Autumn/Winter Maternity Safety Newsletter 2021

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Greater Manchester and Eastern Cheshire

Strategic Clinical Networks

Autumn/Winter Maternity Safety Newsletter 2021

Issue 8




Welcome to the Autumn/Winter Maternity Safety Newsletter with updates from the National Safety Programmes and local work streams. 

Maternity Safety


Its three years since i commenced in post as Maternity Safety Lead for the GMEC Strategic Clinical Network (SCN) & Health Innovation Manchester (HIM) and i have thoroughly enjoyed meeting so many of you and working collaboratively to improve maternity safety across GMEC.

As some of you may know i am moving on in January 2022 to work in the regional midwifery team for the Midlands as their Senior Governance and Assurance Lead Midwife which will be a challenging role but i am excited about it.

The last three months has continued to see high levels of activity across all areas.I have been constantly amazed at our resilience and fortitude during these times to continue to produce such brilliant work.I would like to thank you all for the assistance and support over the last three years and ,no doubt, our paths may cross in the future.The Strategic Clinical Networks' Maternity Network and Health Innovation Manchester will continue to support maternity providers as requested and with the ongoing maternity safety agenda.

Chantal Knight

Maternity Safety Lead

Greater Manchester and Eastern Cheshire (GMEC) Strategic Clinical Networks/Health Innovation Manchester

Ockenden Report update


KEY MESSAGE: Assurance Visits to commence to all maternity providers by the Regional Midwifery Team

Across GMEC all maternity providers are now receiving their CSU reports highlighting the gaps in evidence against all 7 Immediate and Essential Actions from the Ockenden Report.

The next steps will include assurance visits by the North West regional maternity team, which will be in a supportive and appreciative inquiry style.There will be an expectation of a full MDT approach and MVP involvement. There will also be representation from the LMS’s with a long term plan that these visit’s will be led by the LMS’s. A template is currently being developed which will be shared with all providers by the end of January 2022.

The assurance visits will give the provider an opportunity to discuss any gaps in the evidence submitted and inform the regional team on progress for the provider action plan.

NHS Resolution CNST Maternity Incentive Scheme


NHS Resolution is operating year four of the Clinical Negligence Scheme for Trusts (CNST) - a maternity incentive scheme to continue to support the delivery of safer maternity care.

The maternity incentive scheme applies to all acute Trusts that deliver maternity services and are members of the CNST. As in previous years, members will contribute an additional 10% of the CNST maternity premium to the scheme creating the CNST maternity incentive fund.

As in year three, the scheme incentivises ten maternity safety actions. Trusts that can demonstrate they have achieved all of the ten safety actions will recover the element of their contribution relating to the CNST maternity incentive fund and will also receive a share of any unallocated funds.

Trusts that do not meet the ten-out-of-ten threshold will not recover their contribution to the CNST maternity incentive fund, but may be eligible for a small discretionary payment from the scheme to help them to make progress against actions they have not achieved. Such a payment would be at a much lower level than the 10% contribution to the incentive fund.Trusts must submit their completed Board declaration form to NHS Resolution by 12 noon on 30 June 2022.

CNST Safety Action 2 Criteria 1 update and replacement of requirement

By 31 March 2022, every Trust should have an up to date digital strategy for its maternity services which aligns with the wider Trust Digital Strategy and reflects the 7 success measures within the NHSX What Good Looks Like Framework. The strategy must be signed off by the Integrated Care Board. As part of this, dedicated Digital Leadership should be in place and have engaged with the NHSX Digital Child Health and Maternity Programme by 31 March 2022.

Technical guidance has been circulated by can also can be requested by contacting:

Progress to the 10 safety actions will be monitored by the LMS and any support required will be given. 


Report concludes review into intrapartum stillbirths during first wave of Covid-19

This report published in September 2021 sets out findings from HSIB review into intrapartum stillbirths in the wake of the COVID-19 pandemic.

The review was prompted by an increase in referrals of intrapartum stillbirths HSIB received, that fitted specific criteria between April and June 2020 (45 compared to 24 in the same period in 2019).

