Summary
The Oxford AHSN Patient Safety Collaborative has taken up the challenge of the ‘Better Births’ national maternity review enabling sustained improvements for mothers and babies through region-wide collaboration. Significant progress has been made in relation to preterm births in particular, giving babies born too soon the best possible start in life and reducing health inequalities. Since 2015 the AHSN has worked with all maternity units in the region on a coordinated approach which has improved outcomes for preterm babies and saved NHS and related resources. These include ensuring more preterm babies are born in the right place, increasing uptake of magnesium sulphate to reduce risk of cerebral palsy and establishing an evidence-based clinical pathway for every pregnancy where preterm labour is suspected.
Background
Pregnancy and childbirth are critical times determining the future health and wellbeing of both mother and baby. The National Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) led by NHS England is delivered by AHSNs through their Patient Safety Collaboratives (PSCs). The programme aims to reduce the rate of preterm births (before 37 weeks) from 8% to 6% and halve the rate of stillbirths, neonatal death and brain injuries occurring during or soon after birth by 2025. This will be achieved through collaborative working, introducing and spreading innovation and reducing unwarranted variation.
Securing the best possible outcomes for preterm babies is a key national priority. Prematurity is the biggest cause of mortality in children before the age of five and is associated with significant morbidity in surviving children. More than two thirds (69%) of babies who die before their first birthday are born prematurely (National Child Mortality Database 2019/20). Prematurity has a significant impact on parents, their wider families and society as a whole. Women from minority ethnic backgrounds and lower socio-economic groups are at greater risk of preterm birth – so focusing on this issue helps to address health inequalities.
The focus of the safer care theme outlined in the National Maternity Review ‘Better Births: Improving outcomes of maternity services in England’ is on culture, learning, reviewing data and open communication. The review highlights multi-professional working and shared learning within and across organisational boundaries as fundamental to the delivery of safe, personalised care to women and families. In response the Oxford AHSN PSC began hosting regular multidisciplinary shared learning events in 2016 with support from all maternity units within the region and beyond. Staff value the opportunity to share challenges and successes in a safe, supportive and non-judgemental environment. The network is now embedded within local integrated care systems, contributing to improvements in safety and quality of care for mothers and babies. After a hiatus due to the pandemic the face-to-face events returned in March 2023 with more planned. The programme reflected our close working relationships with parent advisory groups.
What have we done?
1 Place of birth
The first region-wide project with a specific preterm focus looked at place of birth. Mortality is halved if birth of an extremely premature baby takes place in a high volume, neonatal intensive care setting (known as a level 3 unit). These are also associated with reductions in conditions which can affect the gut and brain. Revised pathways, guidelines and audits were introduced in the Oxford AHSN region from 2015. As a result, the proportion of preterm babies born in the right place rose from 50% to over 80% in 2019. An independent study conducted by the Office of Health Economics and RAND Europe found that four additional babies’ lives were being saved per year. This initial success has been sustained.
2 Magnesium sulphate
England’s 15 AHSNs worked together from 2018-20 to increase uptake of magnesium sulphate in preterm labour. Timely administration of magnesium sulphate (MgSO4) reduces cerebral palsy in preterm labour by 30% and results in one fewer baby with cerebral palsy for every 37 women treated. The national target for this programme known as PReCePT was 85%. The magnesium sulphate rate was exceeded from the outset in the Oxford AHSN region and was sustained at 93% in 2022/23. Nationally, 16,000 babies have benefited with almost 300 cases of cerebral palsy prevented. Potential savings of up to £367 million were recorded.
3 Preterm perinatal optimisation pathway
The preterm perinatal optimisation pathway is an evidence-based clinical pathway which should be followed whenever preterm labour is suspected. It is aligned with the Saving Babies’ Lives Care Bundle, and supported by the National Neonatal Audit Programme (NNAP) and the British Association of Perinatal Medicine (BAPM). It is a comprehensive care plan including seven interventions that should be implemented. This pathway follows the woman through birth up to and including the initial part of the baby’s admission to the neonatal unit. The pathway has been adopted in the Oxford AHSN region and improvements have been achieved in a number of elements including:
- Deferred cord clamping
Newborn babies benefit from a delay before clamping the cord, allowing time for extra blood to flow from the placenta into the baby – even more so in preterm babies. The proportion of babies in the Oxford AHSN region born before 34 weeks who had their cord clamped at or after one minute rose from 25% in 2019 to 70% in 2022.
- Antenatal corticosteroids
Mothers who give birth before 34 weeks receive a complete course of antenatal corticosteroids ideally within one week prior to birth. Timely and appropriate administration of antenatal corticosteroids leads to one more baby surviving for every 8-10 women treated.
Download the antenatal corticosteroids guidelines
- Receiving mother’s breast milk
The benefits of breast milk are well known but preterm babies often miss out. The proportion of babies born before 34 weeks in the Oxford AHSN region who receive their own mother’s milk in the first two days of life rose from zero in 2019 to 72% in 2022.
Introducing innovation
The Oxford AHSN Patient Safety Collaborative Maternity/Neonatal programme facilitated a simulation workshop for perinatal multiprofessional teams at Frimley Health enabling shared learning to improve outcomes for preterm babies.
The perinatal regional clinical network has proved to be a catalyst for innovation supporting the translation of evidence into clinical practice. Examples include training videos, simulation-based education and training and a series of podcasts focused on each element of the optimisation pathway, created by Michelle East, Buckinghamshire Healthcare Lead Midwife for Governance & Quality. Current focus areas include further increasing the proportion of preterm babies born in the right place and improving experience for parents and families. A summary report of the parent and staff surveys undertaken across the South East will be shared with key stakeholders. This report has informed the development of a number of improvement initiatives including a multi-professional ‘Train the trainer’ programme to support education teams in each trust to deliver simulation-based education to optimise outcomes for preterm babies whether they are born in hospital or in the community. A pilot study is underway to gather feedback on a structured handover tool designed to support improved communication and documentation between trusts related to transfers where preterm labour and birth are suspected and/or confirmed.
What people said
“Working with the Oxford AHSN Patient Safety Collaborative on quality improvement projects across our maternity and neonatal services enables us to drive continuous improvement, particularly around the Maternal and Neonatal Safety Improvement Programme. Together we have improved standards of care, embracing innovation and best practice that will progress the delivery of safe care across our services and ultimately improve outcomes.” – Michelle East, Buckinghamshire Healthcare Lead Midwife for Governance & Quality
“I have been working closely with the Oxford AHSN now for over five years and find the work we do together so rewarding. They have really facilitated more network-based collaborations which serve to enhance the care we provide to women and their families.” – Dr Meena Bhatia, Consultant Obstetrician and Lead for Maternity Quality Improvement and Postnatal Care, Oxford University Hospitals NHS Foundation Trust
Feedback from shared learning event, March 2023:
- “Great engagement and some of the work presented was stellar!” – Tony Kelly, National Clinical Advisor for Maternity and Neonatal Safety Improvement Programme and Leadership and Culture Programme
- “Really positive to hear how working together is helping the region improve outcomes”
- ”Definitely one of the best events I have been to in some time”