Transformation of Acute Maternity Services: Six-month review

Introduction

Safety must be the thread that runs through maternity services; however, what constitutes a safe service is far more complex than a healthy woman and a healthy baby, encompassing everything from safe staffing levels, experience, training and wellbeing of staff, to the interdependencies and the organisational and service culture.

We want everyone across the Northern Trust area to benefit from safe, effective and high quality maternity services and this was the driving force for the recent transformation of our acute maternity services. To ensure sustainability and excellent outcomes, our services needed to adapt and develop to meet guidelines and changing population needs.

To achieve this, we developed clinically deliverable options for public consultation to address the challenges we faced in acute maternity services. The options were shaped by the staff who deliver our acute maternity services, including our Obstetricians and Midwives who were confident that they gave us the best opportunity to meet the challenges and provide the best quality care for years to come.

Following a 14-week public consultation, the Board of the Northern Trust, at its public meeting in March 2023, approved a recommendation that all inpatient care and hospital births should take place at Antrim Area Hospital. Causeway Hospital would retain antenatal and postnatal care, which are recognised as critical local services for women.

That recommendation of the Trust Board, was approved by Peter May, the Permanent Secretary of the Department of Health (DoH) on 8 June 2023.

The new model came into effect operationally on the 17July, 2023 when all maternity inpatient services and births moved to Antrim Area Hospital.

The DoH stipulated that given the significant service change, the Trust should put monitoring arrangements in place to provide assurances that the consolidation of services had proceeded as planned and carry out a robust six month review and evaluation of the new maternity services. This included a review of:

• the expanded capacity within Antrim Area Hospital and an assessment as to how the service in Antrim Area Hospital is dealing with the increased number of births;
• the number of babies born before arrival (BBAs) in Antrim Area Hospital from Causeway Hospital catchment postcodes.
• any instances where women have presented in labour at Causeway Hospital after the service change; and
• intervention rates for instrumental deliveries and caesarean sections.

This evaluation spans activity from 17 July 2023 to 18 January 2024 and focuses on the above considerations, as specified by DoH.

Expanded capacity within Antrim and how the service in Antrim is dealing with the increased number of births.

Capacity

Estates work to provide additional capacity within Antrim Maternity Unit has been completed and is fully operational. Core birthing room capacity has been increased from seven to eight rooms, with the option to use two further single rooms for birthing during times of increased activity.

Provision of two additional clinical rooms has enabled the service to enhance and streamline ambulatory (same day care) pathways. Previously the Fetal Maternal Assessment Unit provided both scheduled and unscheduled care 24/7 for pregnant and postnatal women. Due to this enhanced capacity, we have been able to separate the scheduled and unscheduled ambulatory activity to provide a Day Obstetric Unit (DOU) with scheduled appointments including caesarean section pre-assessment and an Emergency Obstetric Unit (EOU) for unscheduled attendances 24/7.

Unscheduled ambulatory activity moved from Causeway to Antrim Maternity as part of the reconfiguration of our maternity services and table 1 shows that in August 2023 (post service change) unscheduled activity was similar to the previous year. However, there was a 25% increase in telephone calls (853 vs 682).

	Total Recorded Daily Attendance	Telephone Calls (Recorded)	Scheduled Work (Appointments)		Total Recorded Daily Attendance	Telephone Calls (Recorded)	Scheduled Work (Appointments)
Jun- 22	509	604	118	Jun- 23	518	621	150
Jul- 22	578	675	143	Jul- 23	596	852	160
Aug- 22	634	682	186	Aug- 23	652	853	153

Table 1. Comparison of unscheduled and scheduled ambulatory activity and telephone contacts in 2022 and 2023

As part of the service model change, a number of staff chose to be redeployed from Causeway to Antrim as their first preference. This has enabled the service to safely staff the separate ambulatory pathways which are now in two areas, as well as manage any additional activity and telephone calls.

The data is recorded to reflect the new pathways and the six month activity following the reform is detailed within table 2.

