Where is maternity care failing?
Norway is one of the safest countries in the world to give birth in. Perinatal mortality is low, with only 3.8 deaths per 1000 births (5). Expectations are therefore high as regards safe and good-quality maternity care. However, when assessing the quality of maternity care, we cannot solely rely on official statistics such as perinatal mortality, maternal deaths, number of perineal lacerations or other quality indicators (6). In order to form an overall picture, adverse events must also be recorded and analysed internally in the ward to ascertain whether routines and practices should be changed.
It is important to identify the underlying causes of substandard care. Feedback must therefore be sought from patients and their families after an adverse event has occurred. In a hectic working day, quality assurance is often downgraded, which is unfortunate because it prevents lessons being learned from adverse events.
In 2004, a nationwide inspection was carried out in Norwegian maternity units. The results showed that routines and practices for dealing with acute incidents, calling a doctor, accountability, documentation and training of obstetricians and midwives had scope for improvement (7). Improvements have been made since this inspection, but experiences from the inspection and some of the cases in the Norwegian System of Patient Injury Compensation show that there are still shortcomings in maternity care. It is particularly concerning that the same errors appear to recur over time (2, 3, 8, 9).
During childbirth, acute events are not uncommon. Most are dealt with quickly and in accordance with good practice. However, accidental injuries, complications that require further treatment, prolonged hospital stays or, in rare cases, death can also occur. International studies show that adverse events occur in one in every ten births (10). Adverse events may be the result of medical errors, but can also be due to other reasons. In 2016, the Norwegian Board of Health Supervision investigated how three categories of acute events with adverse outcomes were dealt with in Norwegian maternity units. Substandard maternity care was found in six out of ten events, and this was shown to be directly associated with the serious outcome (8). We discuss below some areas where errors are often repeated.
A breach in the standard of maternity care was found in six out of ten events, and this was shown to be directly associated with the serious outcome
It is important to monitor the fetus during labour. A fetal stethoscope or handheld Doppler is used to monitor low-risk parous women, while electronic fetal monitoring (cardiotocography (CTG) and ST analysis of the fetal ECG (STAN) are used for high-risk parous women (11). Several studies, both Norwegian and international, have shown that the recommendation to use CTG monitoring in high-risk cases is not always followed. In addition, CTG findings can be misinterpreted, which has been the case in many of the events with adverse outcomes (8, 9).
In order to prevent injury in an acute event, the timing of the delivery is of the essence. Delays in diagnosis and delivery often lead to adverse outcomes. Misinterpretation of CTG over several hours and failure to examine the patient when serious complications arise, such as placental abruption or uterine rupture, are some examples. Precious time may also be lost after the decision has been made to perform a surgical delivery, e.g. delays in getting the patient to the operating theatre, lack of information/communication about the degree of urgency, and delays due to the anaesthesia method chosen. Delivery can also be delayed because an attempted forceps or vacuum extraction has exceeded the recommended maximum of 15–20 minutes (8).
A large proportion of parous women are given oxytocin to increase uterine activity, which in some cases leads to uterine hyperstimulation (when contractions are too frequent). This can reduce the placental blood flow and thus also the oxygen supply to the baby. Obstetricians and midwives are now more aware of the risks with oxytocin, but it is still used uncritically, particularly so in relation to women who have previously had a caesarean section and have a high risk of uterine rupture (12).
Obstetricians and midwives are now more aware of the risks with oxytocin, but it is still used uncritically
Postpartum haemorrhage is another serious complication that is relatively common. There are various ways to treat this, but medication to stimulate uterine contractions is extremely effective in stopping atonic bleeding. Reviews of such events show that medication is underused, and when it is used, the dosage is not in accordance with stipulated recommendations (8).
In order to provide good maternity care, the midwife and obstetrician must work together when necessary, likewise the doctor on duty and the doctor on call at home. The midwife may have sole responsibility for normal deliveries, but when complications occur, an obstetrician needs to be involved. A multitude of inspections have found that obstetricians and midwives do not always seek assistance when necessary. In such cases, they go beyond their scope of expertise, thereby increasing the risk of errors of judgement. This has proven to be the case in a number of adverse events in maternity care (3, 8).