It thematically analysed 37 maternity investigation reports focused on intrapartum stillbirths, from the April to June time period to understand what learning could be drawn from these cases. While none of the women and pregnant people were recorded in HSIB maternity reports as having the virus, the national report describes how the pressures and changes as a result of the pandemic may have impacted on the care they received.

Findings in the report suggest that many safety risks that were identified in the review were already known to maternity services and these were further exacerbated by the pandemic, for example, the sustainability of staffing levels in maternity units. It also highlighted that COVID-19 created specific safety risks including the impact of limiting face to face interactions and increasing remote consultations.

Key themes

The findings have been summarised into six key themes:

  • Guidance - findings in maternity investigation reports emphasised the challenges in interpreting and ensuring the consistent implementation of rapidly changing national guidance in relation to COVID-19.
  • Management of risk – this theme covered how Trusts balanced emerging and uncertain risks of COVID-19 with known existing risks associated with pregnancy and the impact of operational changes e.g. the move to remote consultations.
  • Telephone triage - difficulties in communication were identified, relating to the availability and presentation of clinical records, documentation and communication of information from triage calls, and availability of interpreters particularly in urgent circumstances.
  • Interpretation services – the review highlighted that during the first wave of the pandemic, when women and pregnant people were required to attend antenatal appointments alone, the provision of interpretation services was even more critical.
  • Work demands and capacity to respond – recognised challenges in ensuring consistency and availability of appropriate clinicians within maternity services were exacerbated due to the response to the COVID-19 pandemic and increased levels of staff sickness and absence.
  • Neonatal resuscitation (resuscitation of the newborn baby) – this theme highlights the variability in the timing and efficiency of neonatal resuscitation and suggests a need for Trusts to proactively manage predictable risks.

Read the full report here:

Equity and Equality Strategy Gap Analysis

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A national ask was received in September 2021 for all LMS' s across England to submit an Equity and Equality Gap Analysis by 30th November 2021 .These were the asks:

  • Understand the local population needs
  • Map the community assets
  • Conduct a baseline assessment of the experience of maternity and neonatal staff by ethnicity
  • Set out a plan to co-produce interventions to improve equity for mothers ,babies and race equality for staff


GMEC demographics:17% of the GMEC population are from Black, Asian, or Minority Ethnic backgrounds, with a higher than national average of young women of childbearing age living in Manchester. 33% of pregnant women are from Black, Asian, or Minority Ethnic backgrounds.
• GMEC has high levels of social deprivation, with more than a third of pregnant women and people living in the 10% most deprived Local Super Output Areas (LSOA). Over 25% children (0-15 years) live in poverty, compared to the England average of 15.6%.
• GMEC data highlights that overall, there is a significant and growing pregnant population from ethnic minority backgrounds, particularly in Bolton, Manchester, Oldham and Rochdale.
• More than 40% of women did not book before 10 weeks of pregnancy in 2019. It is unclear whether this is due to access, language barriers, culture or other health inequality/inequity reasons. Further work is required to ensure access is equitable for all ethnic minority communities.
• Manchester has higher than the national average number of asylum seekers/refugees who face unique health challenges and additional support to overcome the barriers they face when attempting to access care. Many of these are pregnant and with children who require additional perinatal support.
• Data highlights the high levels of obesity above the national average which is linked to increased interventions and poorer perinatal health outcomes.

Completing this analysis has highlighted pockets of good work undertaken at local maternity service level, linked to postcode or geography as bespoke pieces of work. However, there are many more gaps in data related to maternity outcomes broken down by ethnicity and indices of deprivation across GMEC as a whole. The ability to harness this valuable information would allow areas of concern to become the focus of health and social care initiatives.
Community Assets: A huge range of community assets exist - but not all professionals or women. people and their families are aware of what is available.
• Some geographical areas in GMEC have more assets than others.
• There is no central portal for community assets for clinicians and families to sign post / access.
• We acknowledge that there are likely to be further assets not yet captured.
Staff experience: The experiences of Midwives from minority ethnic groups have been disproportionately worse when compared to their White counterparts across all the WRES indicators.
• We have no greater understanding of the wider Maternity workforce experience including obstetric, neonatal and MSW staff.
• Some WRES Indicators have little data and need further exploration locally.
Co-production: There are many organisations working on projects to improve health inequalities across GMEC.
• The ask of MVP's and VSCE is increasing markedly with a clear need to increase the capacity and funding to improve the pace for progression
of work.
• The staff experience findings indicate significant need for improvement for BAME midwives which can be achieved through planned co-design work.

