107.In this chapter we consider women’s experience of maternity care and the changes required to ensure that personalised, safe care is reality for every mother and her baby. We focus on the steps needed to be taken to tackle unacceptable inequalities in outcomes; specific interventions to improve outcomes, including continuity of carer and screening; and finally and most importantly, supporting informed choices and personalised care, to ensure that no woman faces pressure to have an unassisted vaginal birth.
108.At our third evidence session we heard from Atinuke Awe and Clotilde Rebecca Abe, co-founders of Five X More. Five X More is a grass roots campaign that is “dedicated to supporting mothers with its campaigning work and recommendations. It focuses on empowering Black women to make informed choices and advocate for themselves throughout their pregnancies and after childbirth.” It is also “committed to calling on those in power to change the outcomes for Black women”. Atinuke Awe told us of her experiences of pregnancy and childbirth:
There were signs of pre-eclampsia, high blood pressure and protein in my urine from midway through my pregnancy […] It was not until a last-minute midwife appointment at the end of my pregnancy that it was picked up. By that time, I was so swollen that I was advised to go straight to the hospital by my midwife, which of course was really worrying to hear as a first-time mum […] I was left for hours without any pain relief. By the time my waters finally broke and I was checked over, the midwife realised that I was 8 centimetres gone. I had indeed progressed really quickly in a short amount of time. I was rushed to the delivery suite, as my baby’s heart rate was dropping. In the end, I ended up having an assisted delivery because, honestly, I was too exhausted. I did not have the strength to push my son.
Atinuke Awe explained to us how that experience affected her:
I was left feeling that I was not important and that I was not listened to at all. My pain was not taken seriously. The more I spoke to women in my immediate network, through Mums and Tea, which is a social network for mothers to connect, I found that my experience was not an isolated one. I was not alone in having a really poor experience […]. The MBRRACE report came out in 2018, telling us that black women are indeed five times more likely to die, which validated our voices and our experiences. One of the key messages of the campaign is that, as we like to say, there are real people behind the statistics.
109.In 2020, Five X More launched a petition “Improve maternal mortality rates and health care for black women in the UK” which gained over 187,000 signatures. They told us they started the petition because they believed that not enough was being done to address the disparity in outcomes:
This is a consistent issue that we believe has been worsening over the years. It has led us to believe that it was not important enough to those in charge of maternity services or the decision makers, as the number was steadily rising as opposed to going down.
110.Inequalities in maternal and neonatal outcomes have been well documented for many years, but we heard that there has been little progress in closing the gap. A recent report by the Joint Committee on Human Rights concluded that “the NHS acknowledge and regret this disparity but have no target to end it”. During our inquiry, Professor Jacqueline Dunkley-Bent, Chief Midwifery Officer, told us:
The wider determinants of health are not just related to 40 weeks of pregnancy. We have the social deprivation, financial deprivation, inequality, discrimination and racism that many people who get pregnant and use our maternity services have to contend with.
In the maternity space, I cannot say categorically when we will close the gap on equity—the five times more likely—and the neonatal challenge for black and Asian babies.
111.Many contributors to this inquiry emphasised addressing inequalities as a necessary part of the safety agenda. Birthrights told us that “a litmus test” for a safe maternity service was, how safe maternity care is for more vulnerable groups of women and their families. It described this as “an overlooked but essential aspect of safety”. Dr Daghni Rajasingam, Consultant Obstetrician and Deputy Medical Director at Guys and St Thomas’ Hospital NHS Foundation Trust, also highlighted the importance of making services safer for the very vulnerable group of women. If that work was done, she was confident that “we will start learning systems issues and will make services safer for all women and their babies”.
112.During our inquiry we heard that most maternal deaths are women who die from medical problems that are aggravated by pregnancy or by the care they received because they were pregnant. MBRRACE-UK highlighted that 20% of those who died in 2015–17 where known to social services and 6% were at severe or multiple disadvantage (including a mental health diagnosis, substance misuse and domestic abuse). Reflecting on maternity safety, Professor Marian Knight, Professor of Maternal and Child Population Health, University of Oxford, and Lead for MBRRACE-UK, told us that when addressing inequalities, “we need to think much more broadly than just maternity services” and recent research had convinced her of the need to “think much more widely than the professional groups of midwives and obstetricians.
113.Dr Matthew Jolly, National Clinical Director for Maternity and Women’s Health at NHSE&I, agreed. He said that in order to achieve equity for women “we need to go the extra mile for those who are the most vulnerable”, and highlighted the example of the Saving Babies Lives Care Bundle as positive action in this respect:
We have designed best practice care and have put in place a way of identifying those who are at greatest risk. In areas where we have worse outcomes, we need to do more, and target those people and give them absolutely the best-quality care to address the disparities between different units.
