The Tommy’s National Centre for Maternity Improvement: What needs to change?

In the UK, nearly 60,000 babies are born prematurely every year (before 37 weeks). Some do not survive, and those that do can face a lifetime of health issues. As well as this, tragically, around 3,000 babies are stillborn in the UK every year. In terms of stillbirth, the UK is outside the top 20 safest high-income countries in which to give birth. There is clearly room for improvement.

At the Tommy’s National Centre for Maternity Improvement we want to improve the care that every woman receives so that we can reduce the number of families who have to experience the pain of stillbirth or premature birth. To do this, we are focusing on four key areas of improvement.

We need better ways of assessing risk early in pregnancy

Currently, the risk of premature birth or stillbirth is assessed by a midwife at a woman’s first antenatal appointment (the booking appointment) and then throughout her pregnancy. A checklist is used to determine a woman’s risk, but this is inaccurate because:

• it considers all risk factors to be equally significant;
• it does not take into account the interaction between risk factors;
• for premature birth, risk is often based on previous history, meaning that many parents must experience loss before being referred to a doctor;
• it does not provide a risk score – a woman is simply classed as high risk or low risk;
• this system unreliably labels around 25–30% of all pregnant women as high risk at booking and may class women as low risk who eventually go on to experience complications such as premature birth or stillbirth.

We need to ensure continuity of care

Even when risk assessments are performed appropriately in early pregnancy, the use of paper records or digital maternity notes can mean that crucial information about a woman’s risk factors is not available or is not understood at key points later in the pregnancy, for example, when a woman attends hospital because she has concerns about her pregnancy. This lack of continuity of care can mean that problems are missed, which can very sadly sometimes lead to poor outcomes for the woman and her baby, such as premature birth or stillbirth.

We need to make it easier for doctors and midwives to make the right decisions

The National Institute for Health and Care Excellence (NICE) produces guidelines to help midwives and doctors make the best decisions about the women in their care. However, there are a huge number of different guidance documents that clinicians need to follow, and this is in addition to guidelines from the National Screening Committee, the Department for Health and Social Care and the Royal College of Obstetricians and Gynaecologists (RCOG).

It is clearly unrealistic to expect that midwives and doctors will remember every single recommendation and be able to apply them in a tailored way for every woman they see – especially if a woman attends the hospital out of hours. This means that it can be difficult for healthcare professionals to make the right decisions about every single pregnant woman in their care.

We need to help women make the best lifestyle choices

For some pregnant women, there may be things that they can change themselves that would reduce their chances of experiencing complications. For example, smoking during pregnancy increases a woman’s chances of having a premature birth, a small baby or a stillbirth. Similarly, women who are underweight while pregnant have a slightly increased risk of giving birth prematurely or of having a low birthweight baby. By making different lifestyle choices during pregnancy, it is possible that women can increase their chances of having a healthy baby.

What are we doing to make things better?

At the Tommy’s National Centre for Maternity Improvement, we are creating The Tommy’s Pathway – an online medical tool that will help midwives and doctors work out a personalised risk score and treatment plan for each pregnant woman in their care. The Pathway will use artificial intelligence and algorithms to generate this risk score from the information that is already routinely collected during antenatal appointments, making it more accurate than the checklist that is used at the moment. Treatment recommendations will also be tailored to each woman, making sure that the best decisions are made at every point in her pregnancy. A woman’s risk assessment and care plan will be available to any midwife or doctor looking after her, either routinely or in an emergency, which will ensure continuity of care. A smartphone app will also give women personalised information, support and advice, empowering them to engage in their care and, where necessary, encouraging them to make different lifestyle choices that will improve their chances of having a healthy pregnancy.