Maternity services cannot single-handedly address all the issues highlighted in this analysis.
The GM Health and Care Partnership will work to tackle the inter dependencies of deprivation and ethnicity to improve health outcomes in their entirety.

GMEC LMS, including, valuable support from HIM, set a task and finish group to complete this enormous task in the short time span required and are now need to undertake an action plan for submission by 28th February 2022.A big thank you is extended to everyone involved for their continued help and very valuable contributions.

Chantal Knight GMEC Maternity Safety Lead

Saving Babies Live Care Bundle(2)

Maternity providers continue to embed the SBL Care bundle.  Current work includes standardised definitions and methods of collation of common metrics across the LMS and adjustments to key guidelines including Fetal Growth Restriction, Preterm birth and Reduced Fetal movements.

Dr Samiksha Patel, Obstetrician at St Mary’s Oxford Rd, has been appointed as SBL lead for fetal monitoring.  Planned work will include updating the fetal monitoring standards and teaching package, visiting each provider unit to discuss training, and establishing a fetal monitoring forum held 2 or 3 times a year for clinicians to attend, share learning and discuss common issues.

Eileen Stringer

Clinical Lead Midwife    

Greater Manchester & Eastern Cheshire Strategic Clinical Networks

Continuity of Carer


Maternity providers are in the process of developing plans for developing the MCOC that will describe how key building blocks will be put in place in order to make MCOC the default model of care by March 2023, focusing on those who are most vulnerable and who will benefit from this model of care. The LMS has funded 5 pilots to support the expansion and development of MCOC models of care in some of the areas in GM that have the highest percentage of ethnic population and deprivation.


Eileen Stringer

Clinical Lead Midwife    

Greater Manchester & Eastern Cheshire LMS

Covid-19 Vaccination for Pregnant Women


KEY MESSAGE-Promote Covid-19 vaccination to all pregnant women

A task and finish group has been established led by the GM Immunisation & Vaccination with representation from the SCN and each maternity provider in GMEC to improve uptake of COVID-19 vaccination in pregnancy.  The group are working closely with the GM Health and Social Care Partnership Comms team to provider a variety of resources to maternity units to aid discussion, decision making and sign posting.  Information is being translated into some of the top languages used and information is available on the Mybirthmychoice website with a translation facility available in a number of languages.  A number of maternity units are now offering regular pop-up vaccination clinics and others are working to improve the offer to women and families.  Further comms are planned for a podcast and targeted vaccination in pregnancy for vulnerable groups.

Recent data shows 1 in 5 of the most critically ill COVID-19 patients are pregnant women who have not been vaccinated. The Preg-CoV study is urging pregnant women across England to step forward and help researchers discover the most effective use of vaccines during pregnancy to protect women and their babies against COVID-19. To identify the best interval between vaccine doses, during and following pregnancy, more volunteers are urgently needed. Pregnant women who have not received any COVID-19 vaccines or who have received their first, second or booster dose are all invited to join the study. The study compares vaccines currently being used for the UK vaccination programme (Pfizer/BioNTech and Moderna) as well as new vaccines as they are approved. The NIHR-supported study will provide vital clinical trial data on the immune response to vaccination at different dose intervals - either four to six weeks or eight to 10 weeks.

