Uniform standard of care in midwife delivery rooms
GRB Gesellschaft für Risiko-Beratung mbH, a subsidiary of the Ecclesia Group and sister company of hevianna Versicherungsdienst GmbH, has developed an audit procedure for the midwife delivery room care model together with the German Midwives Association (DHV). This allows midwife delivery rooms to be certified, thus confirming the quality of care for the benefit of mother and child.
A midwife-run delivery room is a supplementary care model to an already existing delivery room. Midwives take responsibility for the care of healthy pregnant women without risk factors, on the basis of a catalog of selection criteria that has been agreed upon by an interdisciplinary group. The GRB and the DHV have developed a procedure for this that sets a quality standard for midwife-led delivery rooms and ensures transparency. After successfully completing the audit procedure, which can be carried out by the GRB, the midwives' association awards the “Hebammenkreißsaal Plus (HKS+)” certificate to the previously audited midwife-led delivery room.
The discussion about the midwife-led delivery room
So far, the midwife-led delivery room model has not been implemented. Opinions among midwives and gynecologists differ; while some support it, others reject it. This is despite scientific evidence that it is safe for both mother and child. In addition, state funding is available to support the introduction of the midwife-led delivery room. Furthermore, the model offers an opportunity to attract and retain midwives.
The reasons for rejection are manifold. There is already a shortage of midwives, so that no personnel resources are available for this. There are fears regarding liability risks and some see the safety of mother and child endangered – despite scientific evidence. In addition, there is the opinion that obstetrics is already very “midwife-oriented” and that the midwife delivery room does not bring any improvement for pregnant women and also does not serve to recruit personnel.
In addition, some obstetrics departments do not introduce the care model, but advertise with a “midwife birth”, a “midwife-led birth” or a “midwife delivery room”. However, these models do not correspond to the characteristics described in the literature and science. However, the naming is possible because there is no generally valid definition for a midwife delivery room. These diverse arguments, views and approaches mean that there is currently no common understanding of the midwife delivery room among pregnant women, midwives and gynecologists. In order to make a uniform quality standard in the midwife delivery room visible in the interest of mother and child, the GRB and the DHV have now developed the HKS+Zertifikat.
Reducing risk and liability
Obstetrics is a high-risk area and a midwife-only delivery room can be set up in any inpatient obstetrics unit. Recent developments show an increasing interest in this form of care, but there is a lack of standards and transparency towards third parties. Due to the high claims for damages, the interest of insurers in measures that contribute to risk and liability reduction in the field of obstetrics is immense. The hospitals themselves are also keen to take action to avoid possible excess limit losses. The combination of features of the midwifery delivery room, patient safety and liability aspects is suitable for identifying and closing existing gaps in the safety net of a midwifery delivery room. The reservations and concerns of clinic managers and employees regarding implementation should be reduced with the acquisition of the HKS+ certificate. Since the same midwives usually work in the midwife delivery room and in the interdisciplinary delivery room, synergy effects can also be assumed, such as the transfer of a risk-oriented way of thinking and working.
Positive presentation of the midwife delivery room
The awarding of the certificate is also an opportunity to present obstetrics in a positive light in the media. It shows that scientific findings are being implemented in practice and that one-to-one care, which women want, is highly valued by midwives. Since the certificate is linked to requirements, it contributes to transparency for pregnant women. A certified midwife delivery room can also increase an employer's attractiveness.
Requirements
The requirements for a midwife delivery room consist of three thematic complexes:
- The implementation of the care model with the characteristics described in the literature is required. This includes, for example, one-to-one care of the woman in labor, a uniform level of qualification in the midwife team, and agreements with the gynecologists regarding risk selection of the pregnant women.
- The second set of topics calls for the implementation of patient safety measures. Not only the use of clinical risk management tools – such as the error reporting system – is being examined, but also the direct practical implementation of safety measures in the birth process. This includes adherence to a four-eyes principle when evaluating the course of the birth as well as monitoring the number of swabs used to treat birth injuries.
- The last topic is intended to reduce the risks of possible liability as far as possible. Liability results partly from errors and gaps in documentation, but also from late reactions and the involvement of doctors in the event of abnormal birth processes. Therefore, the agreements with the gynaecologists and their application are critically scrutinized. In addition, the medical records are checked according to the criterion of verifiability vis-à-vis third parties.
The individual audit criteria are assigned to the various categories:
- the design of the midwife delivery room,
- the selection and criteria catalog,
- the information provided to pregnant women,
- quality assurance,
- the instruments of clinical risk management,
- public relations,
- defined obstetric procedures,
- emergency management,
- personnel management and
- documentation.
Audit process
The process is set out in the cooperation agreement between GRB and the German Midwives Association. The client commissions an external audit firm to carry out the process. The audit firm must be authorized by the German Midwives Association, as the auditors have to comply with certain quality requirements. For example, the auditor must be a midwife with professional experience and valid certification in clinical risk management.
The customer and the inspection company enter into a contractual relationship for the entire duration of the procedure, which is 36 months.
The procedure can start when the first registrations of pregnant women for birth in the midwife delivery room are available, as the project phase of implementation will have been completed by that time. In an initial audit, the auditor checks whether the inspection criteria are met by means of interviews, site inspections, inspection of documents and patient files. If this is the case, the result is communicated to the midwives' association and the awarding of the HKS+ certificate is recommended. The midwives' association, as the owner of the certificate, contacts the customer to arrange an appointment to hand over the certificate.
If an award cannot be recommended, the inspection company and the midwives' association agree on how to proceed. If necessary, the missing requirements are verified in a follow-up inspection within six months of the initial audit.
Twelve months after the certificate is awarded, the client prepares a self-disclosure in which it presents its further development. This is checked by the auditor, who then communicates the result to the midwives' association. The certificate can be continued if the auditor concludes that the specified requirements are met.
After a further 24 months, the auditor conducts a peer dialog with midwives, gynecologists and other parties involved in the midwife delivery room on site. In addition, the auditor will once again review medical records and any changes to agreements. If all requirements are again met, the audit firm will recommend that the midwives' association continue the certificate.
The procedure is completed after a total of 36 months. If the certificate of the midwives' association is to be continued, a new application must be submitted.
The midwives' association and GRB would like to encourage the establishment of more midwives' delivery rooms. These should be run in accordance with the established quality standards, in the interests of mother and child, but also to ensure transparency for staff and the hospital. As with other certification procedures in the healthcare sector, this is intended to make the quality of care clear to pregnant women, insurers and other interested parties.
Editorial team