Jack Hamer (Birmingham Women’s and Children’s NHS Foundation Trust), Jane Whitehurst (Public Contributor), Fiona Cross-Sudworth (University of Birmingham), Sara Kenyon (University of Birmingham)
Background
Induction of Labour (IOL) is principally undertaken when the risks of maternal and/or fetal morbidity and mortality are greater when a pregnancy is prolonged[i] [ii]. We have seen a rise globally over recent decades in the rates of women undergoing IOL, particularly within high-income countries[iii],[iv]. Within the United Kingdom (UK), the rates of women experiencing IOL were approximately[v]
· 20% in 2009-10
· 29% in 2016-17
· 33% in 2021-22
The increased rates add substantial pressure on patient flow in UK maternity units. These, combined with severe shortages in midwifery and clinical staffing, have led many maternity service leaders to have concerns over current IOL practices[vi]. This has also been highlighted within the most recent Ockenden report, whereby current IOL pathways have impacted on patient safety and care quality[vii].
Information on local policies and practices for IOL was lacking until the recently published UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) survey[viii]. This study, led by the Maternity Theme of the Applied Research Collaborative West Midlands (ARC WM), found that there is substantial variation in induction rates, processes and policies across UK maternity service. Delays were commonly reported as a cause of safety concerns impacting on women’s experience of care. Induction was an area of concern for nearly half responders and many reported induction-focused quality improvement work.
Development of this report
An ‘Improving IOL’ session was held at the British Intrapartum Care Society (BICS) meeting in September 2022. From this session it was clear that many UK maternity units were already undertaking local quality improvement (QI) work to optimise current shortcomings within IOL care pathways.
A subsequent national workshop was organised by the maternity theme of the ARC WM to facilitate further collaboration, aiming to share local QI work that tackled common barriers faced within the IOL journey. Maternity units nationwide were contacted to submit their current quality improvement work for inclusion in this national workshop. In person participants were selected based on area (England, Wales, Scotland and Northern Ireland), region, size, induction rate and the QI focus. ARCWM hosted the collaborative workshop in January 2023, with representatives from:
· Royal College of Obstetricians and Gynaecologists (RCOG)
· Royal College of Midwifery (RCM)
· Regional Obstetricians
· BICS alongside
· Clinicians from 40 maternity units from across the UK
Participants consisted of academics, obstetricians, midwives and midwifery leads. Patient representatives also joined the group to share personal experiences and marry local quality improvement work with women’s views and expectations.
The quality improvement work which was submitted by all 40 trusts who attended was divided in to five key themes:
Quality improvement work from all the units was discussed in a table-top discussion format in the morning, with the projects felt to be most useful being shared with the entire group in the afternoon. Agreement was sought at the meeting to produce a document reflecting QI work from across the UK that provided improvement projects relevant to all 5 themes. Within the summaries of these projects are key documents which can be shared, but their original developers must be acknowledged.
Route to Impact
The aim of this document is to share local QI projects and highlight both barriers and facilitators within the IOL process. It provides a snapshot of the excellent ideas and QI work being undertaken across the UK with the details of who to contact to further explore any particular idea. It is anticipated that maternity units will use this document to consider what might be relevant to their circumstances and provide helpful tips to support the use of QI in the local implementation. Each of the chapters contains a summary of the projects selected by those who attended, with links to materials and the name and email of who to contact for further information.
Note: If you are intending to use any of these materials, please acknowledge the Trust/Health board who have developed the original ideas e.g. ‘This work was originally described by XXXX Trust/ Health Board’.
The increasing role of Quality Improvement and its limitations
Quality improvement involves the use of a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement within a health care setting.
In the history of the NHS, there has never been a greater focus on improving the quality of health services and many Trusts reported in a recent survey8 that IOL had been the focus of quality improvement projects. Improving quality is about making health care safe, effective, women-centred, timely, efficient and equitable. It’s about giving the people closest to problems affecting care quality, the time, permission, skills and resources they need to solve them.