However, he cautioned that more had to be done and that people in the sector were “absolutely determined to carry on exploring how else we can improve”.
114.In response to the petition ‘Improve maternal mortality rates and health care for black women in the UK’, the Department outlined the following as actions:
115.Professor Knight, who led the research into the underlying ethnic disparities in maternal mortality in the United Kingdom, told us that there was “no difference” in the causes from which women were dying across aggregated ethnic groups when looking at Black women, Asian women, white women or women from other groups. However, she went on to explain that the research identified a number of themes that were considered potential explicit or structural biases impacting on care received. She described the three most frequent were “not like me”, complexity and microaggressions:
“Not like me.”[…] was observed most in black women. Assessors felt that staff needed more listening, learning and nuance around women’s background, making sure that women received individualised care, and thinking about place of birth, language, cultural factors and the socioeconomic background, to enable the most appropriate care, as opposed to the default one size fits all […]
Complexity—clinical, social and cultural. The vast majority of women who die have multiple and complex problems. Our systems are not set up [for this]. There is definite evidence of structural biases that impact on women receiving the care they need—for example, clinics based at different hospitals requiring different appointments, with communication not necessarily occurring between them. Clinical complexity was a theme observed equally among all ethnic groups. It was a theme for white women, Asian women and black women.
The third most frequent theme observed was micro-aggression. It was perhaps most predominant among Asian women […] there were racial or ethnic stereotypes, such as black women having lower pain thresholds. A particular concern was women who do not necessarily speak English fluently. Agitation was assumed to be due to mental health problems, when they were actually seriously physically ill. That misinterpretation was on the basis of their language.
116.Professor Dunkley Bent emphasised to us the importance of hearing the voice of mothers from Black, Asian and minority ethnic backgrounds and that the voice of mothers must not be restricted to “those who have advantage and speak well”. She explained that Maternity Voices Partnerships (groups of user representatives, commissioners, doctors and midwives) helped this by prioritising mentoring schemes for Black, Asian and minority ethnic parents and a focus on “the context of where communities are to be able to provide purposeful and meaningful care that will drive up outcomes”.
117.The evidence we received from Local Maternity Systems welcomed the role of Maternity Voices Partnerships (MVPs) but reflected that “the biggest challenge from the MVPs is that they often don’t represent the population that most need support - eg deprived and BAME”. The Shelford Group recommended that “resource should be made available and work expanded to ensure the voices of all are heard, particularly from an equality perspective”.
118.Clotilde Rebecca Abe, co-founder of Five X More, also emphasised the need for co-production to address inequalities but highlighted that too often that was not achieved:
There needs to be more research into the much wider issue and it needs to be co-created by and include black women and lived experience. Black women who are experts in their fields need to be part of the research. There is lack of representation in the strategy and the delivery. When we are involved or invited, it often feels very tokenistic.
119.Importantly, reflecting on the complaints and investigation process a midwife in our clinician roundtable told us:
The sad reality is, when you are black, Asian, or from a diverse ethnic background you are less likely to complain, you are more likely to take the first review given to you, and all you need to do is look at your local PALS complaint procedure to see that they’re not representative of the communities we care for, which shows that we’ve potentially got a huge number of blanketed near-misses which we’re not even aware of.
120.The Government has made significant progress in its ambition to improve maternal and neonatal outcomes. However, there remains marked disparities in outcomes for mothers and their babies. Our Expert Panel assessed progress against the Maternity Safety Ambition (Box 3). The Expert Panel overall rated progress against this commitment as ‘Requires Improvement’, stating:
To improve birth outcomes for women and babies, significant focus has been directed towards improving maternity safety, with promising trends in reducing unnecessary deaths and disability. However, changes to the way progress is measured makes it difficult to attribute improvements to Government intervention. Significant health inequalities for women from minority ethnic and socio-economically disadvantaged backgrounds persist which have not been adequately addressed in current improvement plans. [Expert Panel]
Box 3: Expert Panel CQC-style Ratings–Maternity Safety
Maternity Safety: By 2025, halve the rate of stillbirths; neonatal deaths; maternal deaths; brain injuries that occur during or soon after birth. Achieve a 20% reduction in these rates by 2020. To reduce the pre-term birth rate from 8% to 6% by 2025
Overall: Requires Improvement
Further analysis can be found in the Expert Panel’s independent report: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England.
121.In December 2017, NHS England published, its five year forward view for maternity safety, Implementing Better Births: Continuity of Carer. In its summary, NHS England said:
At the heart of this vision is the idea that women should have continuity of the person looking after them during their maternity journey, before, during and after the birth.
