Children Young People and Families programme

Research and Investigation Findings

Confidential Enquiry into Maternal and Child Health (CEMACH)

The Enquiry conducts confidential reviews of every maternal and neonatal death in the UK. It publishes reports on its findings, which show trends and make evidence-based recommendations for improvement in care and procedures. In addition other audit work following specific topics such as diabetes adds breadth to the scope of their work.

	Saving Mothers' Lives was published in December 2007, and this triennial report examines the factors behind the deaths of 295 women who died from causes directly or indirectly related to their pregnancy, out of more than 2 million women who gave birth in the UK between 2003-2005. There are ten recommendations which MSLCs should be considering to ensure that the women accessing local services are provided with safe services and appropriate and timely care. In particular, there are recommendations relating to early access to services, learning from incidents and managing specific groups of women such as those who are obese, are substance misusers or have other factors connected to social exclusion. There are 10 key recommendations for maternity professional communities to address Click here to download document
	"Why Mothers Die" was published in 2004 and shows the immense impact of mental health and deprivation on maternal mortality. The next triennial report will be launched in December. Click here to download document
	Perinatal Mortality Surveillance Report Published in April, this annual report details all perinatal deaths in 2005 and traces their possible cause, making recommendation into how services could be designed to mitigate deaths in future. Click here to download document
	"Diabetes in Pregnancy - are we providing the best care?" This report is the culmination of a three-year research project on the implications of type 1 and type 2 diabetes on pregnancy. It makes clear recommendations about the organisation of care and the specific circumstances and needs of women with diabetes in pregnancy to ensure safe outcomes for them and their babies. Click here to download document

Healthcare Commission Reports

The Healthcare Commission is the independent inspectorate and regulator of
health services (NHS and independent) in England. Its prime purpose is
inspection against standards and regulation of the independent sector, and
production of the "Annual Health Check" of NHS bodies. Part of its work
includes conducting detailed reviews, experience surveys and investigations
into specific aspects of services. For maternity services in particular
there are a number of key documents and information sources which are
highlighted below

Survey of women using maternity services. A detailed survey of all women
who gave birth in February was undertaken during the summer. Over 26,000
women responded, and details of the findings, trust by trust, are
published here

These results are presented in a national report together with a series of
14 spreadsheets since they provide the full findings. For a rapid review
of individual trusts and how they compare with the England average, please
refer to http://www.birthchoiceuk.com/.

Another function of the Healthcare Commission includes conducting
interventions and investigations into services where concerns are raised
about the safety of services.

	Investigation into 10 maternal deaths at/or following delivery at, Northwick Park Hospital Click here to download
	Review of Maternity Services provided by North West London Hospitals NHS Trust July 2005 Click here to download
	Investigation into Maternity Services provided by the Royal Wolverhampton Hospital s NHS Trust at New Cross Hospital June 2004 Click here to download
	An intervention took place into an antenatal care backlog which provides an example of the role of the Healthcare Commission in helping Trusts address issues of concern raised with them. Interventions such as this are usually confidential during the process but are part of the ongoing surveillance being carried out by the Healthcare Commission on behalf of service users and the public. Click here to find out more

National Audit Office

Caring for Vulnerable Babies: The reorganisation of neonatal services in England - This report contains a number of recommendations which locally and nationally we will need to consider our response to.

Click here to download

National Perinatal Epidemiology Unit

"Recorded Delivery" A National Survey of women's Experience of Maternity Care Published in March 2007, this report outlines the findings from a National survey of around 3,000 women who gave birth in Summer 2006. It compares changes since the last such report in 1996, and provides useful indicators for exploration into how services are tailored for specific groups of women.

Click here to download document

Hard copies of the report can be obtained by e-mailing postal details to maternity@healthcarecommission.org.uk

Kings College

Support Workers in Maternity Services - This independent study, sponsored by the Department of Health, looked at the use of matenrity support workers (and equivalents) in NHS Trusts in England and provides a useful summary of some of the roles in which they are working and raises questions for MSLCs over staffing, competencies and supervision arrangements.

Click here to download

MIDIRS Informed Choice (Midwives Information and Resource service)

This charitable organisation provides evidence-based information and guidance for women and health professionals on its website www.infochoice.org. Born Unequal - why we need a progressive pre-birth agenda (2007)An immensely readable booklet which sums up recent policy and
statistics and examines some of the demographic, social and historical
factors influencing inequality, child poverty, prematurity, neonatal health
and poor pregnancy outcomes.

http://www.fabians.org.uk/publications/policy/bamfield-prebirth-07/

BLISS - the premature baby charity

BLISS funds research into neonatal service provision across the UK. During 2007 the charity has published reports for England and Scotland highlighting pressures on the services due to understaffing and transport difficulties.

	Special Delivery or Second Class; are we failing special care babies in the UK? Published April 2007
	Handle with Care - a review of Scottish Neonatal Services Published June 2007
	Too Little, Too Late; are we ensuring the best start for babies born too soon? - Launched in October 2007, this national report reports primarily on inadequate nurse staffing levels in neonatal units in the UK and concludes that many units are working significantly above the average occupancy levels recommended by experts.