	Emergency Obstetric Unit (EOU) Unscheduled Attendances	Telephone calls (Recorded)	Day Obstetric Unit (DOU) Scheduled appointments	C/section prep
Jul-23	596	852	160	28
Aug-23	652	853	153	49
Sep-23	584	840	107	49
Oct-23	632	781	108	48
Nov-23	577	745	113	50
Dec-23	540	796	90	37
Jan 1-18 2024	307	177	52	29

Table 2. Six month activity of unscheduled and scheduled ambulatory activity and telephone contacts

Additional capacity has also been provided in main theatres to enable maternity services to run an elective caesarean section list twice weekly, increasing to three sessions per week from October 2023 (although currently paused due to a temporary Consultant vacancy). This increased birthing room and recovery space capacity within the Delivery (Birthing) Suite provides an improved pathway and experience for women undergoing elective caesarean sections.

The service is managing the increased number of births as the result of the reconfiguration by utilising the Capacity and Escalation Plan for maternity services during periods of peak activity. This plan makes provision for increasing birthing bed capacity from eight to 10 birthing beds and flexing up inpatient beds from 29 to 35 beds if required.

Tables 3 and 4 provide an illustration of the capacity versus demand for both the Birthing Suite and the inpatient ward, using the daily average bed occupancy measured over six hourly intervals.

This provides a level of assurance that Antrim has sufficient capacity to consolidate inpatients and births for the short to medium term, based on birth projections.

Table 3. Antrim Delivery Suite daily birthing bed occupancy Jul 23 to Jan 24

Table 4. Antrim inpatient daily ward bed occupancy Jul 23 to Jan 24

A Midwifery Co-ordinator role has been created to ensure the efficient flow of activity through the unit and will take appropriate steps to ensure sufficient capacity is available for a safe and positive experience for women, babies and their families. A daily huddle is held each morning to review activity, acuity and staffing levels within Antrim Maternity Unit and a situation report is sent to the Senior Midwifery Team and Director of Nursing & Midwifery.

The Maternity service is complex and dynamic, with conditions that can change very quickly. In order to ensure we can respond appropriately, we use tools to assess the situation as concisely and accurately as possible. The Trust has recently procured the Birthrate Plus acuity tool which provides objective interpretation and intelligence around clinical activity and acuity. This is a nationally accredited tool used by the majority of NHS England maternity units. This allows Labour Ward Coordinators to present their acuity, activity and challenges in real time, whilst providing an easy to use audit tool for senior managers. Alongside clinical and management actions, this will allow us to better support our staff to meet the needs of our service, and crucially our service users. The maternity service has been piloting the use of the new software alongside the daily situation report which is a live assessment of acuity and staffing levels as determined by the Midwifery Co-ordinator at the huddles.

The table below depicts the number of occasions we have assessed demand and capacity issues as at amber or red escalation due to a lack of bed capacity and/ or insufficient staffing levels.

Since the service change on 17 July 2023 to 18 January 2024, there has been an amber status on 23 occasions and a red status on 1 occasion.

Escalations from 1st August 2023* up to 18 January 2024
Lack of bed/ birthing suite capacity	10	1
Increased workload (activity/ acuity) vs staffing	13	0

Table 5. Amber or red escalations in Antrim Maternity Unit over past six months

An amber escalation is a fairly regular state for any busy maternity unit due to the largely unpredictable nature of spontaneous labour and birth. Each escalation triggers four-hourly multidisciplinary huddles allowing escalation to return to green within a few hours as staff focus on discharges to create bed capacity or additional staff have been redeployed from other areas, if required.

The one red escalation episode was a very brief period of acuity as the Birthing Suite temporarily had no core birthing rooms available (as six were in use and two requiring cleaning) and staff were immediately identified and redirected. The situation was quickly de-escalated and returned to green within the hour. As a red escalation is a trigger to submit an incident (DATIX) report, a Datix form was completed however, there were no associated safety issues or impacts noted during this period.

Birthing data

As an overall assessment of how the Antrim site has dealt with the increased number of births, the following data reflects that it has been a busy period as anticipated. However activity was managed safely and effectively via the prospective assessment of capacity and demand and effective multi-disciplinary working.

