birth which may have altered the outcome for the baby.

To enhance the safety of childbirth, the enquiry recommends that a fully documented discussion should take place with each woman to inform her decision as to where to give birth. This birth plan should then be revisited during pregnancy and at the start of labour care.

Considering risk factors at the start of labour care

At the start of labour 25 of the 64 women presented with risk factors for emerging complications including reduced fetal movements or prolonged rupture of membranes. For 15 of these 25 women, the panel concluded that their management was not appropriate.

The enquiry recommends developing a standardised risk assessment tool to use at the start of labour.

Monitoring the fetal heart rate

Monitoring the baby’s heart rate during labour is an important part of making sure the baby is coping well with labour. One method for monitoring the heart rate is by intermittent auscultation whereby the baby’s heart is listened to for a minute after each contraction and at intervals.

Nearly three quarters of the women (72%) had intermittent auscultation at some stage during their labour. The panel identified issues relating to intermittent auscultation in 28 of these women. Issues included monitoring the fetal heart too infrequently or at the wrong time in relation to contractions; and a delay in recognising and acting on fetal heart rate concerns.

The enquiry recommends that routine audits are carried out to check that midwifery teams are monitoring the fetal heart in accordance with the national guidance.

Resuscitation

The enquiry panels identified issues in relation to resuscitating babies which included uncertainty over who was leading the resuscitation.

The panels found that, on occasions, the midwives had deferred to paramedics or other colleagues who were less experienced than they were. They concluded that for four of the cases, the issues associated with resuscitation are likely to have affected the outcome for the baby.

The future of childbirth

We are all so grateful to the NHS for caring for us from the day we are born to the day we die. As a lawyer working with families who have been affected by birth injuries I am only too aware of the high standard of care we are lucky enough to expect in the UK. The findings of this national enquiry offer an opportunity to yet further improve care for women considering birth in midwifery led settings and drive us towards the national goal of making childbirth even safer.

i - https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.16327

ii - Draper ES, Kurinczuk JJ, Kenyon S, on behalf of MBRRACE-UK, editors. MBBRACE-UK 2017 Perinatal Confidential Enquiry: Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester; 2017.

iii- Department of Health. Safer Maternity Care. The national maternity strategy - progress and next steps. London: Department of Health; 2017. Available from: https://www.gov.uk/government/publications/safer-maternity-care-progress-and-next-steps

iv - Walsh D, Spiby H, Grigg CP, Dodwell M, McCourt C, Culley L, et al. Mapping midwifery and obstetric units in England. Midwifery. 2018;56:9-16.