122.Continuity of carer refers to consistency in the midwife or clinical team providing care for a woman and her baby throughout pregnancy, labour and the postnatal period. The aim of continuity of carer is for a woman and her responsible clinician to develop a relationship over time, so that she receives coordinated, timely and appropriate care which meets the needs of her and her baby. Professor Dunkley-Bent told us in February 2021 that there were 2,322 midwives providing continuity of carer to one sixth of women who birth in England each year; and that 94,458 women are now benefiting from continuity of carer, compared to 10,500 two years ago. Professor Dunkley-Bent, pointed us to the following benefits of continuity of carer:
She went on to say that if without that continuity, many women felt “embarrassed” or that “their questions are silly or not valid”, and that a strong relationship with the clinical lead ensures that women can have those “frank conversations”.
123.Research has also shown that midwifery-led continuity of carer can improve outcomes for mothers and babies, including a 16% reduction neonatal mortality, 24% reduction in preterm birth and increase the experience of care for mothers.
124.Despite these benefits, Donna Ockenden felt a lack of continuity of carer was not a factor in the tragedies that occurred at Shrewsbury and Telford:
We have looked at the 250 cases, and the issue of continuity of carer […] did not come up as something that would have influenced women’s care. It did not come up as, “If only we’d had that, it would have made a difference.”
125.However, we did hear evidence that when care is disjointed, vulnerable women and babies can be left to fall through the gaps. For example, suicide is the leading cause of maternal death between six weeks and one year after childbirth. Professor Knight told us:
The vast majority of women who die by suicide have sought help on multiple occasions, but nobody has recognised the overall pattern because there isn’t holistic care. We have very siloed systems and women’s voices are not necessarily heard.
126.When asked whether the continuity of carer model could address such issues, Professor Knight said that there was “absolutely no doubt” that a trusted relationship with a midwife, or a group of midwives or health professionals, enabled women to disclose their concerns about symptoms and feel listened to and that this would “make a difference”.
127.The clinicians in our roundtable also told us how continuity of carer helps provide more personalised care for the women they look after:
The continuity part of this is important, because once people have a [professional] relationship with a woman […] then they are invested in that woman as an individual. They see her as an individual, they see her holistically within a whole paradigm of care and they have that sort of motivation, you know it’s a very human thing isn’t it to give that relational care which means that they’re communicating with colleagues to dot i’s and cross t’s to ensure that things are followed up and that things happen in a timely manner. [Midwife]
128.However, while there was a consensus in the benefits of continuity of carer, Dr Jo Mountfield, Vice President for Workforce and Professionalism, Royal College of Obstetricians, expressed concerns about the practicalities of delivering care in that way:
Of course having continuity of carer for every woman is a really good idea, but the reality of delivering that […] is really challenging. It boils down to not just the cost but midwives wanting to work in that way. [Jo Mountfield]
These challenges have been most obviously seen at Worcester NHS Trust. This was also highlighted by attendees at our roundtable:
There’s a lot of evidence to say how valuable it is for women. But there is something about supporting the needs of the doctors and midwives who would actually be delivering that. [Midwife]
I welcome very much [continuity of carer], but practically speaking my understanding from midwives is that it can be a difficult model to work in. […] I am speaking in terms of lifestyle rather than being on call, struggling to get away. Working patterns can be quite tricky in the continuity of care model. [O&G Trainee Doctor]
129.Dr Niamh Maguire, Consultant Obstetrician and Clinical Lead for Sussex Local Maternity System, also highlighted to us the risk that continuity of carer can result in brand-new midwives being “pushed out into the community” at a very early stage in their career which can result in them feeling unsupported. Furthermore, Clotilde Rebecca Abe believed that continuity of carer was “a great model” if it worked well but noted that it may not always be possible because the midwife “might not be there at the end”. Clotilde emphasised to us that “you really need her at that crucial point, when you get to the end”.
130.The Ockenden Review team shared similar concerns regarding the successful roll out of continuity of carer:
Staff want to do their best and work within a framework of messaging that is realistic and woman-focussed but they have not been supported to do this as CoC [continuity of carer] was introduced without additional funding. A change of this magnitude must come with the staffing resources to facilitate it and the ears to hear when safety concerns are raised. Safe staffing levels are critical to this discussion.
We do not doubt for one moment the positive impact that CoC [continuity of carer] has on some women’s overall satisfaction and pregnancy outcomes. Our concerns are focussed on an ambition which has been rolled out with the expectation to implement with what appears to be limited thought given to the impact on the workforce providing the service.
131.When she gave oral evidence, Nadine Dorries, Minister of State for Patient Safety, Suicide Prevention and Mental Health, acknowledged that due to the working patterns of midwives, it was not always possible to have the same midwife “from the second that you either self-refer or are referred by your GP to the maternity unit, until the point of birth”. Rather, the Minister stressed that the objective was for a woman to remain with the same midwife “through pre-delivery care”. She went on to say that for a midwife to be on call 24 hours a day was not a working pattern that all midwives “will commit to or want to commit to”, nor did she believe that they should be asked to commit to such a working pattern. In relation to capacity, the Minister stressed that it was not a question of “whether we have the numbers” but “whether we have the ability in terms of the expectations on midwives to do it”.