2022 births				2023 births
	CAU	AAH	TOTAL	ANTRIM
July	71	241	312	July	323 (33 in CAUS)
August	74	241	315	August	321
September	86	277	363	September	286
October	83	252	335	October	308
November	71	227	298	November	261
December	69	237	306	December	284

Table 6. Number of births for six months in 2022 and 2023

Consistent with the regional birth rate, the overall birth rate has fallen in the Northern Trust over the past four years. Health Intelligence have not been able to access the South Eastern Health and Social Care Trust data due to their recent Encompass implementation so the full dataset of regional births in 2023 is not yet available. However provisional data suggests that a decrease in births in 2023 is also being reported in all five HSC Trusts. Local information within the Northern Trust reflects the total number of births has decreased to 3,484 in 2023 (see table 7).

Table 7. NHSCT annual births 2019-2023

Homebirth data

Women can choose to give birth at home with the support of the community midwifery teams or the Continuity of Midwifery Carer (Lotus) team. Activity in relation to homebirth requests and homebirths completed are depicted below and reflects an increasing trajectory over the past five years.

Table 8. NHSCT Homebirth Data 2019-2023

In relation to homebirths requests and homebirths completed by locality, the data below reflects homebirth requests increased in the Mid-Ulster area and Causeway area in 2023 (as Lotus team homebirth requests are also based within the Causeway locality). However, completed homebirths in Causeway (including Lotus team births) are less than the previous two years.

Table 9. NHSCT Homebirth requests by location 2019-2023

Table 10. NHSCT Completed Homebirths by location 2019-2023

Impacts on other Health & Social Care Trusts

It is important to understand if the reconfiguration of the Northern Trust’s acute maternity services has had any significant impact on other Trusts in relation to increased activity. As women have the choice of where in Northern Ireland they would like to access their maternity care, historically there have been women who live in the Northern Trust near the borders choosing to birth in other Trusts.

The table below shows the place of birth for women resident in the Northern Trust area, from the date of the service change to end of January 2024.

Table 11: Women resident in NHSCT, by place of birth, 17 July – 31 January each year

Table 12 shows number of births by selected place of birth and Trust of residence 17 July to 31 January for past three years.

All women giving birth in Northern Ireland, by selected place of birth and Trust of residence, 17 July – 31 January each year
		Date of birth
Place of birth	Trust of residence	17 Jul 2021 – 31 Jan 2022	17 Jul 2022 – 31 Jan 2023	17 Jul 2023 – 31 Jan 2024
Antrim	Northern HSCT	1,565	1,502	1,829
	Western HSCT	7	4	<5
	All other Trusts	36	35	21
	Trust not known	1	0	<5
Antrim Total		1,609	1,541	1,853
Causeway	Northern HSCT	495	469	0
	Western HSCT	7	<5	0
	All other Trusts	0	<5	0
	Trust not known	0	0	0
Causeway Total		502	476	0
Altnagelvin/SWAH	Northern HSCT	35	27	106
	Western HSCT	1,895	1,719	1,690
	All other Trusts	50	41	34
	Trust not known	28	21	27
Altnagelvin/SWAH Total		2,008	1,808	1,857

Table 12: All women giving birth in Northern Ireland, by selected place of birth and Trust of residence, 17 July – 31

To assist with projection of approximate future activity for the next six months, table 13 shows the number of women resident in Northern Trust who have booked for care by hospital of choice between 17 July and 31 January and for past three years.

Table 13: Bookings by women resident in NHSCT, by intended place of birth recorded at antenatal booking appointment, 17 July – 31 January each year

Table 14 focuses on the NHSCT and WHSCT bookings for women and their choice of hospital for past six months.

All bookings for antenatal care in Northern Ireland, by selected intended place of birth and Trust of residence, 17 July – 31 January each year
		Number of bookings by date of antenatal booking appointment
Place of birth	Trust of residence	17 Jul 2021 – 31 Jan 2022	17 Jul 2022 – 31 Jan 2023	17 Jul 2023 – 31 Jan 2024
Antrim	Northern HSCT	1,565	1,549	1,765
	Western HSCT	8	<5	<10
	All other Trusts	36	45	21
	Trust not known	5	<5	<5
Antrim Total		1,614	1,600	1,799
Causeway	Northern HSCT	546	491	0
	Western HSCT	12	<10	0
	All other Trusts	<5	0	0
	Trust not known	<5	<5	0
Causeway Total		563	499	0
Altnagelvin/SWAH	Northern HSCT	31	32	39
	Western HSCT	1,920	1,859	1,855
	All other Trusts	41	35	33
	Trust not known	39	19	26
Altnagelvin/SWAH Total		2,031	1,945	1,953
NHSCT hospital (hosp not known)	Northern HSCT	56	42	57
	Western HSCT	1	0	2
	All other Trusts	0	0	0
	Trust not known	0	0	0
NHSCT Hospital Total		57	42	59

