Nine in ten women who require critical or enhanced maternal care during childbirth, are fit and healthy when they arrive at the delivery suite.
This is just one important new discovery about women who deteriorate during their delivery, revealed in a regionwide Yorkshire and the Humber data-led initiative that aims to improve outcomes for women and babies.
Dr Deborah Horner, consultant in anaesthetics and critical care for Bradford Teaching Hospitals NHS Foundation Trust, chairs the region’s Maternal Enhanced and Critical Care (MEaCC) Steering Group. “There is a big focus nationally in maternal care on looking after really sick women,” she explains. “But it turns out that if you only look out for women with complex health problems, you are potentially missing 90% of women who are likely to become ill. No one knew that.”
The new understanding is just one of the important findings emerging in Yorkshire and the Humber’s MEaCC programme. The initiative has implemented enhanced maternal care, a new standard of care for women who deteriorate during pregnancy, and a model for both identifying and looking after unwell women outside of critical care, the impact of which is now being tested using the CaseCapture clinical audit system.
“Our work is about ensuring women receive the right care in the right place from the right people,” says Dr Horner. “People become sick in places other than intensive care. When they become sick staff need to be able to recognise that, and they need the skills to appropriately look after them.”
MEaCC’s model is the first in the country to be accepted by every maternity unit across a region, in part because the team quickly recognised a “one size fits all” approach “wouldn’t work for units of varying sizes”, explains Dr Horner.
A flexible model involving training, guidance, examples on how to set up a unit, and different thresholds on when to transfer to critical care for units of different sizes and experience levels, has been deployed in all 17 maternity units in the region, which collectively cover 10% of births in England.
Testing the model has required data that didn’t exist. “It became apparent that there was no data being collected specifically for sick women on delivery suite,” explains Elizabeth Audsley, quality improvement lead for the Yorkshire and the Humber Maternity Clinical Network.
“We knew that having robust and reliable data would help inform and provide evidence for quality improvement across Yorkshire and the Humber. Over time, the data would highlight whether the care provided was improving.”
An effective clinical audit was needed to generate the required data. Spreadsheets were used in an initial trial, but proved ineffective, due to manually intensive data entry and limited visibility of insights.
Midwives across each maternity unit are now using CaseCapture to quickly capture crucial audit data on women receiving maternal enhanced and critical care. This is helping units understand the quality of services, areas to address, and outcomes for women and their babies.
“We are at the beginning of a journey,” says Dr Horner. “But by capturing the data, we can show the effect of our improvements. We haven’t had the data about those women who are less sick previously. We can track what makes a difference, and the impact on morbidity rather than just looking at deaths.”
“We can now create a detailed view of women we are worried might deteriorate, right through to those in critical care.”
Insights so far have shown the most common problems women encounter when needing maternal enhanced or critical care. These include postpartum haemorrhage, hypertension and sepsis.
The audit is also proving resourcing needs. “We previously had little understanding of man-hours involved in looking after someone receiving enhanced maternal care,” explains Viv Dolby, lead audit midwife for MEaCC. “We are now capturing that data, with tremendous goodwill from staff, who have done so in the midst of Covid, recognising this is about improving care and patient safety.”
“CaseCapture has proven itself,” she adds. “It is so user friendly, can be used by a range of staff with minimum instruction and allows us to capture data that teams can use in real-time when they need it, to present performance data and resourcing requirements to executives and evidence business cases. Staff would not be happy to go back.”
The team behind the CaseCapture solution has also made a difference, she says. “The people at CaseCapture have been responsive and great to work with. They have provided advice along the way to help us to get the most from our audit and data.”
A better understanding of major haemorrhage has already resulted from data – how staff are able to respond, what can be done to reduce blood loss, and a better understanding of outcomes.
In traumatic birth cases, data is also being used to track and improve multidisciplinary follow ups for women who require psychological support.
A longer-term aim is to use the clinical audit to create a risk prediction score. “We want to be able to determine the risk of somebody deteriorating as they come through the door of the delivery suite,” says Dr Brian Wilkinson, a critical care consultant anaesthetist involved in driving the MEaCC project. “If we know the factors that increase the risk of a woman or their baby becoming unwell, we can better assess how and where we need to care for them.”
Work in Yorkshire and the Humber is now informing national approaches. “When I talk to people outside Yorkshire and the Humber, it becomes clear how important our MEaCC model is,” says Dr Horner. “We have created something that works for all our 17 midwifery units, and we are the only region with a model working where every unit buys in.”
“Our data now shows that you have to be flexible with care models, to provide the best care for women,” she adds. “The Intensive Care Society’s Maternal Critical Care Group is now writing national guidance based on what we have learned in Yorkshire and the Humber.”
“If national approaches go forward, it must not be based on retrospective databases – they need user-friendly, real-time approaches like this.”