Mind the Gap report identifies series of failings in maternity training
Commissioned by Baby Lifeline, the Mind the Gap report investigated 124 NHS Trusts and found that 90% were not receiving training deemed to be essential. It also found that the average spend on maternity training had decreased considerably, £34,290 in 2020-2021 compared to £59,873 in 2017-2018.
Safety concerns/factors to consider in training included:
- Medical co-morbidities
- Maternal age
- Communication
- Domestic and sexual abuse
- Impact of smoking
- Previous problems/complications in pregnancy
- Substance misuse
- Multiple pregnancy
- Perinatal mental health
- Cultural competency
It showed that there were "detrimental gaps" in training, which repeatedly led to avoidable harm, including baby deaths. It noted the following recurring themes:
- Clinical risk recognition
- Human factors and communication
- Fetal monitoring
- Management of labour and delivery
- Cultural considerations and communication
- Newborn life support and neonatal collapse
- Reduced fetal movements
- Fetal growth
- Management of complications and emergencies
It also identified a lack of training based on local demographics, and taking account of factors such as clinical signs in women of colour, differences in outcome of women from ethnic minorities, and language barriers.
I have written several pieces on maternity care in the past, including those involving the Shrewsbury & Telford NHS Trust and Nottingham Hospitals NHS Trusts, both of which have ongoing investigation into substandard maternity care.
In February 2020 I appeared on BBC News commenting on my case of baby Andrew Witkowska, and I also settled a case for a young woman who suffered a stillbirth due to midwifery failures in recognising and acting on an abnormal fetal heart rate.
It is heartbreaking to read yet another report identifying issues that we see regularly, and that simple, effective measures are not being followed to prevent avoidable harm.