Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation

Elisa Giulia Liberati, Carolyn Tarrant, Janet Willars, Tim Draycott, Cathy Winter, Karolina Kuberska, Alexis Paton, Sonja Marjanovic, Brandi Leach, Catherine Lichten, Lucy Hocking, Sarah Ball, Mary Dixon-Woods*, the SCALING Authorship Group, Cathy Bevens, Lia Brigante, Kate Brintworth, Jenni Burt, Carol Carlile, Denise ChafferSanhita Chakrabarti, Tracey Christmas, Victoria Clark-Ward, Sophie Clements, Joanna Crofts, Paul Davis, Lesley Deacon, Fiona Donald, Rachel Duckett, James M.N. Duffy, Charlotte Dyson, Sian Edwards, Diane Farrar, Matthew Fogarty, Mandy Forrester, Aidan Fowler, Richard Haddon, Robyn Halliday, Clea Harmer, Jill Houghton, Carolyn Johnston, Matthew Jolly, Tejinder Kaur-Desai, Tony Kelly, Joy Kirby, Karin Leslie, Sandy Lewis, Amanda Lindley, Louise Locock, Nuala Lucas, Audrey Lyndon, Nicola Mackintosh, Joanne Matthews, Bernadette McCulloch, Siobhan McHugh, Sarah Merritt, Edward Morris, Alison Nicol, Anita Patil, Rebecca Percival, Farrah Pradhan, Daniel Punch, Amanda Rowley, Catherine Roy, Elizabeth Russell, Magdalena Rzewuska, Kathleen Simpson, James Titcombe, Michele Upton, Gill Walton, Sascha Wells-Munro, Caitlin Wilson, Rebecca Wilson-Crellin, Alison Wright, Christopher Yau

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Reducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of ‘what good looks like’. Objective: We aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement. Methods: We conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group. Results: We identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification. Conclusions: This large qualitative study has enabled the generation of a new plain language framework—For Us—that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units.
Original languageEnglish
Pages (from-to)444-456
Number of pages13
JournalBMJ Quality and Safety
Issue number6
Early online date25 Sept 2020
Publication statusPublished - 19 May 2021

Bibliographical note

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Funding: Health Foundation (THIS Institute), Wellcome Trust
Senior Investigator Award (WT097899MA) and NIHR Senior
Investigator Award (NF- SI-0617-10026).


  • healthcare quality improvement
  • obstetrics and gynecology
  • patient safety
  • qualitative research


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