New research by the Sands and Tommy's Joint Policy Unit has found concerning levels of variation across the advice for women and birthing people given by NHS trusts in England on contacting maternity triage in early labour.
The Joint Policy Unit's Ceilidh Harris Al Amoodi explains why this is an area of concern for the safety of maternity services, with delays preventing people receiving the appropriate care and support
Issues with maternity triage have come up repeatedly in national reviews and reports into individual maternity services. As the gateway to the service, it’s the first point of call for women and birthing people when they have concerns during their pregnancies and need help and support. However, guidance on how and when to contact triage is not clear and consistent between services.
It can be difficult for women and birthing people to know when labour has started and when they should be contacting their hospital. Research has shown increased levels of worry around labour and birth for first-time parents and those from minoritised ethnic backgrounds. Other studies show that generally, women feel uncertain during early labour and seek reassurance and permission to go to hospital.
At the same time, delays in admitting women and birthing people to hospital have prevented them from receiving the care and support they need. In some cases, this has led to the worst outcomes. The Ockenden review of the Shrewsbury and Telford Hospital Trust’s maternity services highlighted three cases where women had telephoned maternity triage in early labour with concerns, including their waters breaking and bleeding, and were not invited in to hospital for assessment or transferred to the appropriate unit . All three babies died in their first 28 days of life.
The CQC’s national maternity inspection programme, which aims to support learning and improvement across maternity care nationally, has already identified maternity triage as a key emerging theme.
In the context of these issues and uncertainty surrounding early labour, we reviewed 35 sources of information found on NHS Trust websites under their section on guidance for contacting triage in early labour.
We included five Trusts from each region in England to ensure a geographical spread. We assessed consistency in advice provided on when to contact maternity triage, focussing on six main topics: bleeding, waters breaking, reduced fetal movements, pain and pain relief, feeling unwell and timing and length of contractions .
Our analysis found concerning levels of variation across these topics. Less than half of Trusts included experiencing pain and needing pain relief as a reason to contact maternity triage in early labour.
It’s unclear why some Trusts would include this information and others wouldn’t. Not including needing pain relief as a reason to call triage can prevent people from feeling able to ask for and access the support they need.
Although recognised as a warning sign in labour, five Trusts did not include bleeding as a reason to contact maternity triage. Amongst the 30 that did, there was variation in how this was described. It was most often described as experiencing ‘any bleeding/blood loss’, however four Trusts said to call if the bleeding was ‘bright red’ or ‘fresh’, and three said if the bleeding was ‘more than/different to a bloody show’. For people experiencing any bleeding in labour, this could add another layer of confusion and worry about whether they are allowed to contact their hospital for support.
There was a large variation in information around the length and timing of contractions. It was most often described as being advised to call when experiencing ‘regular’ or ‘regular and painful contractions’, however there were a number of Trusts that gave specific timings and lengths of contractions which varied significantly. As with variation in the other topics, there is no clear reason for this to differ amongst services.
We also looked at language encouraging people to stay at home in early labour. Just under half of the Trust websites encouraged women to stay at home if they were not experiencing other symptoms discussed above. This was usually due to home being seen as a more comfortable environment, assuming that home would be a safer place to be in early labour than hospital. This is contrasted by research showing that some women consider hospital to be safer as it provides reassurance for them during this time .
It is often not clear what the evidence behind phrases such as "staying at home is important to help you relax. Feeling safe and secure will help your body produce oxytocin”. These appear to be based on assumptions about what an individual’s home environment is like, and what their preferences are when in labour.
It is crucial that all advice is centred on evidence and women’s needs and preferences. It should encourage them to contact triage when they need to, rather than preventing them from raising concerns for fear of being sent home.
Our research raises serious concerns about the consistency of advice being given to women and birthing people, and the use of language encouraging them to stay at home without a clear evidence base.
It is vital that maternity services provide consistent guidance around contacting triage, as well as clear information to women and birthing people about their rights in accessing maternity care, and the services they are entitled to.
To make progress, development of national guidance (such as NICE guidelines) in this area should be considered, as well as the development of a consensus to ensure messages are evidence-based and consistent. Our research focused on advice and information available to women and birthing people when contacting triage, but there is a need to look at experiences across the whole pathway of triage.
Read Tommy's response to the research.
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