In 1996, the Norwegian Board of Health Supervision published the report Faglige krav til fødeinstitusjoner [Functional requirements for maternity institutions] (1). The aim was to provide an overview of the functional requirements that should apply to maternity institutions. The report recommended that births should take place at institutions at three levels: level 1 birth units (university hospitals/central hospitals), level 2 birth units (small and medium-sized departments of obstetrics and gynaecology) and level 3 birth units (midwife-managed birth units including modified midwife-managed birth units with preparedness for acute caesarean sections). Minimum requirements were made with respect to the number of births at each level, and emphasis was placed on sound risk assessment and on placing the woman at the right level.
The report formed the basis for the report to the Storting (Norwegian parliament)En gledelig begivenhet [A joyous occasion] (2). Maternity care should be differentiated and decentralised. The division of maternity institutions into three levels should be maintained. Modified midwife-managed birth units should be converted into midwife-managed birth units. The use of birth rates as a criterion for selecting an institutional level should be replaced by quality requirements for maternity institutions.
In 2010, the Directorate of Health published the guide Et trygt fødetilbud – kvalitetskrav til fødselsomsorgen [A safe maternity service – quality requirements for maternity care] (3). The guide followed up the intentions of the report to the Storting, with "quality" applying to requirements regarding organisation, distribution of tasks and functions and competencies, systems for following up the requirements, and requirements regarding information and communication.
The guidelines provide specific selection criteria for births – who can give birth at level 1, level 2 and level 3 birth units. Guidelines are provided for monitoring and treatment of low-risk and high-risk deliveries, including the importance of having clear guidelines for when a doctor must be summoned in connection with complicated births.
It is recommended that the bulk of the permanent staff of level 1 and 2 units should consist of specialists. A succession of locums should be avoided, and the competencies of locums should be checked. The obstetricians should not have more than four-shift rotation, to ensure a minimum number of obstetricians in the department. There is a requirement for level 1 units that the senior on-call doctor must be on duty. There are requirements relating to the use of different types of fetal monitoring, including competencies and instruction for both doctors and midwives. Instruction and practical training in acute situations form part of the requirements.
In 2011, the Journal of the Norwegian Medical Association published a three-year summary by the Norwegian Board of Health Supervision of cases brought before the Board in which the baby died or was severely harmed during delivery (4). The cases showed that there were often mistakes in fetal monitoring, in the summoning of qualified personnel, in rapid delivery of the baby when necessary, and in the duty of the health enterprise to report serious incidents in accordance with the statutory reporting arrangement. A study by the Norwegian System of Compensation to Patients (NPE) revealed similar findings (5).
The Directorate of Health's national guide are intended to be advisory and designed to achieve a professionally acceptable service and a means of ensuring high quality and correct priorities. The regional health authorities and the health enterprises are responsible for ensuring that the service is properly executed and that national guides and guidelines are used and applied in practice. The purpose of this study was to obtain information on the implementation of the guide Et trygt fødetilbud [A safe maternity service] (3) in maternity institutions. The survey was not conducted as a supervisory activity.