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How to be a very safe maternity unit: An ethnographic study

Why it matters

Safer maternity care can protect babies from avoidable harm and save health systems from rising litigation costs. Yet attempts to improve maternity care don’t always have the intended impact.

Some improvement projects focus on implementing and evaluating an intervention – like a checklist or care bundle – but may not pay enough attention to the context that makes that intervention work. Other projects focus on identifying the characteristics of one safe maternity unit, but don’t provide enough information about how to replicate that context in another unit.

This paper aims to describe exactly what needs to happen for maternity care to be safe by examining how interventions and context work together to nurture and sustain safe practice.

What we did

To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, our study focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.

Distinguished by having some of the lowest rates of birth complications in the UK, this hospital’s maternity unit has achieved sustained improvement in a variety of safety measures since 2001. One way of explaining these improvements is to attribute them to the PROMPT maternity safety training programme, which was created and implemented at Southmead. But PROMPT alone doesn’t seem to be the full story, so if the success at Southmead is to be reproduced, deeper understanding is needed.

To understand what makes Southmead Hospital’s maternity unit so safe, we spent 143 hours observing the unit’s staff at work, conducted 12 semi-structured interviews and two focus groups. We then used this data to identify mechanisms that seem to support safe maternity care.

What we found

  • A very well-founded training programme is very important to achieving safety, but on its own doesn’t provide a full explanation of what makes a maternity unit safe.
  • At Southmead Hospital, safe maternity care was influenced by a training intervention (PROMPT) as well as broader social, organisational and cultural factors.
  • These factors include:
    • collective competence and agile professional boundaries
    • insistence on technical competence
    • systems to facilitate coordination and distributed cognition
    • clearly articulated and constantly reinforced standards of practice, behaviour, and ethics
    • monitoring multiple types of data about the unit’s state of safety
    • a highly intentional approach to safety
  • The mechanisms were also influenced by the unit’s structural conditions, such as staffing levels and physical environment.
  • The intervention (PROMPT) interacted constantly with these mechanisms. Though PROMPT was not a ‘magic bullet’ for safety, it both fostered and reinforced the conditions needed to achieve safety.
  • Improvement interventions and the context that enables their success should be considered in tandem.

Related content from our open-access series, Elements of Improving Quality and Safety in Healthcare

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