The United Kingdom’s seems to have reeled from one maternity crisis to another over the past decade. Things are not all that wonderful here in Australia either, with the NSW Birth Trauma Enquiry still fresh in many people’s mind, and a recent storm in a teacup about the safety of public hospital maternity care. Governments (particularly in countries with socialised healthcare models) are keen to ensure good press about how they are fixing the problem and ensuring maternity care is high quality.

One approach favoured under the “risk management” approach to healthcare is to set out standards for maternity services and then to inspect and assess them to see if they are meeting these standards. The assumption is that this encourages services to lift the quality of their services to meet the standards, and that in doing so, outcomes must inevitably be made better. It seems logical – but does it work?

That is the very good question that a team of UK based researchers asked recently (Henderson et al., 2025).

What did they do?

Each maternity service in the UK is inspected by the Care Quality Commission and given a rating of “outstanding”, “good”, “requires improvement” or “inadequate”. Routinely collected outcome data for women with a singleton pregnancy who gave birth at 37 or more weeks of gestation* and their babies was collated. The study specifically looked at severe maternal morbidity, severe perineal trauma for women; a composite adverse outcome measure for babies plus Apgar score of less than seven at five minutes of age, stillbirth, and neonatal death to 28 days; and also labour onset and intrapartum caesarean section as a measure of obstetric intervention. Statistical adjustments were made for women’s age, ethnicity, socioeconomic deprivation, parity, prior caesarean sections, smoking, BMI, and the presence of diabetes or hypertension – thereby reducing the possibility that different outcomes were due to the service providing care for different populations of women.

What did they find?

In total, 501,719 women were included, with 8% giving birth in services rated as “outstanding”, 71% rated as “good” and the remaining 21% in units with a “requires improvement” or “inadequate” rating. For 67% of the services, quality inspections had taken place in the prior 12 months. Services rated as “requires improvement” or “inadequate” were more likely to serve white and younger women, smokers, and those from more deprived socioeconomic areas.

There were no differences in the proportion of women who experienced a poor outcome or severe perineal trauma across the different service rating categories. There were also no differences in the proportions of babies who died, had a low Apgar, or another poor outcome. Intervention rates were also consistent across all service rating categories – with caesarean section rates in labour of around 16% and non-spontaneous birth around 48%.

What to make of this…

Maternity services categorised as “requiring improvement” or “inadequate” achieved the same kind of outcomes for women and babies, with the same levels of intervention, as those categorised as “outstanding” or “good”. This might be reassuring for women and families caught in the UKs “postcode lottery” where the only maternity service(s) available to them are those in less favourable categories. However, it calls into question whether the things that are being measured during inspections that result in the assignment of the appropriate category are not themselves linked to safe and effective care provision.

As the authors of this study noted, this is not the first time that researchers have demonstrated no clear link between outcomes of interest and quality of care ratings in the UK. Australian academics have raised similar concerns about ineffective hospital accreditation processes here (Gamble et al., 2021) – pointing out that one known and proven standard for achieving better outcomes (midwifery continuity of carer for all women who want this) was not something hospitals were being measured against.

While I’m not familiar with the precise details of what is assessed by the Care Quality Commission, I suspect they are similar to those used here in Australia for hospital accreditation. There is a very strong focus on the use of risk assessment, mitigation, and management strategies that result in standardised rather than individualised approaches to cares. There is evidence to suggests that many such risk based approaches to maternity care provision are simply ineffective (e.g., Haws et al., 2009). This includes the widespread, yet not evidence-based, practice of splitting women into “low” and “high” risk categories and assigning different approaches to fetal heart rate monitoring according to the category used.

It seems to me that what is needed is a radical rethink about whether quality and risk improvement strategies that have been (more or less) effective in manufacturing and business spheres are fit-for-purpose when applied to health and maternity care.

*While I understand the choice of this measure as is makes it easier for comparisons with other similar research, I do worry that researchers rarely repeat their analyses for women with multiple and / or preterm births. Does this reflect a lack of concern that quality of care is relevant for this group of women too?

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References

Gamble, J., Browne, J., & Creedy, D. K. (2021, Mar). Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review. Women & Birth, 34(2), 113-121. https://doi.org/10.1016/j.wombi.2020.01.016 
Haws, R. A., Yakoob, M., Soomro, T., Menezes, E. V., Darmstadt, G. L., & Bhutta, Z. A. (2009). Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy and Childbirth, 9(Suppl 1), S5-48. https://doi.org/10.1186/1471-2393-9-S1-S5 
Henderson, I., Gurol-Urganci, I., Frémeaux, A., Morelli, A., Webster, K., Karia, A.M., Carroll, F., Dunn, G., Harris, J., Oddie, S., Khalil, A. and van der Meulen, J. (2025). A comparison of regulatory maternity unit ratings with clinical outcomes and practice measures: An observational study using routinely collected data. BJOG, 132: 1285-1296. https://doi.org/10.1111/1471-0528.18188

• If in doubt, do more of the same?
• Does CTG monitoring during labour save lives?

Categories: CTG, New research, Stillbirth

Tags: accreditation, Care Quality Commission, Quality improvement, risk management, safety, UK