132.The Department and NHSE&I have highlighted continuity of carer as a major action point to address inequalities in maternity outcomes. In 2019, the Long Term Plan committed to providing continuity of carer for 75% of women from Black, Asian and minority ethnic communities and those from the most deprived backgrounds. In oral evidence, Professor Dunkley-Bent told us that there were 165 midwifery continuity teams placed in areas “where many black, Asian or mixed-race ethnicity women are currently living”, and that there were 214 teams placed in areas of deprivation.
133.Although this represents good progress, the skill set and expertise of those midwives was equally important. Atinuke Awe told us that it needed to be “the right midwife and set of midwives”. As an example, she told us that if the midwife did not know the statistics and poor outcomes for black women the care provided would not address those inequalities.
134.Professor Knight agreed. She told us that the “crucial thing” was that the group of midwives had “the right expertise”. Without that, continuity of carer would not make the difference it was intended to deliver. In conclusion, she stressed to us that it could not be a “one size fits all” approach. One of our attendees at the roundtable also highlighted the importance of this:
It needs to prioritise more vulnerable people to begin with because the barriers and the trust that needs to be built up there is extremely important. But the staff also need to be completely competent and be trained to the level where they can give it. They need to understand the biases that they carry and also their lack of knowledge around informed consent. [Midwife]
135.The Government has committed to ‘the majority of women’ benefiting from continuity of carer by 2021. Our Expert Panel assessed progress delivering the continuity of carer model (Box 4). The Expert Panel overall rated progress against this commitment as ‘Requires Improvement’, stating:
This is an important commitment with a strong evidence base. Effort has been directed towards achieving this target, but lack of clarity over its definition, lack of reliable data collection method to evidence progress, and lack of clear resources and organisational support for its implementation has made it difficult to evidence and achieve. Continuity of Carer represents a major change to maternity systems and services and further support is required to ensure Trusts are enabled to successfully manage this scale of organisational change. [Expert Panel]
Box 4: Expert Panel CQC-style Ratings–Continuity of Carer
Continuity of Carer: The majority of women will benefit from the ‘continuity of carer’ model by 2021, starting with 20% of women by March 2019. By 2024, 75% of women from BAME communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period.
Overall: Requires Improvement
Further analysis can be found in the Expert Panel’s independent report: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England.
136.England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements. However, the Expert Panel overall rated the Government’s progress on maternity safety outcomes as ‘Requires Improvement’. The Expert Panel highlighted that the Government’s commitment to halve the rate of stillbirths, neonatal deaths, brain injuries and maternal deaths is not currently achieving equitable outcomes, with women and babies from minority ethnic and socio-economically deprived backgrounds at greater risk when compared to their white or less deprived peers. We acknowledge the positive steps the Department and NHS England and Improvement have taken, including the commitment to continuity of carer for 75% of women from Black, Asian and minority ethnic groups. We support the principles of the continuity of carer model but conclude that further work is required to ensure it can be implemented in a sustainable manner. The Expert Panel overall rated progress towards delivering continuity of carer as ‘Requires Improvement’. Continuity of carer alone is also unlikely to resolve the deep seated and long-standing inequalities persisting in maternal and neonatal outcomes.
137.Having the right skill set, as noted above, is crucial for the successful implementation of continuity of carer. We therefore recommend that those involved in delivering this model have received appropriate training and that all professionals are competent and trained in all areas that they work in, particularly in relation to Black mothers where the disparities are the greatest.
138.Given the underlying causes of these outcomes for women from Black, Asian and minority ethnic groups relate to a range of issues beyond the remit of the Department, we recommend that the Government as a whole introduce a target to end the disparity in maternal and neonatal outcomes with a clear timeframe for achieving that target. The Department must lead the development of a strategy to achieve this target and should include consultation with mothers from a variety of different backgrounds.
139.During pregnancy all women have a scan at 12 and 20 weeks. Women with additional risk factors may also be offered additional scans throughout their pregnancy. However, there is a body of opinion that an additional routine scan in the 3rd trimester could improve outcomes for babies. Professor Gordon Smith, Professor of Obstetrics and Gynaecology at the University of Cambridge, told us that introducing a routine scan at 36 weeks could allow for the detection of breech pregnancy earlier, preventing emergency c-sections or high-risk breech vaginal deliveries. Professor Smith explained that while midwives routinely performed palpation to determine whether the baby was headfirst or otherwise, that procedure detected only between 50% to 70% of non-cephalic presentation. For the remainder, the woman loses the opportunity to consider external cephalic versions (where the baby is turned) or discuss a planned caesarean section or a planned vaginal breech birth. Professor Smith told us “there isn’t a research question left, other than the best way to implement it”.