Table 14. All bookings for antenatal care in Northern Ireland, by selected intended place of birth and Trust of residence, 17 July – 31 January each year

These figures indicate that the majority of births that would previously have taken place in Causeway during the six months after the service reconfiguration moved to the Antrim site, with a smaller impact on Altnagelvin Hospital. The booking data may suggest that any impact on Altnagelvin will reduce in the coming months, and this will be kept under review.

Delays in care

During times of increased activity within any maternity unit, it is part of normal operational management for scheduled births to be delayed if appropriate and safe to do so, to ensure safety and ability to provide one to one midwifery care for women in labour (as this is the minimum standard). Such ‘smoothing’ activity also entails occasionally bringing the date/time for an elective caesarean section or induction of labour (IOL) forward.

Table 15 shows the number of occasions when scheduled induction of labour (IOL) and elective caesarean sections have been delayed or brought forward for reasons related to capacity, demand and staffing levels over the six month period.

IOL Delays	July	August	September	October	November	December	January
Delay ≤ 12 Hours	14	37	23	26	7	5	8
Delay within 24 Hours	1	6	8	5	0	7	7
Delay over 24 Hours	0	0	0	3	3	0	0
Brought Forward	0	2	2	5	8	6	5
C Section Delays	July	August	September	October	November	December	January
Delay ≤ 12 Hours	0	1	0	2	1	1	0
Delay within 24 Hours	0	1	0	1	0	0	0
Delay over 24 Hours	0	8	4	0	1	2	2 STRIKE
Brought Forward	0	0	1	0	2	1	0

Table 15. Delays in scheduled work over the six month period

2. Born Before Arrivals (BBAs)

Since the consolidation of inpatient maternity services and births in Antrim Area Hospital, six women (accounting for seven babies as there was one set of twins) have experienced birth before arrival to hospital. Three women were within the Causeway locality and four resided closer to Antrim. There has been no significant increase in the average number of BBAs, which is approximately one per month.

Table 16. Number of babies born before arrival to hospital 2021 to 2023

3. Instances where women have presented in labour at Causeway Hospital

Since the maternity service reform, no women have presented in labour at Causeway Hospital. Seven pregnant woman (not in labour) have attended Causeway Emergency Department and appropriate pathways have been followed to ensure safe and timely care.

4. Intervention rates for instrumental deliveries and caesarean sections

The table below shows the intervention rates of instrumental birth and caesarean sections in NHSCT for 2023 and shows that there has been no significant increase since the service change.

Table 17. NHSCT intervention rates 2023

5. Enhancements to Service

Additional complex clinics in Causeway Maternity Hub

We are committed to enhancing the Causeway Maternity Hub by improving local access to antenatal and postnatal services for women within the Causeway locality. Complex antenatal clinics have been moved to Causeway so as to mitigate the distance women have historically been asked to travel to receive this care. We are committed to continuously reviewing this care provision and hope to expand the provision of further complex antenatal care within the Causeway Maternity Hub in the future. Complex clinics established in September 2023 are;

• 3rd trimester Midwifery Led Scanning clinic
• WTHP (Weigh to a Healthy Pregnancy) for women with increased BMI in pregnancy

The development of local services in the Causeway Maternity Hub for women with gestational diabetes is underway.

6. Patient Experience Feedback

The Northern Trust remains committed to ensuring that patient experience is firmly embedded into our review process.

There has been one formal complaint in relation to the maternity reform and two comments received from mothers indicating they were unhappy with the closure of Causeway inpatient maternity services.

Care Opinion (an online Service User feedback platform) allows service users to share their experience of services online. There have been 25 stories shared on Care Opinion relating to maternity care within the review timeframe. Together these stories have been viewed 3,730 times on the online platform.

