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It forms part of a broad programme of work to receive assurance on the safety of maternity and neonatal services for NI. It resulted from two related developments:

1. A request from the Coroner that the Department of Health NI investigates her concerns following an inquest into the death of a baby that raised questions about care in Freestanding midwifery led units, and 
2. Several other reports, both local and national, concern the safety of services for pregnant women, new mothers, and babies

The RCPCH supported the development of this report through the established Advisory Group, and it’s good to see the full publication. Professor Renfrew has identified 32 evidence-informed recommendations with operational details for each. These recommendations aim to address the system-level issues that must be addressed to enable safe, equitable, quality care and services for women, babies and families. 

Background

The report identified a range of issues at the population and operational levels. Overall, a larger proportion of total births are to women living in the most deprived quintiles in NI. Alarmingly, perinatal mortality rates presented for 2021 exceed the UK average and are the highest amongst all UK countries, this is coupled with an increase in all stillbirths in NI to 4.09 per 1000 total births. Notably, caesarean birth (both elective and emergency) represented 40.1% of all births in 2023.

The report identified substantial workload pressures across the maternity continuum of care. In terms of neonatology and paediatrics, some examples included: 

• Vacancies in senior posts leave some smaller units particularly vulnerable, with only a small number of specialist neonatologists.
• While decisions about induction are made by obstetricians, there are substantive consequences for paediatric services; neonatologists and paediatricians are managing complications including more babies requiring resuscitation and having respiratory distress syndrome. This concern included a lack of appropriate forums in which strategic discussion could take place with obstetricians.
• Increased attendance at emergency caesarean births as these babies have more complex needs at birth. 
• Concern that care was focussed on treatment rather than early intervention and prevention, with a lack of strategic planning at the population level in relation to infants, children, and young people.
• A lack of understanding at the management level of the interdependencies between midwifery, obstetrics and paediatrics/neonatology, and that general paediatrics plays a critical role in maternity services. 
• PROMPT training for emergencies included obstetricians, anaesthetists and midwives but not neonatologists/paediatricians or ambulance staff.
• Although overall rates of admission to neonatal units are falling, more babies are presenting following difficult births, especially caesarean births. 
• Rates of term admissions to neonatal units are rising, especially among babies born at 37-38 weeks. 
• A critical need for safe quality care in out-of-labour ward settings, well integrated into the maternity and neonatal system and adequately resourced, and with efficient emergency transport. 
• A mismatch between current maternity service provision and staffing levels; the increasing complexity and increased intervention levels require more, and more focused, obstetric, neonatal/paediatric, and midwifery input.
• An important specific need will be to support general paediatricians to develop and maintain airway skills for neonatal emergencies, to ensure safe emergency care in the DGHs.

In terms of requirements to enable safe out-of-labour ward deliveries, the report sets out that the on-call consultant obstetrician and neonatologist should know that they may be asked to provide advice 24/7 for the whole HSC Trust including midwifery units and home births. They should be familiar with the out-of-labour ward settings and the equipment available. Moreover, a Training Needs Assessment should be conducted to assess the readiness of all staff including neonatologists and paediatricians and should have some experience of work in out-of-labour ward settings. The RCPCH urges careful contemplation in the commissioning and placement of paediatric staff, which must be done strategically to protect all related infant and children’s services as well as the workforce that supports them.

Recommendations

RCPCH believes that there are a number of core recommendations which should be taken forward without delay. 

We also hope that the development of a more integrated and networked approach allows for adequate linkage with the Child Health Partnership to enable safe, quality planning and continuity of care at the strategic level. The RCPCH acknowledges the devastating detail within this timely report and would echo the need for the publication of the Independent Review into Child Death report and recommend exhausting every route to include Northern Ireland in the NNAP. 

The full list of recommendations may be found at the link at the bottom of the page.

1. A Maternal and Newborn Strategy for NI should be developed and implemented. Its implementation should be fully costed, appropriately funded, monitored and evaluated.
2. A funded interdisciplinary regional Maternal and Newborn Partnership should be established to lead the development, implementation, and oversight of evidence-based, safe, quality maternity and newborn care and services. The Partnership should have adequate funding and involvement from midwifery, obstetrics, neonatology/paediatrics, neonatal nursing, and service user advocacy.
3. Fully funded evidence-based interdisciplinary regional standards for care and services should be developed and implemented. These should be used to inform commissioning, governance, policies and protocols, monitoring and review of services.
4. Education commissioning and planning should recognise the critical need for interdisciplinary education and training for emergencies for all relevant staff, and fund this appropriately, including equipment and space for simulation. 
5. Approaches to the detection and escalation of safety concerns and ensuring appropriate timely responses must be regionally led and adequately resourced.
6. A review and revision of governance arrangements for maternity and newborn services in all HSC Trusts is needed, informed by the findings of this report.
7. Important deficits in care for women and babies resulting in adverse outcomes must be addressed. They should be examined to understand the root causes.
8. Audit is an essential tool to alert the system to impact and unintended consequences of practices, and to inform and drive service improvement. All HSC Trusts should participate in and respond to regional and national audits of priority topics.

Dr Rory Sweeney, Deputy Officer for Ireland and Enabling Safe, Quality Midwifery Services and Care Advisory Group member said:

RCPCH welcomes Professor Renfrew’s Report which represents a very thorough review of midwifery and wider maternity services in NI. It is devastating to hear the experiences of women, babies and families who have suffered pain, harm and long-lasting distress. The profound effect on staff who have been unable to consistently provide the level of care they know is needed leads to stress, sickness and increased workforce pressures, worsening conditions which have already been described as unsafe and unsupported.

The RCPCH represents paediatric and neonatal doctors across NI and supports the findings and recommendations contained in this report. However, delivery on these recommendations needs to be achieved through proper funding and service planning as the already stretched workforce will be unable to take on additional burden without adequate support. RCPCH has been highlighting the lack of funding towards services for babies, children and young people as well as the paediatric workforce for some time, most recently and starkly demonstrated by the "Worried and Waiting" report into paediatric waiting times published in April 2024.

Medical cover for maternity services outside of the tertiary maternity hospital is provided by general paediatric teams. Paediatric teams are required to be available for emergencies across multiple different areas of DGHs including the emergency department, paediatric inpatient wards, neonatal intensive care, labour ward and postnatal wards. Therefore, we must echo caution around recommendations relating to additional medical support for out of labour-ward deliveries. The Department of Health must carefully consider the impact on the paediatric workforce of providing support for out of -labour ward deliveries and balance within the broader system configuration and funding models against a backdrop of patient safety. Professor Renfrew clarified that appropriate funding, leadership, and governance for out of-hospital settings is a core requirement for community and alongside midwifery units and home births.

Increasing awareness and skills through interdisciplinary education and training would be an excellent first step to encourage better team working and understanding amongst staff. This is crucial if improved outcomes are to be achieved. However, due consideration is required to ensure neonatal and paediatric staff are appropriately trained, experienced and supported to deliver the trajectory of this work as it develops and safe staffing levels are maintained in all services at the same time.