Recommendations from the ESMiE Confidential Enquiry

Sara Ledger
Head of Research and Development


The latest findings and recommendations from the ESMiE Confidential Enquiry look at intrapartum stillbirths and intrapartum-related neonatal deaths planned in midwifery-led settings: alongside midwifery units (2015-2016), freestanding midwifery units and home births (2013-2016).

The enquiry aims to make births in midwifery-led care even safer, and so I will lead with recommendations for care.


General Recommendations
Evidence-Based Discussion

All women at low risk of complications, and others considering birth in a midwifery-led setting, should have an evidence-based discussion with a midwife and/or doctor about the risks and benefits of different birth settings.

  • This discussion has to take into account any risk factors for complications, and the woman’s values and preferences.
  • The discussion should be fully documented in the woman’s notes; including evidence about safety, intervention and transfer rates, and a specific care plan for the management of any risk-factors in the midwifery-led setting.
  • Care plans and planned place of birth decisions should be revisited during pregnancy and at the start of labour
Risk Assessment & Routine Audit
  • The development of a standardised risk assessment tool should be considered, for use at the start of labour care and as labour progresses.
  • A routine audit of the frequency and timing of monitoring in labour is recommended to ensure alignment with guidance.


Recommendations for Providers
Work with Local Ambulance Services & Receiving Hospitals
  • Ensure prompt ambulance attendance and transfer by developing appropriate pathways and protocols with local ambulance services.
  • Adopt a standardised communication of urgency in relation to transfer with receiving hospital and ambulance services.
  • Prompt obstetric and neonatal assessment processes need to be in place at receiving hospitals when a woman is transferred urgently for obstetric care.
  • When a baby dies after a planned birth in a midwifery-led setting, a senior midwife with experience of providing care in a midwifery-led setting should be involved in the follow-up care and local review.
  • When a baby dies and the care involves ambulance transfer, the review should include information from paramedics and the ambulance service.
Management of Neonatal Emergencies
  • Develop and maintain clear guidance for the management of neonatal emergencies in a community setting.
  • Mandatory annual multi-professional skills and drills or in-situ simulation training on neonatal emergencies guidance and management.


Findings: What led to those recommendations?
  • In 75% of the intrapartum-related deaths improvements in care were identified which may have made a difference to the outcome for the baby.
  • In 75% of deaths improvements in care may have also made a difference to the mother’s physical and psychological outcome or future wellbeing.
  • For women at low risk of complications, with the exception of first-time mothers planning to birth at home, planning a birth in a midwifery-led setting is as safe for babies as planning a birth in an obstetric unit. It also has benefits in terms of substantial reductions in medical intervention.
New themes emerging

Transfer is an intrinsic aspect of care in midwifery-led settings. Almost 75% of women were transferred to obstetric care. There were several good examples of good care in relation to transfer; however, there were some significant issues identified:

  • Delay occurring because of failures of monitoring and risk assessment
  • Failure to recognise a developing problem
  • Poor communication of urgency
  • Apparent lack of resource

Improving Care

  • The use of communication and handover tools, like SBAR (Situation, Background, Assessment, Recommendation).
  • Safety huddles
  • Communication and information developed together with the local ambulance service


Evidence-Based Discussions

In over half of deaths reviewed there was little evidence of discussion, a failure to appropriately assess, and a lack of planning for the management of risk factors.

  • A documented evidence-based discussion with women about the risks and benefits of different birth choices and settings is an essential part of a woman’s care.
  • Place of birth and birth choices should be an ongoing assessment throughout pregnancy and on admission in labour and as labour progresses.
  • Decisions should always take into account a woman’s preferences and values.

Improving Care

  • Improving confidence by supporting midwives who need to have these discussions.
  • Finding common ground between woman and health professionals through mutual respect, openness and a shared commitment to an agreed care plan.

The authors of the enquiry sign-post research from the Netherlands into how to implement this and its benefits, which can be found here.

Intermittent Auscultation

The issues identified within this enquiry mirrored many found in other enquiries; however, the enquiry points out that there is no clear national guidance about the timing and frequency of intermittent auscultation (IA) in the first and second stages of labour.

Improving Care

The authors recommend that providers of midwifery-led services should actively audit the frequency and timing of IA in their services, and act on those findings to improve care.


Neonatal Care

The enquiry found issues with the management of neonatal emergencies in the community setting:

  • Transfer of the newborn baby from the community setting
  • Resuscitation did not meet national standards
  • Absence of clear protocols for the management of a neonatal emergency

Improving Care

Local enforcement of national guidance that:

  • All birth professionals attend annual training in neonatal resuscitation that’s nationally accredited
  • Call for help with resuscitation can be facilitated
  • There facilities for resuscitation and transfer
  • There are emergency referral pathways
Local Reviews

Most of the cases looked at by the enquiry were considered to have been conducted poorly, and were lacking in health professionals with the relevant clinical skills or experience.

Improving Care

Involving midwives who work in a midwifery-led setting, paramedics and ambulance staff, and neonatologists.


This enquiry is an opportunity to look at the 75% of babies whose outcome would have been different with different care, or the 75% of women for whom improvements to care would have made a difference to their psychological and physical wellbeing and make those changes.

The enquiry sets out ways to improve care at every finding and, if followed, this report will make births in midwifery-led settings even safer.




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