140.A 3rd scan has the potential to identify other risk factors for stillbirths. However, further research is required to prove the clinical usefulness of a 3rd scan for those risk factors. In March 2021, the UK National Screening Committee considered the addition of a 3rd scan for breech presentation.
141.We were pleased to hear that the UK National Screening Committee believed that the current evidence for a 3rd trimester breech presentation scan “looks promising” and may be a “suitable candidate for a screening programme once further research had been published in the coming years”.
142.Group B Streptococcus (GBS) is the most frequently identified cause of severe infection in newborns. On average, at least one baby a week in the United Kingdom dies from GBS infection, and 70 babies a year are left with lifelong disabilities as a result of contracting meningitis or sepsis in their first days of life.
143.In 2017, updated guidelines stipulated that all women should receive information about GBS, the use of Enriched Culture Medium (ECM) where testing was recommended, and identified women who should be offered antibiotics during labour. However, a recent report found 20% of trusts had not updated their local guidelines since 2017 and the majority were using the wrong swab and lab methods for testing for GBS. The Minister of State for Patient Safety, Suicide Prevention and Mental Health, told us that she was aware of these shortcomings and that she had written to the CEOs of all trusts on the matter making clear that trusts “ensure that they are using the ECM testing as of the moment they receive the letter”.
144.Screening for GBS in pregnancy is not currently recommended for all women. However, in 2019, new research investigating the use of universal screening compared to current risk based testing was announced, and the UK National Screening Committee will review its recommendation on screening after that research trial has concluded.
145.Pregnancy and childbirth are normal, physiological processes. Moreover, they can be a time of unprecedented joy. But they are not without risk both to mother and to baby, and skilled support and intervention from maternity services are often required. In the UK, nearly 40% of women giving birth have an instrumental delivery or caesarean section. For first-time mothers this rises to 50%.
146.The report of the Morecambe Bay investigation describes the “pursuit of normal childbirth ‘at any cost’” Similar themes have emerged from the interim Ockenden report into Shrewsbury and Telford. When she came before us, Donna Ockenden said that the review had:
Spoken to hundreds of women who said to us that they felt pressured to have a normal birth […] at that trust, there was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.
147.This alone was not responsible for the tragedies that occurred, it was one amongst a constellation of other failings at these units. Our expert witnesses told us that these very badly failing units should not be taken as an indication that such problems are widespread. However, we were shocked to hear from Clotilde Rebecca Abe that a mum she supported was made to feel like a failure by her midwife, because she opted for a caesarean section. Clotilde told us that the woman “felt like a failure because she felt that she had let the midwife down”. ‘Anecdotal evidence like this suggests that, in some cases at least, there is still clinician-led pressure for women to choose vaginal delivery, even when this may not be in their best interests.
148.Michelle Hemmington simply and eloquently argued that rather than the method of delivery, the outcome of the birthing process must be the focus, with all professionals working together:
Consultants, registrars, and midwives all need to be working together and to be joined up. At the end of the day, the outcome is to have a safe, healthy, positive experience of birth and to come home with a baby. They should all be working together to achieve that.
149.The midwives we heard from—including England’s most senior midwife, Professor Jacqueline Dunkley-Bent, told us that it was “not in a midwife’s DNA” to support normal birth at any cost. Donna Ockenden told us that the pursuit of normal childbirth was not a midwifery issue, but was a multi-professional issue ingrained in the culture of both obstetricians and midwives at Shrewsbury and Telford. The obstetricians we heard from were equally emphatic that any ideology-driven practice that prioritised normal childbirth above safety had to be “wiped out”.
150.Instead, we heard that personalised care, shaped to a woman’s own risks and situation, and that can be adapted quickly if situations change, was the best policy. Dr Bill Kirkup, explained this approach to us:
There is a slightly simplistic view that there is only one lever we can pull: either lots of intervention and it is safe, or much less intervention and it is a normal birth but it is not safe […] That is too much of an oversimplification. People sometimes describe the debate, and try to frame the debate, in those terms. I think there are multiple levers; we can have lots of appropriate normal births, and we can also have a safe service provided that we do the right things to maintain surveillance of the service and make sure that we give safe care as well as appropriate care.
151.Professor Baker, Chief Inspector of Hospitals, Care Quality Commission, agreed that care needed to be “individualised” and that the woman’s “needs and her risks” had to be taken into account. Furthermore, he said that each woman needed to be given advice to make the right decisions for herself and not be told “you have to do it this way or that way.” Professor Baker explained it in the following terms:
She should be given the choice and understanding how to do it … The sense of normality against intervention, as if you have to choose one or the other, is nonsense. You have to have what is right for you under the circumstances. When the risk changes, the service needs to be able to escalate care rapidly to make sure that you get consistent and safe care.
