Swedish maternity units failing health inspections, understaffing a key factor [Advocacy Lab Content]

Swedish maternity care is failing to meet expected quality criteria standards. According to an alarming new report, only one of the 45 Swedish maternity units passed all of the health inspectorate’s examinations.

In the spring of 2023, the Swedish government asked the Health and Social Care Inspectorate (IVO) to step up its supervision of the country’s 45 maternity units, as the extra government funds allocated since 2015 didn’t seem to address maternity care challenges.

In its first report, the inspectorate claims that Swedish maternity care is generally of good quality. However, it also identifies different shortcomings at 44 of the 45 maternity units, which are said to not meet all aspects of the requirements for quality care in accordance with Swedish health and patient safety legislation.

Lack of compliance with recommendations

Some maternity units are, for example, reported to have problems with following and interpreting the cardiotocography, CTG, or the monitoring of the baby’s heart rate in the womb and the woman’s contractions in a correct way.

Others do not follow up on serious events and report back to the maternity staff to a sufficient extent so that the personnel can learn how to prevent risks.

“We see that healthcare providers lack regular and systematic self-monitoring, which is an important part of patient safe care. By monitoring your own care, you can identify, prevent and avoid serious risks and events,” said Lennart Pettersson, head of the supervision division, Southeast, at IVO.

The inspections also show that the health care providers largely do not follow the working methods recommended by the Swedish National Board of Health and Welfare concerning pelvic floor fractures, which are important to identify early to prevent future problems for women.

At the examination and stitching of a new mum after childbirth, at least two midwives or an obstetrician and a midwife should be present.

However, according to the inspectorate’s report for Sweden’s largest hospital, Sahlgrenska University Hospital in Gothenburg, seen by Euractiv, for example, 91 per cent of the midwives reported that the criteria couldn’t be followed due to heavy workload.

On top of that, emergencies could be challenging, explains Lennart Pettersson.

“A third shortcoming that we would like to highlight is that almost 70% of those interviewed by IVO believe that the leadership role in maternity wards is unclear in emergency situations. This is serious because it can lead to injuries in care, which we also see in the reports to IVO,” he said.

When Sahlgrenska was inspected on 11-12 April this year, a large majority of staff also told the inspectorate that the necessary competence or professionals were not always present in emergency situations.

Falling number of midwives

The report evoked strong reactions.

“The results of the inspectorate’s report are deadly serious. We live in a country that has the prerequisites to conduct first-class maternity care, and we have very skilled midwives. But as a group, we are at a standstill, just trying to maintain the most basic care and basic safety on all days of the year,” said Åsa Mörner, a midwife and spokesperson for the Swedish Association of Health Professionals (the union for nurses and midwives).

The Swedish midwives’ unions have long called for the principle of one midwife for every woman in labour to be applied. A new maternity plan is being investigated by a Swedish agency but will not be finished until next year.

“The main problem,” Mörner said, “is that there are very few midwives in the maternity units”.

This is also why, for example, the maternity ward at the Skånes University Hospital in Malmö introduced 12-hour work shifts for midwives last May to cover all the vacant shifts this summer.

“Many midwives feel that ‘unhealthy’ working conditions do not allow them to work in a way that is safe for patients. Maternity units must start to lay the foundations for decent working conditions and then build better care based on that,“ Mörner emphasised.

Actions needed

The 44 maternity units must now present action plans before 1 September or face sanctions by the inspectorate.

Christer Borgfeldt, chairman of SFOG, a professional association for Swedish gynaecologists and obstetricians within the Swedish Medical Association, welcomes the inspection report. He now hopes that the outcome can lead to improvements.

“We will closely monitor the development,” he told Euractiv.

Concerning the staff’s views that leadership is often unclear in emergencies, he clarifies that the midwife takes care of normal labour. But if a birth is not proceeding normally, the doctor is called in, and then the doctor is responsible.

“At the same time, [who is responsible in certain situations] is something that we in SFOG and the midwives’ associations must discuss and try to convey further to the units that handle births,” Borgfeldt added.

The Swedish Association of Local Authorities and Regions (SKR a health employers’ organisation), points out that patients and their partners “mostly have a positive experience during and after childbirth.”

Room for improvement

Nevertheless, Johan Kaarme, head of health care and social services at the SKR, tells Euractiv that there is still room for improvement.

“Although it is difficult to find common explanations, most maternity units struggle with staffing and today’s need for documentation and working in multiple medical record systems,” he said.

Improving the working environment will, therefore, be a key to retaining and recruiting staff, Johan Kaarme explained.

[By Monica Kleja, Edited by Vasiliki Angouridi, Brian Maguire| Euractiv’s Advocacy Lab]

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