Eileen Stringer

Clinical Lead Midwife    

Greater Manchester & Eastern Cheshire LMS


Manchester Smoke Free

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New figures reveal smoking in pregnancy rates at all-time low in Greater Manchester

Smoking at the Time of Delivery (SATOD) rates have fallen by around a quarter in the past four years - down from 1 in 8 (12.6%) new mothers in 2017-18 to fewer than 1 in 10 (9.8%) in 2020-21[1], meaning nearly 1000 more babies were born smoke free. It shows the success of the Greater Manchester Health and Social Care Partnerships’ Smokefree Pregnancy programme which was set up in 2018 and is now recognised a national exemplar of best practice.

In the 12 months between April 2020 and March 2021, the programme supported more than 1,700 people on their journey to stop smoking, including pregnant women and their partners, and saw a 75% successful 4 quit rate. In Q1, the programme has seen an increase of over 110% of people engaging with the programme compared to previous quarters. Over 75% of those engaging are making successful quit attempts.

Carbon monoxide testing has been re-instated at every antenatal contact in line with newly published NICE guidance. Although face to face is returning slowly the success of the virtual appointments and individual carbon monoxide monitors will remain part of the programme, enabling a flexible and multifaceted environment to ensure a true person centred approach in supporting their individual quit journeys, meaning we can continue to save babies lives!

Jane Coyne

Treating Tobacco Dependency Programme Lead

Long Term Plan Programme Implementation Advisor - Tobacco Dependence  NHS England & NHS Improvement



MBRRACE-UK Saving Lives, Improving Mothers' Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19


  • There was a statistically non-significant decrease in the overall maternal death rate in the UK between 2014-16 and 2017-19 which suggests that continued focus on implementation of the recommendations of these reports is needed to achieve a reduction in maternal deaths. Assessors judged that 17% of women who died had good care. However, improvements in care which may have made a difference to the outcome were identified for 37% of women who died.
  • There remains a more than four-fold difference in maternal mortality rates amongst women from Black ethnic backgrounds and an almost two-fold difference amongst women from Asian ethnic backgrounds compared to white women, emphasising the need for a continued focus on action to address these disparities.
  • Cardiac disease remains the largest single cause of maternal deaths. Neurological causes (epilepsy and stroke) are the second most common cause of maternal death.
  • Thrombosis and thrombo-embolism remains the leading cause of direct maternal death during or up to six weeks after the end of pregnancy.
  • Maternal suicide remains the leading cause of direct deaths occurring within a year after the end of pregnancy.


Maternity Neonatal Safety Improvement Programme


Since September,  Health Innovation Manchester have been supporting the SCN with the Equity and Equality Analysis and will continue to support with the development of the action and implementation plan.

 Our MatNeo improvement teams have started to re-engage with their MatNeoSIP QI projects and some teams are reporting improvements in outcomes in their units relating to antenatal risk assessments and a reduction in term admissions to neonatal units.

 A Task and Finish Group has been established re the Birmingham Symptom-specific Obstetric Triage System (BSOTS) including representatives from all GM units. Bolton FT and Manchester FT have already embedded the system and both units have reported improved flow and a reduction in the number of incidents within triage We are looking to identify the changes made to the Triage Assessment Cards (TAC) by Bolton and Manchester, with the intention being to have some alignment across the system with regards to the delivery of the system.

 Regarding the new national MEWS, we are awaiting further instructions from the national team, its likely there’ll be further testing in early spring of 2022.

 A task and finish group has been established to explore the prescription of omega-3 supplementation to women in most at risk of preterm birth. So far there has been lots of discussion and fact finding, in the coming weeks we hope to agree our approach to testing i.e. providers who will be test sites, definition of population, dosage and evaluation etc.

We are currently in the process of finalising our approach to the optimisation of the preterm infant workstream in 2022, our hope is to commission neonatal QI champions at each unit to lead on this (similar to the PReCePT delivery model). Once we have confirmed the resource required for this approach we will confirm next steps across the system. The two interventions in the preterm optimisation care pathway that we will focus on are; optimal cord management and normothermia. This workstream will be delivered in collaboration with the ODN. Our plan is to have a launch event for this workstream on the 10thFeb 1:30 – 16:30.

If you require further information regarding the above please contact

Tom Openshaw Programme Development Lead Patient Safety Collaborative, Health Innovation Manchester.