152.In a similar vein, Dr Jolly, National Clinical Director for Maternity and Women’s Health at NHSE&I, told us that “different women have different agendas about what they want to do” and that their views needed to be respected. He explained that the job of the clinician was “to do the best possible risk assessment, communicate clearly and respect women’s autonomy”.
153.At our roundtable, we heard from one clinician that they had worked in a place where an “antagonistic atmosphere” did exist between different professions, with doctors’ ID cards not allowing them into certain parts of the unit without permission. However, we were encouraged to hear that majority of attendees had not experienced a culture that promoted ‘normal birth’ at the expense of safety:
In my experience in the trust I’ve been in, it’s actually quite the opposite […] I’ve not found that at all. It’s usually the women pushing for the normal births in a lot of circumstances and it’s the staff—not that they push for caesareans but […] it kind of comes into the defensive practise thing, they’re frightened of things going wrong with vaginal births in what is probably outside of their comfort zone so they try and get the women to have a caesarean. [Midwife]
I haven’t come across it; I haven’t seen it exist. [Midwife]
This is something I’ve not come across at all in my training […] people putting so-called normality above safety. [Midwife]
There is overwhelming evidence that a physiological birth benefits women and babies and there isn’t as far as I’m aware an ideology that promote this to the detriment of women. There shouldn’t be. If women need interventions, we should be there intervening, absolutely straight away, we shouldn’t be delaying. [Midwife]
154.Instead, our attendees highlighted the pressures of the wider community, social media, and antenatal classes as contributing to “a big expectation of normality” amongst expectant parents, who, in their view, were often given insufficient information about many aspects of their pregnancy and labour:
I think that we have to look at the wider community and in particular social media to look at what images are produced across that and the impact that has on women’s expectations. I think there’s a big expectation around normality, there’s an expectation that it will all go well, and going back to the role that the midwife has to play in the antenatal period in terms of managing expectations and being clear about what the women wants. [Midwife]
The difficulties that I’ve experienced is certainly around parental ideology and expectation around what their birth is going to be. I think there is a benefit to knowing what you would like to have for your birth, and what the options are if you have the choice, but there really needs to be an emphasis on mother and baby coming out of this in the healthiest way possible. If physiological birth is the way, and it can happen, then that’s fantastic but it’s not a failure if it can’t. And the fact that, particularly in antenatal classes, sometimes there isn’t the awareness there of what can go wrong, what will happen if things don’t go exactly optimally and actually having the healthy mother and baby at the end of it is a success. [Paediatric Trainee Doctor]
I think with respect to normal birth ideology, I think there are very few women who aren’t holding out for a completely physiological birth. Almost everyone wants that, and the problem is not I don’t think generally midwives […] of course when things are getting tetchy they would call us. The problem is that the women have read online, and gone to NCT, and been exposed so much about how important a physiological birth is, which doesn’t really need to be underlined. Most people know that they don’t want to be in hospital, and they don’t want drips and these horribly invasive things and that’s underlined at the cost of the other things […] teaching people to be flexible and teaching people what could happen is very important at any stage. [O&G Trainee Doctor]
155.We heard the IDECIDE tool is being developed to establish better choice and consent procedures to ensure that women have access to full and unbiased evidence about the risks associated with C-sections and other interventions and also with physiological vaginal birth. Gill Walton, Chief Executive, Royal College of Midwives, told us:
The most important thing is that when women are making choices, whether it is a home birth or a caesarean section, they understand clearly the risk and benefits of those choices, because there are risks and benefits in all choices.
156.However, the RCM cautioned that making time and space to educate women and families about their choices and the risks and benefits takes clinical time and resources. The RCM explained that the ability to provide the necessary education and advice depended on having “enough workforce, enough midwives and enough obstetricians to make sure that we can have conversations with women, from an early stage, around informed choice and what their options are”. In particular, when women attended antenatal clinics, they would often see midwives that were “harassed and overworked” and as a result were reticent to ask all the questions they wanted answering. Gill Adgie, stressed that to overcome this it was vital to have “enough staff in the right places and enough time to be able to have those conversations with women”.
157.A clinician at our roundtable explained the difficulties of trying to discuss these things in a pressurised situation:
I’m very much of the opinion that women need to have all of the options laid on the table. To try and explain forceps to a woman in the last ten minutes of her labour can be really traumatic sometimes for us, and for them. [O&G Trainee Doctor]
158.As well as the mode of delivery, pain relief during labour is an essential component of safe, personalised care. However, we heard that this does not always happen. Atinuke Awe told us that her pain was not taken seriously, and she was “left for hours without any pain relief”.
