Maternity high dependency care in obstetric units remote from tertiary referral centres: findings of a modified Delphi study

Background. Increasing numbers of pregnant and postnatal women require higher levels of care, including maternity high dependency care (MHDC), due to comorbidities and/or obstetric complications. Up to 5% of women in the UK will receive MHDC, although there are varying opinions as to the defining features and definition of this care. Furthermore, some evidence suggests that the size and type of obstetric unit (OU) influences the way MHDC is provided. Objectives. The aim of this modified Delphi study was to ‘determine what constitutes high dependency care in OUs remote from tertiary referral centres’. The research objectives were to achieve a consensus on the definition and defining features of MHDC in OUs remote from a tertiary referral centre, examine whether the definition for defining features of MHDC were the same for OUs with differing annual birth rates and to investigate if the definition for, and defining features of MHDC were the same for the professional groups of doctors and midwives working in OUs with similar annual birth rates. Ethics. Ethical approval was granted by the NHS research ethics committee and the relevant local NHS research and development departments. Method. A three-round modified Delphi survey was conducted. The first-round questionnaires were sent to 193 obstetricians, anaesthetists, and midwives who worked across seven OUs (with annual birth rates ranging between 1500 and 4500), remote from tertiary referral centres, in southern England. Round one involved completion of a qualitative self-report questionnaire. Rounds two and three were predominantly quantitative and respondents were asked to rate their level of agreement or disagreement against five-point Likert scale items for a series of statements derived from the first-round findings. The level of consensus for the combined percentage of strongly agree/agree statements was set at 80% for the second and third rounds. A detailed account of the research methods used are reported in the September 2017 issue of Evidence Based Midwifery (James et al, 2017). Findings. Response rates for the first, second and third rounds were 44% (n=85/193), 87% (n=74/85) and 90.5% (n=67/74) respectively. The respondents achieved consensus regarding the defining features of MHDC with some exceptions including post-operative care and postnatal epidural anaesthesia. MHDC was defined as ‘an interim level of care for women requiring interventions over and above the [specialised] “high-risk” obstetric care that will be carried out routinely on a consultantled labour ward, but not requiring care on an intensive care unit. It will be implemented where a woman has deteriorated clinically but her care can be managed appropriately on the labour ward’. MHDC was likened with level 2 care (Intensive Care Society, 2009) although respondents from the three smallest OUs agreed it also comprised level 1 care. The smaller OUs were less likely to provide MHDC and had a more liberal policy of transferring women to intensive care. Midwives in the smaller OUs were more likely to escalate care to the intensive care unit than their medical colleagues. Conclusion. MHDC is complex and this Delphi survey corroborates previous evidence that local variations exist in MHDC provision. Varying opinions as to the level of care that equates with MHDC were apparent, but it is unknown how these variations influence women’s care. Organisationally robust systems are required to promote safe, equitable MHDC including precise escalation of care guidelines incorporating standardised terminology