Harriet Smith, Risk and Safety Specialist – Healthcare
Harriet Smith Risk and Safety Specialist – Healthcare

According to the American Congress of Obstetrics and Gynaecologists (ACOG), in 2011, America had one of the highest maternal mortality rates in the developed world.  The overall leading causes of maternal deaths being haemorrhage, blood clots, high blood pressure, infection, stroke, amniotic fluid in the blood stream and heart disease.  In the United Kingdom the Lancet ranked the country 24th out of 49 high income countries for stillbirth rates.

In the large majority of cases having a baby is a safe and wonderful experience for the mother, and her partner.  However there are cases which are higher risk, and clinical staff need to be well trained in the skills needed to deal with them. The right staff need to be available and the most up to date, best practice guidelines need to have been absorbed, so that the staff in these difficult situations go into automatic pilot – drawing on skills that are so ingrained, that it is second nature to act as a team, and manage the situation unfolding before them.

The ACOG within their Women’s Health Stats and Facts document in 2011 state that:

90% of Obstetricians and Gynaecologists in the USA have been sued at least once in their career, with an average of 2.7 claims occurring per practitioner.  43% of these doctors have been sued for care given in their residency when they were training.

Here is the dilemma.  Which is preferable?

  • Putting the women at the heart of her own care, and firmly in the driving seat for the decisions made regarding clinical interventions or
  • Having a risk adverse practitioner who is forced to change their practice due to the threat of negligence and the rising costs of medical liability insurance?

The ACOG goes on to state that;

59% of Obstetricians and Gynaecologists made changes to their practice in 2009;

30% stopped taking high risk patients

26% stopped offering women a vaginal birth following a caesarean section

29% increased their caesarean section rates

8% stopped practicing obstetrics all together

What is inevitable is that clinical incidents are always going to occur, and litigation is ever present.  But should the threat of litigation dictate a woman’s birth plan?  What happens if the Obstetricians all avoid high risk, complicated pregnancies?

What is clear is that maternity services need to fully commit to quality improvement, risk reduction and risk management principles.  There needs to be a well established safety culture where staff feel confident to challenge colleagues in a safe and supportive environment; lessons need to be learnt and action taken following any clinical incident which should be improved upon; changes in practice to incorporate international best practice should be shared, not only between individual clinicians at the same hospital, but throughout all hospitals.

Surely we can’t be complacent? It is essential that maternity services show a real commitment to safety, a determination to improve and evolve?

One of the ways to show a commitment to continual improvement and to quality initiatives is to adopt the new AACI’s Clinical Standards for Maternity Services.  They have been written to include high risk areas of maternity care, and have adopted international best practice guidelines to form a framework for maternity services to work towards.

AACI’s new Maternity Standard’s have five key objectives:

  1. Improve the safety of women and their babies
  2. Provide a framework to support the delivery of quality improvements in the care of women and their babies
  3. Contribute to embedding risk management into the maternity services culture
  4. Enable maternity services to determine how to manage their own risks
  5. Reduce the likelihood of clinical error occurring the therefore reduce the financial costs of adverse incidents occurring in it will terms of additional treatment and days in hospital.

Utilising the AACI Standards focuses maternity services on continual development.  Clinicians and management can work together and make a commitment to improvement, and it will be hard, it will take time, and there will be incidents. But hopefully by making small, yet significant steps forward, and by sharing our experience and knowledge – being open when things go wrong and being proactive in finding solutions; we can see some significant risk reduction within obstetrics, a decrease in litigation and perhaps even see a more real choice for women.



  1. American Congress of Obstetrics and Gynaecologists (ACOG), Women’s Health Stats and Facts
  2. The Lancet Stillbirth Series 2011: Ending preventable stillbirths 2016