Most of the stories reflect a very positive experience particularly regarding good communication and sharing of information, quality of care, treatment, staff attitudes and behaviour. Many compliments have been posted about named staff who are reported to have ‘gone the extra mile’. Six stories complimented the Continuity of Midwifery Carer team (Lotus Team) highlighting continuity of care and the positive relationships developed with midwives.

Some additional issues were raised in the stories such as:

• more practical and emotional support for first time mothers
• perceived lack of staff, space and privacy
• poor communication

Since these stories have been posted on Care Opinion, scheduled and unscheduled workloads are now managed within separate areas which the staff feel has made a difference to the volume of footfall in particular areas.

The recruitment of 22 newly qualified midwives during September/ October 2023 means the majority of vacant midwifery posts have now been filled which further enhances the care and support offered to all women.

All stories on Care Opinion that provide feedback or suggestions on how experiences could be improved are followed up with staff for learning and development opportunities. The stories continue to be welcomed by staff as valuable insights towards shaping improvements and this process will continue beyond the timescale of this review.

As part of our review process, we made contact with the women who had their babies in the maternity unit in Antrim Area Hospital in August 2023. 309 letters were issued to women asking them to respond to the survey. We also now have an on-going survey via a QR code which all women receive on discharge from the community midwives. To date we have received 75 responses. The table below illustrates the level of satisfaction recorded by those using the maternity services since the move to Antrim Area Hospital.

In total 76% of respondents indicated they were very satisfied or satisfied with the care they received.

While the Trust received a high level of positive feedback, respondents raised other issues, and these have been themed below:

Environment

The issues raised about the environment in Antrim Maternity Unit included busyness, noise and lack of privacy. There was concern about the location of the labour ward being beside the induction bay, as it appeared to raise anxieties.

Staffing

While the majority of respondents praised staff for the quality of care provided there was some feedback about lack of compassion from a small number of staff, poor communication and lack of support with breastfeeding. A number of respondents felt that there were not enough staff on the wards.

Treatment and Care

Some issues were highlighted about treatment and care including perceived lack of support post birth, particularly for first time mothers who described feeling isolated and alone. In addition, several people were concerned that family visiting was restricted and fathers were not able to provide much needed emotional support. Some respondents described discharge planning as slow because medication was not available and others described feeling that they had been discharged too early.

We remain committed to improving the experience of our service users. Feedback from the survey on how the service could be improved is summarised below:

• Better support for first time mothers.
• Increased staffing levels.
• Improvements to environment to make it more restful and private.
• Reduced waiting times at antenatal clinics.
• Provision of in person antenatal classes.

We have considered all the feedback provided in detail. It has given us valuable information to help us to improve our services. We would like to thank all those who responded and provided feedback.

7. Staff Wellbeing

The service engaged the HSC Leadership Centre to facilitate three team development days for the newly formed maternity team based in Antrim, during September and October. The aims of the development days were:

• To develop the merged teams in a structured way to ensure effective team working for the future.
• To ensure that effective team working further enhances patient outcomes and quality.
• To ensure that all team members see their value as equals across the service.
• To create a space to recognise the new team structures and allow staff to consider challenges and work collectively to resolve these issues.
• To create effective workplace networks to further connect the team.

The three emerging themes from the development days are as follows;

Communication

Communication between staff members and across teams was a theme identified on each of the days and the initial survey as an area for improvement. Based on this, participants were asked to suggest ideas for the future team communication approach.

Based on this feedback, the service is working to;

• Develop a staff communications strategy.
• Hold regular ‘listening events’ between senior team and clinical teams.
• Hold regular Professional Midwifery Update meetings.
• Focus on annual appraisals with discussions around personal development and challenges faced.
• Refresh the staff newsletter to create awareness of roles/responsibilities within the team through regular features and focussed team communication.
• Undertake exit interviews.
• Facilitate attendance of clinical staff to multidisciplinary team meetings.

Staff wellbeing and support

Staff wellbeing and support was a major theme identified. Staff referenced workload and burnout as a major concern moving forward. While we are pleased that the reconfiguration of our acute maternity services has not produced a ‘them & us’ culture, it has increased some of the pre-existing challenges Antrim Maternity has faced with regards to space, workload and time.

