While the majority of women in the UK say their births were positive experiences, too many have anguished memories of not being listened to by medical staff, of babies dying, writes Hattie Garlick in The Telegraph.
This week, the results will be published of the long-running Ockenden Review into maternity services at the Shrewsbury and Telford Hospital NHS Trust – scene of one of the biggest scandals in NHS history.
Its findings, amassed by a team under Donna Ockenden, a former senior NHS midwife, are expected to be shocking. The report is likely to encompass the experiences of 1,862 families between 2000 and 2019 – almost certainly the largest clinical review into a single service in the history of the NHS.
More than 40 babies and a dozen women are thought to have died unnecessarily in the Trustʼs care. The reviewʼs interim report, published in December 2020, catalogued catastrophic failures, including “continuous errors in the assessment of foetal well-being” and “failure to recognise and escalate the management of deteriorating mothers”.
Between 2013 and 2016, stillbirths and early neonatal deaths at the Trust were up to or more than 10% higher than comparable UK NHS Trusts.
But, writes Garlick, what the report is also likely to expose is a wider, more insidious problem: the creeping influence in the health service of a movement that promotes “natural” or “normal” birth above modern obstetric science.
It is a tragic paradox that what began decades ago as an attempt to make childbirth a happier experience for mothers has instead made it more dangerous for some.
How the cult of natural birth took hold
Back in 1960, after giving birth in a Hertfordshire NHS hospital, a mother called Sally Willington wrote a scathing letter to a newspaper recounting her experiences.
“In hospital, as a matter of course presumably, mothers put up with loneliness, lack of sympathy, lack of privacy, lack of consideration,” she wrote. “Our maternity hospitals are often unhappy places with memories of unhappy experiences. They are overcrowded, understaffed and inhumane.”
For mothers like Willington, an artist and activist, the dramatic medicalisation of childbirth left them feeling like spectators – or even unwelcome guests – at this most intimate and significant event in their lives.
Willington wanted to restore womenʼs agency and dignity by getting rid of unnecessary medical interventions, writes Garlick. And it worked. Her letter gave rise to a new organisation, the Association for Improvements in the Maternity Services (AIMS), which helped to introduce more humane NHS policies – fathers came into labour rooms, routine humiliations such as pubic shaves and enemas were abandoned.
The revolution did not stop there, however. While Willington had pushed successfully for a rebalancing of medical science and human kindness in maternity units, another more radical campaign was soon being waged by champions of womenʼs empowerment.
Their target was male obstetric interference, and their goal was a return to nature. Medicalisation disempowered mothers, they argued, and natural childbirth could put modern woman back in touch with her primal power.
This legacy of the social upheavals of the 1960s and 1970s is still with us. Over the past half-century, a whole industry developed around encouraging women to keep doctors at bay. Breathing exercises, birthing suites, hypnobirthing classes all proliferated.
Caroline de Costa, a professor of obstetrics and gynaecology, sums it up scathingly in her book The Womenʼs Doc (out this June): “If pesky doctors and midwives would just leave women alone they would get on with it. Lambs would gambol in green fields and Judy Garland would sing Over the Rainbow as the babyʼs head crowns gently, with nary a tear in the perineum.”
At the turn of the millennium, parts of the NHS were being co-opted into a similar narrative, at a time when the rising rate of Caesarean sections was causing concern.
C-sections were considered expensive, resulting in long recovery times for mothers and depriving the baby of the benefits associated with vaginal delivery. In 2005, the Royal College of Midwives launched a campaign to encourage expectant mothers to have “normal births”. Maternity units were asked to keep the Caesarean rate to about 20%.
But what were “normal” births? Swiftly, they became synonymous with “natural”, writes Garlick.
So when it emerged in 2011 that C-section rates in Shropshire (Shrewsbury and Telford Hospital NHS Trustʼs backyard) were the lowest in England, the Trust openly boasted to a local paper about “an environment that encourages natural childbirth and a wide range of strategies to keep Caesarean deliveries low”. It was given a pat on the back by both the Care Quality Commission and the Royal College of Obstetrics and Gynaecologists.
Some mothers may have seen the NHS using that word “natural” and considered it evidence that the trust was a safer place than many in which to labour. Behind the myth of ecstatic water-births powered only by smoothies and the sound of whale-song, however, lay a grim truth that Ockenden has laid bare:
“A woman was in agony but told that it was ‘nothing’; staff were dismissive and made her feel ‘pathetic’. This was further compounded by the obstetrician using flippant and abrupt language and calling her ‘lazy’ at one point.”
The scandal Ockenden dissects has nothing to do with mothers being too lazy and everything to do with women who – in pregnancy or labour – either voiced grave concerns that were discounted or displayed warning signs that were overlooked. They were disempowered not by having obstetric interference forced on them, but denied to them. And with devastating consequences.