159.The Expert Panel chose personalisation as a key policy to examine (Box 5). The Expert Panel overall rated progress towards personalised care as ‘Inadequate’, stating:
This is an important aspiration and is likely to improve safety and satisfaction for women. However, there has been inadequate consideration of ways to mitigate potential barriers to impactful care planning. PCSPs represent a significant change in workplace culture and aim to empower women as lead decision makers in their own care. However, lack of clarity about how plans will be used to inform service delivery planning has resulted in PCSPs becoming a potentially time-consuming tick box exercise. [Expert Panel]
Box 5: Expert Panel CQC-style Ratings–Personalised Care
Personalised care: All women to have a Personalised Care and Support Plan (PCSP) by 2021.
Further analysis can be found in the Expert Panel’s independent report: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England.
160.During our evidence session on patient choice, we heard that the collection of central data on Caesarean section (C-section) rates, and the “penalisation” of maternity units with high rates, had the potential to act as a perverse incentive to reduce C-section rates to the detriment of safety. Dr Daghni Rajasingam, Consultant Obstetrician and Deputy Medical Director at Guys and St Thomas’ Hospital NHS Foundation Trust, explained to us that on the one hand, she wanted to give every woman the choice to have a caesarean section, if that is what she chooses. On the other hand, however, as head of service in her directorate, she was penalised doing so. She described the caesarean section rate as a whole as “one of the key parameters and metrics that we look at” but that it was not intelligent data:
Every caesarean section that we do contributes to our caesarean section rate. […] We absolutely need to look at caesarean section rates but in a much more intelligent way, using the Robson criteria. If you remove the broad caesarean section rate, you enable clinicians to have a very different conversation with women wanting to explore that.
161.Gill Walton of the Royal College of Midwives agreed that this was not appropriate. She told us “for some time, services were performance managed on things like their caesarean section rates and their forceps and ventouse rates, and were penalised when they went up” and should be replaced with “the right targets for maternity services, promoting a woman-centred approach that is about good birth”.
162.In his oral evidence, Dr Matthew Jolly, noted the importance of monitoring C-section rates but stated that they should not be used to “performance-manage” trusts. He told us that the NHS had not used C-section rates as a performance metric “for many years” but acknowledged that witnesses to our inquiry perceived that it was happening. In response to that perception he said that the NHS needed to “work hard to stop that”.
163.In relation to current monitoring of trusts, Dr Jolly explained that in January 2021, the NHS introduced a national maternity dashboard that included 14 clinical quality approved metrics on which trusts were assessed. Three of these are based around the Robson criteria. Dr Jolly explained to us that the dashboard was used to divide trusts into quartiles:
If you are at one extreme, you need to have a conversation and think about why you are there […] It is all about using the data to create a better understanding of our maternity services, so that we can reflect and improve.
164.The central aim of maternity services must be to achieve, in the words of Michelle Hemmington, “a safe, healthy, positive experience of birth and to come home with a baby”. And yet, during the course of this inquiry, we heard of women who were made to feel like a failure for having a Caesarean Section. We have heard clear agreement among those working in maternity services, that “the only birth is a safe birth”, and we challenge all those working in leadership positions in maternity services in NHS England and Improvement, the Royal Colleges, and individual services, to take action to enshrine that ideology at the heart of England’s maternity services. Furthermore, those organisations need to work hard to stamp out the damaging ideological focus on “normality at any costs”, which caused such huge loss and suffering at Morecambe Bay and Shrewsbury and Telford - and may exist in other trusts today. We heard that senior leaders in maternity services no longer use the term ‘normal birth’ and we urge an end to the use of this unhelpful and potentially damaging term.
165.The Expert Panel overall rated the Government’s progress towards providing personalised care as ‘Inadequate’. We believe that personalisation must go hand in hand with safety and women must be fully and impartially informed about the safety risks associated with all birthing options. Women should also be provided with clear information about the likelihood of interventions.
166.Timely and appropriate pain relief is also an essential part of safe and personalised care, and we believe that every woman giving birth in England should have a right to their choice of pain relief during birth, in line with clinical advice on what would be safest for them and their baby.
167.We recommend that NHS England and Improvement establish a working group comprising of women and their families, organisations providing support for women throughout their pregnancy and clinicians to develop a set of actions for maternity services to consider in order to ensure no woman feels pressured to have a vaginal delivery and is always informed clearly what the safest option is for her birth. The working group’s remit should also include researching and addressing the wider societal factors, including media and social media, that put pressure on women to want to have an unassisted birth.
168.It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is replaced by using the Robson criteria to measure Caesarean Section rates more intelligently. NHS England and Improvement must write to all maternity units to ensure that they are aware of this change.