Based on this feedback, the service is working to.

• Acknowledge that it has been a challenging time.
• Encourage staff to become wellbeing champions.
• Hold a six-month recognition event for the newly formed Maternity Team based at Antrim.
• Reinstate the Refresh Station in the Birthing Suite for staff to access snacks and drinks during busy periods.
• Progress Reflective Midwifery Supervision.
• Develop a focused People and Culture plan for all Maternity staff.

Role Clarity and Responsibility

Role clarity and responsibility was a further area identified requiring improvement. In recent years, maternity services have developed new specialist roles such as the Perinatal Mortality Review midwife, a bereavement support midwife and a midwife specialist in social complexities to support the senior midwifery management team and consultant midwife. The initial survey produced mixed results, 55% of respondents either disagreed or strongly disagreed that they understood each individual team member’s role and responsibility.

Based on this feedback, the service is working to;

• Undertake a re-visioning exercise with clinical teams to ensure we have a shared vision.
• Specialist and senior midwives join team meetings to discuss their role.
• Newsletter piece ‘A Day in the Life of.”
• Rotation,
• Improved senior midwifery visibility.

8. Conclusion

The change in configuration of our inpatient maternity services was intended to address some significant concerns around the sustainability of the previous two-site model. After six months the Trust is assured that the change has been made safely and successfully, and that the maternity service is now in a more stable, sustainable position.

Consideration has been taken of the four key areas indicated by DoH specifically:

1. The expanded capacity within Antrim Area Hospital and an assessment as to how the service in Antrim Area Hospital is dealing with the increased number of births;

This review provides assurance that Antrim has sufficient capacity to consolidate inpatients and births for the short to medium term, based on birth projections.

2. The number of babies born before arrival (BBAs in Antrim Area Hospital from Causeway Hospital catchment postcodes.

There has been no significant increase in the average number of BBAs, which is approximately one per month.

3. Any instances where women have presented in labour at Causeway Hospital after the service change;

Since the maternity service reform, no women have presented in labour at Causeway Hospital.

4. Intervention rates for instrumental deliveries and caesarean sections.

There has been no significant increase in intervention rates for instrumental birth and caesarean sections since the service change.

Whilst the review provided assurance in relation to capacity, it is important to note, however, that the feedback received indicates that some women find the environment at Antrim challenging with respect to noise and privacy. Whilst there have been positive developments to support scheduled and unscheduled assessment, it is acknowledged that further development and enhancement of the environment is required. Therefore, the Trust continues to work hard to plan and commission the build of an interim 3-bedded Alongside Midwifery Led Unit at Antrim Area Hospital which we expect to be operational in 2025, in advance of the new build Women and Children’s Unit.

In this reporting period the recruitment of 22 Midwives was a positive development which will improve the overall staffing complement. Consolidation of acute maternity services has meant that midwifery vacancies which we had been unable to fill in Causeway, have been redistributed to Antrim hospital and community areas. These positions have all been successfully recruited to. Available staffing is reviewed each day as part of the daily huddle and situation assessment. The role of Midwifery Co-ordinator has evolved since consolidation of inpatient births since 17 July 2023. They provide a key leadership role in co-ordinating the elective and unscheduled care pathways, leading the daily risk assessments and ensuring the actions agreed through the escalation processes are implemented and assessment of impact is considered.

The feedback from women and their families through Care Opinion and the survey has been very valuable to assist with refining pathways, processes and informing planned developments and service improvements.

Whilst there has been one ‘red’ escalation during this review period due to core birthing suite availability, the continued focus by the Midwifery Co-ordinator and wider multi-disciplinary team meant that this was de- escalated effectively within a few hours without recourse to using the identified flexible birthing capacity.

In conclusion, following assessment of the risks of the previous maternity services model over two sites in comparison to the new consolidated model, the clinical, managerial and Executive Teams in the Northern Trust are assured that the transition to the new maternity services model has proceeded as planned and the resultant service model is a safe and sustainable one.

The Trust would like to thank staff for their co-operation, professionalism and dedication to the safety of women, babies and families, now and into the future.