Governing body calls for safety, equity and engagement to improve maternity services

The Care Quality Commission (CQC) has published a report today, which highlights that more than 2 out of 5 (41%) of maternity service providers have been rated “inadequate” or “requires improvement” in terms of their safety rating. As with the last report from the CQC Getting Safer Faster, this most recent report states that “the pace of change is too slow” in terms of improving safety in maternity. It suggests that maternity services need to be better at learning from good and excellent practice across other services.  

Though the report focuses on a few maternity service providers where there are the biggest concerns, the quality improvement themes can be seen across maternity and the themes are not new.

The themes are as follows:

Effective teamworking and culture

  • Learning and improvement
  • Support and teamwork
  • Team training


  • Increasing support of at-risk women
  • Tailored communication and reassurance
  • Conversations around supplements and nutrition for all women
  • Recording ethnicity and risk factors
  • Continuity of care
  • Safeguarding
  • Targeted engagement

Maternity Voices Partnership and engagement

  • Joint working between trusts and MVPs
  • Raising concerns over safety

“We know that there are many maternity services that are providing excellent care, but we remain concerned that there has not been enough learning from good and outstanding services – or enough support for that learning from the wider system. Issues such as the quality of staff training; poor working relationships between obstetric and midwifery teams, and hospital and community-based midwifery teams; a lack of robust risk assessment; and a failure to engage with, learn from and listen to the needs of local women all continue to affect the safety of some hospital maternity services.”

The report states that issues highlighted in previous publications continue to cause concern:

  • Staff not having the right skills or knowledge
  • Poor working relationships
  • Poor risk assessments
  • Not learning from when things go wrong

Baby Lifeline has been urging the NHS and government to prioritise multi-professional training in maternity for many years, with it often being the first thing to go when budget cuts are made. Our research – Mind the Gaphas highlighted detrimental gaps in training relating to avoidable harm, and so it was disappointing that even if training was provided staff engagement and the quality of the training varied:

“While we saw some good evidence of multidisciplinary team training, there were concerns that not all staff were engaged with training. The quality of training and support for staff to maintain and develop their individual capabilities and core competencies also varied between the trusts we looked at.”

There are many factors that need to be prioritised if we want to improve safety in maternity; however, it is a basic requirement that staff should feel confident and be competent in their roles by ensuring that they receive adequate, relevant training.

The report outlines what it feels need to be the next steps for both maternity service providers and the CQC, and they ask that these changes are embedded quickly. These include:

  • Leadership, in line with recommendations from the Ockenden Review
    It asks for Boards to “take effective ownership of the safety of maternity services”.
  • Voices and choices, in line with the Cumberlege Review First do no harm women must receive effective communication and support to allow them to make informed choices about their care.
  • Engagement, in line with Better Births and First do no harm – local maternity systems need to improve their engagement and listen more effectively to the needs of women, particularly women from Black and minority ethnic groups.

    We launched a video for World Patient Safety Day, #ListeningForSafety, which highlights this and we invite maternity service providers to utilise it within in-house training.

  • Data and risk – the report calls upon local maternity systems to review local data they collect relating to ethnicity and to review safety outcomes and take action.

Judy Ledger, CEO & Founder of Baby Lifeline says:

 “It should not be accepted that 2 out of 5 maternity services are rated “inadequate” or “requires improvement”. Most pregnancies and births will be positive, and a baby will be born healthy to a healthy mother, but for those who end in loss it is devastating, and lessons are not being learned quickly enough.

The themes in the report are sadly not new. We owe it to every motherless family and every parent that didn’t get to take their baby home to make the suggested changes at pace. There is some excellent care in maternity, and we need to replicate that – to give every mother, birthing person, and baby the best care possible and the best start in life.”

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