Failures in childbirth care.

The study, first published in 2003, looks at the root causes of adverse events and near misses in obstetrics at seven hospital maternity units by interviewing 93 members of staff, identifying the areas of mismanagement in each case and thematically analysing them.

Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives.

OBJECTIVE: To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives. DESIGN: Prospective semistructured observational study. SETTING: Labour wards of seven maternity units in the north west of England. PARTICIPANTS: All midwives working on the labour ward during the observation period in 2000. MAIN OUTCOME MEASURE: "Latent failures" within the system relating to midwifery staffing levels, deployment, and training or updating opportunities. RESULTS: Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and "near misses" were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence. CONCLUSION: Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.