Quality improvement draws on a wide variety of approaches and methods[ix], although many share underlying principles, including:
• identifying the quality issue
• understanding the problem from a range of perspectives, with a particular emphasis on using and interpreting data
• developing a theory of change
• identifying and testing potential solutions; using data to measure the impact of each test and gradually refining the solution to the problem
• implementing the solution and ensuring that the intervention is sustained and adapted as needed as part of standard practice.
The successful implementation of the intervention will depend on the context of the system or the organisation making the change and requires careful consideration. It is important to create the right conditions for improvement and these include the backing of senior leaders, supportive and engaged colleagues and service users, and access to appropriate resources and skills.
Problems over the effective use of QI methods has been identified and are related to a number of issues[x]:
· Many projects are time-limited and small scale led by professionals without the expertise, power or resources to make the changes.
· Expectations of the results from projects can be over ambitious. Often not enough attention is given to rigorous evaluation of the impact and of the need to share both successes and failures- thus potentially meaning unintended consequences are not identified.
· Much improvement work is undertaken locally, thus missing the opportunity for shared learning and solutions regionally and/or nationally.
Many of the professionals involved in the QI projects within this report will recognise the issues above and many of the projects have not been rigorously evaluated. However, despite these limitations, the ideas generated do provide potential solutions to common problems within the IOL pathway that should be shared. This reflects the reality of maternity services currently and other Trusts looking to utilise any of these ideas should be encouraged to use robust methods and share the outcome both locally and nationally.
Over the last five years there are a number of changes which many units who attended have introduced and found helpful. Some of these appear in the projects described within this publication and others are listed below- many of these do not require QI and are relatively easy to implement:
· Offering women the option to start IOL 7 days a week
· Senior midwifery leadership and Consultant obstetric oversight
· Improving information for women
The workshop also identified other issues around IOL.
· National guidance on IOL (from NICE or RCOG) was not available in one document and those present thought it would be helpful to have the guidance pulled together.
· Clinicians from different maternity units reported lack of adherence to NICE criteria for IOL, several clinicians reported variation in criteria leading to offering IOL for a plethora of reasons not included in evidence-based national guidance. This issue could be addressed by the approach taken by the Midlands in developing a framework as described in Chapter 7.
Those present at the workshop also identified variation in the following issues which would benefit from a national standardised approach. These included:
· Definition of what is termed delay
· Frequency of maternal and fetal observations
· Risk rating used to prioritise women- local examples are given in Chapter 4,5 and 6
[i] Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N et al. A systematic scoping review of clinical indications for IOL. PLoS One. 2020; 15: e0228196.
[ii] World Health Organization (2022). WHO recommendations on IOL, at or beyond term. World Health Organization.
[iii] Martin J.A, Hamilton B.E, Osterman M.J.K, Driscoll A.K, Drake P. Births: Final Data for 2017. Natl Vital Stat Rep. 2018; 67: 1-50.
[iv] Nippita T.A, Trevena J.A, Patterson J.A, Ford J.B, Morris J.M, Roberts C.L. Variation in hospital rates of IOL: a population-based record linkage study. BMJ Open. 2015; 5: e008755.
[v] NHS Maternity Statistics, England - 2021-22 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2021-22 (accessed 03.04.2023)
[vi] Wilkinson E. Implementing Ockenden: What next for NHS maternity services? BMJ. 2022; 377: o1120.
[vii] Independent Maternity Review. Ockenden report - Final: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsburys and Telford Hospital NHS Trust 2022 [Available from: https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf (accessed 15.03.2023).
[viii] Taylor B, Cross-Sudworth F, Rimmer M, Quinn L, Morris R.K, Johnston T et al. IOL care in the UK: a cross-sectional survey of maternity units. (2023), Abstracts of the 2022 BMFMS meeting. BJOG: Int J Obstet Gy, 130: 4-129. https://doi.org/10.1111/1471-0528.17419.
[ix] The Health Foundation https://www.health.org.uk/publications/quality-improvement-made-simple (accessed 03.04.2023)
[x] Dixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hosp J. 2016 Oct;3(3):191-194. doi: 10.7861/futurehosp.3-3-191. PMID: 31098223; PMCID: PMC6465806.
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