“There were cases where an earlier recourse to Caesarean section rather than a persistence towards a normal delivery might well have led to a better outcome for mother or baby or both,” Ockendon told Panorama in a documentary aired in February. “Low Caesarean section rates were a prize.”
The call for “normal births” was so loud that it drowned out the concerns and symptoms of individual women. One mother, Rhiannon Davies, told clinicians at the Trust in 2009 that her babyʼs movements had reduced, but she was told she simply had a lazy baby and was admitted to a midwife-led unit to give birth. This meant that when her baby, Kate, was delivered in need of urgent medical attention, the nearest doctors were 45 minutes away. Six hours later, Kate died.
The crisis in maternity care at SaTH is far from the first of its kind, reports The Telegraph. In 2015, an investigation into University Hospitals of Morecambe Bay NHS Foundation found that an “overzealous” pursuit of normal childbirth “at any cost” had contributed to the deaths of 11 babies.
In 2017, the Royal College of Midwives dropped its “normal births” campaign and abandoned use of the term altogether. Safety experts said an NHS-wide “cult-like fixation” on “normal birth” had fuelled catastrophic errors and record negligence claims, as doctors were kept out of the delivery room even when they were needed.
Yet not until last month – the week the Panorama programme was shown – did NHS England write to all of Englandʼs hospital trusts, instructing them to abandon Caesarean rates as a performance measure, to prevent the pursuit of targets that “may be clinically inappropriate or unsafe in individual cases”.
There is more to be done. In the UK, there are four infant deaths for every 1,000 live births. This is better than Americaʼs rate (5 deaths), but worse than the EU average (3.4) and significantly less impressive than Sweden (2 deaths, and lower rates of neonatal brain injury too). Women from minority ethnic groups are more likely still to lose their baby.
Blame culture stops trusts learning from mistakes
Fixing this requires a definitive end to the pitting of science against positive birthing. But how can we rehabilitate obstetric intervention, without returning to the 1950s?
Back in 2020, the Commons Health and Social Care committee convened to examine safety concerns about maternity services. It heard from Helen Vernon, chief executive of NHS Resolution, the organisation that decides the compensation given to families when things have gone wrong.
“The area of training where we are most keen to get involvement is in skills for engaging with families – communication skills,” she said.
Her point was that while the overwhelming majority of midwives and doctors are the opposite of uncaring, some are being pressured to appear so.
“We hear that people have an ingrained belief… that you should not admit liability on a case, and you should not be open with a family because it might result in litigation,” said Vernon.
Obstetric cases accounted for 50% of the estimated value of new claims reported to her organisation in 2019/20, despite only representing 9% of the total number. So can the NHS afford to be open? Or does not admitting liability mean not learning from mistakes – and thus not avoiding further tragedies?
Recent NHS-wide attempts to improve maternity care have included the Health and Safety Investigation Branch – a programme established in 2017 with a remit to “improve patient safety through effective and independent investigations that donʼt apportion blame or liability”.
This is not easy, because currently, for parents to get the compensation and support they need when things go wrong, they must prove clinical negligence which, in turn, can destroy a doctorʼs career and livelihood.
Thereʼs little point in training doctors to communicate errors openly with parents, if doing so could result in them losing everything.
When New Zealand recognised this and switched to a no-fault compensation system, the average claim processing time dropped from more than five months to 13 days. Clinicians were quicker to acknowledge that something had gone wrong, than they had been to admit personal blame.
In Sweden too, parents no longer need to prove negligence to get compensation, only that care was not delivered according to best practice – a much lower bar and one far fairer to dedicated doctors and midwives. The number of avoidable and serious birth injuries halved between 2000 and 2016.
Moving away from a practice of pursuing targets and apportioning blame, to one of listening and learning wonʼt save the system in England if the number of midwives keeps falling. It was down from 27,272 to 26,901 in the last year alone.
The NHS cannot listen to women if there are not enough midwives left to hear them, as Chief Executive of the Royal College of Midwives, Gill Walton, explained last month: “Maternity services have been at the bottom of the list for investment for far too long and weʼre now seeing what that means in practice.”
On Wednesday, the NHS appeared to acknowledge this, announcing an extra £127m funding boost for maternity services across England that they said would help ensure safer and more personalised care for women and their babies.
“This new multi-million-pound funding will build on the significant steps weʼve taken in recent years to transform the care for pregnant women and their babies,” said NHS Chief Executive, Amanda Pritchard. “We will not hesitate in taking further action to learn, improve and ensure that all women who use maternity services receive the best care possible.”
Ockenden had already demanded these changes in her interim report. Declining to sugar-coat her findings as “recommendations”, she laid out “immediate and essential actions… to positively impact safety in all maternal services across England”. Number two on her list of seven? “Listening to women”.
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