149 Atinuke Awe
151 Atinuke Awe
152 Joint Committee on Human Rights, , November 2020
153 Professor Jaqueline Dunkley-Bent
154 Examples include: Sands UK (), Birth Trauma Association (), Royal College of Obstetricians and Gynaecologists, Royal College of Midwives (),Nursing and Midwifery Council (), Care Quality Commission (), The Shelford Group (), Maternity Action (), The Health Foundation (), East & North Herts NHS Trust (), Group B Strep Support (), HealthWatch England (), Soo Downe OBE, Lesley Page CBE, Mary Renfrew, Helen Cheyne, Billie Hunter CBE, Jane Sandal CBE, Helen Spiby (), Manchester University NHS Foundation Trust (), Association for Improvements in the Maternity Services (AIMS) ()Mrs Caroline Flint (), Birthrights (), Action against Medical Accidents () DISCERN research team ()
155 Birthrights ()
156 Daghni Rajasingam
157 Marian Knight
158 , 2019
159 Marian Knight
160 Matthew Jolly
163 Marian Knight
164 Marian Knight
165 Jaqueline Dunkley-Bent
166 Jaqueline Dunkley-Bent
167 Manchester University NHS Foundation Trust ()
168 The Shelford Group ()
169 Clotilde Rebecca Abe
170 , January 2021
171 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], page 6
172 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], pages 13–36
173 NHS England, , 2017
174 NHS England, , 2017
175 NHS England, , 2017
176 Jaqueline Dunkley-Bent
177 Jaqueline Dunkley-Bent
178 Jaqueline Dunkley-Bent
179 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5
180 Donna Ockenden
181 , 2020
182 Marian Knight
183 Marian Knight
184 Health and Social Care Committee, , January 2021
185 Jo Mountfield
186 Independent, , April 2021
187 Health and Social Care Committee, , January 2021
188 Health and Social Care Committee, , January 2021
189 Niamh Maguire
190 Clotilde Rebecca Awe
191 Donna Ockenden ()
192 Donna Ockenden ()
193 Minister of State for Patient Safety, Suicide Prevention and Mental Health, Department of Health and Social Care
194 Minister of State for Patient Safety, Suicide Prevention and Mental Health, Department of Health and Social Care
195 Minister of State for Patient Safety, Suicide Prevention and Mental Health, Department of Health and Social Care
196 Minister of State for Patient Safety, Suicide Prevention and Mental Health, Department of Health and Social Care
197 NHS England, , 2019
198 Jaqueline Dunkley-Bent
199 Atinuke Awe
200 Marian Knight
201 Marian Knight
202 Health and Social Care Committee, , January 2021
203 NHS England, , 2017
204 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], page 6
205 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], pages 5; 37–51
206 Wastlund D, Moraitis AA, Dacey A, Sovio U, Wilson ECF, Smith GCS. Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis. PLoS Med. 2019 Apr 16;16(4):e1002778. doi: 10.1371/journal.pmed.1002778. PMID: 30990808; PMCID: PMC6467368.
207 Gordon Smith
208 Gordon Smith
209 Gordon Smith
210 Gordon Smith, Edward Morris
213 Minister of State for Patient Safety, Suicide Prevention and Mental Health
214 Royal College of Obstetricians and Gynaecologists,
215 Minister of State for Patient Safety, Suicide Prevention and Mental Health
217 Department of Health and Social Care,
218 Minister of State for Patient Safety, Suicide Prevention and Mental Health
219 National Maternity and Perinatal Audit, This represents the proportion of women birth giving birth to a singleton baby at term who required an instrumental birth (including forceps or ventouse) or caesarean birth (elective or emergency).
220 National Maternity and Perinatal Audit,
221 , 2015
222 Donna Ockenden
223 Edward Morris; Bill Kirkup
224 Clotilde Rebecca Abe
225 Michelle Hemmington
226 Jacqueline Dunkley-Bent
227 Donna Ockenden
228 Edward Morris
229 Bill Kirkup
230 Ted Baker
231 Ted Baker
232 Ted Baker
233 Matthew Jolly
234 Health and Social Care Committee, , January 2021
235 Health and Social Care Committee, , January 2021
236 Health and Social Care Committee, , January 2021
237 Health and Social Care Committee, , January 2021
238 Health and Social Care Committee, , January 2021
239 Health and Social Care Committee, , January 2021
240 Health and Social Care Committee, , January 2021
241 Health and Social Care Committee, , January 2021
242 , Matthew Jolly, Jaqueline Dunkley-Bent
243 Gill Walton
244 Gill Adgie
245 Gill Adgie
246 Gill Adgie
247 Health and Social Care Committee, , January 2021
248 Atinuke Awe
249 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], page 6
250 The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, 5 July 2021, HC 18 [report], pages 5; 52–62
251 Daghni Rajasingam
252 Daghni Rajasingam
253 Gill Walton
254 Matthew Jolly
255 Matthew Jolly
256 Matthew Jolly