There has been a lot going on for UK Maternity services, though you may not have been aware of the news with all going on in the Middle East, the Ukraine and the weather! Neil Stewart, Editorial Director for the Maternity and Midwifery Forum, presents and reflects on a very difficult week.

_________________________________________________

It is hard to think of a week, 12 – 20 October 2023, that has been worse for the reporting of maternity services.

The headlines may have been bigger when Donna Ockenden reported on the outcome of her review into Shrewsbury and Telford or previous inquiries into East Kent or Morecambe Bay.

The terrible news from the Middle East has, however, obscured a series of reports and events that, cumulatively, for maternity and midwifery services, must be one of the worst for the standing of the NHS maternity service.

Three events in 8 days paint a picture of a service under stress, going backwards, losing women’s trust and finally judged “inadequate” in a majority of maternity services.

 

“Maternal mortality has increased by 15% since 2009-11”  

 

First there was the latest MBRRACE-UK Report 2023

“The Government’s ambition in England was to reduce maternal mortality by 50% between 2010-2025. This target is unlikely to be met. Since 2009-11, maternal mortality has increased by 15%.

• Deaths from direct causes (such as childbirth-related infections or suicide) have increased.
• For conditions such as pre-eclampsia, the rates remain more than five times higher than the lowest rate in 2012-14.
• Women from Black ethnic backgrounds remain four times more likely to die, and women from Asian ethnic backgrounds are twice as likely to die, compared to White women.
• Suicide is the leading direct cause of death between 6 weeks and 12 months after the end of pregnancy.
• Women living in the most deprived areas continue to have the highest maternal mortality rate compared to those living in the least deprived areas.
• Twelve percent of women who died during or up to a year after pregnancy in the UK in 2019-21 had multiple severe disadvantages.”

 

Postnatal care

“Over 300 women died in the 12 months after pregnancy. The focus of maternity care needs to extend beyond pregnancy and childbirth. Postnatal care is an important window of opportunity, yet services are currently not joined up; the focus on the mother’s health often falls away and women lack the support they need. This report highlights the importance of improved multi-disciplinary and multi-agency working to include GPs, health visitors, domestic abuse and substance misuse services, mental and public health teams and social care.”

These quotes above speak for themselves.

 

“These results are shocking” – Theo Clarke, MP

 

Second came a debate on Birth Trauma in the House of Commons on Thursday 19^th October, tabled by Theo Clarke, the Conservative MP for Stafford. 

 

In her introduction she said:

“I spent over two hours awake without a general anaesthetic, I could hear them talking about me, and obviously it was not looking good. It was the most terrifying experience of my life.

I remember being wheeled into the recovery ward after surgery, where I encountered a nurse who had not read her notes and assumed that I had had a C-section. I was then moved to a side room, where I was hooked up to a catheter and a drip and was lying in bed next to my baby, who was screaming in her cot. I could not pick her up. I pressed the call button for help and a lady came in and said, “Not my baby; not my problem,” and left me there.

I partnered with Mumsnet—the online forum for mothers—to conduct a national birth trauma survey, given the lack of data. Our survey received 1,042 responses. The key results showed that 53% experienced physical trauma; 71% experienced psychological or emotional trauma; 72% said that it took more than a year to resolve; 84% who experienced tears said that they did not receive information about birth injuries ahead of time; and 32% experienced notes not being passed on between shifts. These results are shocking,..

Today I call on the Government to add birth trauma to the women’s health strategy; recruit more midwives; ensure perinatal mental health services are available across the UK; provide appropriate and mandatory training for midwives with a focus on both mental and physical health; ensure that the post-natal six-week check with their GP is provided to all mothers and will include separate questions on both the mother’s physical health and her mental health in relation to the baby; improve our continuity of care so there is better communication between secondary and primary health care, including explicit pathways for women in need of support; provide post-birth services nationally, such as birth reflections, to give mothers a safe space to speak about their experiences in childbirth; roll out the obstetric anal sphincter injury care bundle to all hospital trusts in England to reduce the risk of injuries in childbirth; provide better support for partners and fathers; and, finally, have better education for women on their birth choices and on risks in order to ensure informed consent.”

It is a list of reform that most in midwifery and maternity services would support. Yet, many localities would report that these services are a long way from available and many are squeezed out by lack of midwives, lack of time and pressure on the service.  It is worth remembering that one of the consequences of Ockenden was an attempt in many localities to put a pause on “continuity of care” which women see as the key to better and safer care.

 

“65% of maternity services are rated “inadequate”

 

Third came the newspaper reports that the CQC report on Friday 20^th found  that 65% of maternity services were rated “inadequate”.

But that is not what the actual report says, it reflects the tendency to believe the worst of maternity services in the current media narrative.

The actual reported figures are below.

 

Source: CQC ratings data, 31 July 2022 and 7 September 2023
Note: Percentages may not add to 100 due to rounding

There is no doubt these figures are going the wrong way.  They also only represent 73% of units being inspected so someone may be doing some creative rounding up to create the 65% figure up from the last media report of 48%.

If you add the “inadequate” to the “requires improvement”, you come to 49%. But the picture is not good. In each of the main categories the numbers are going in the wrong direction. But what are the causes for these ratings? They are not all clinical delivery unit safety as the public might think. They include governance, whether there is board supervisions and engagement.

There is leadership, whether there are management processes in place, including many recommended by Ockenden, which may not have been completed.  A large number of the points in the report relate to staff wellbeing, reports of stress and staff shortages which midwives will be familiar with, highlighting how these have often led to units being closed or declared full and women being sent elsewhere.  Plus, as in other reports, the increasing focus is on the problems in post-natal care up to the first year, not just first 6 weeks.

 

Who would want to run a Maternity Unit today?

As anyone working in schools and education will know, the rating systems often do not reflect what happens just in the classroom but they will also tell you of the  devastating impact on parental trust when terms like ‘inadequate’ or ‘requires improvement’ are used about a school.

Parents hear “failing my kids” which then often undermines the ability of schools to attract the staff and leadership commitment to put things right.

There have always been enough midwifery leaders who were prepared to step up to the Head of Midwifery role to turn units around.  But how many will want to do that if so many of the inspection factors are out of their control but the overarching stigma of “inadequate” or “require improvement” can blight the top of a great career?

This is not an academic question.  There is now a growing recognition in education at both school and university level that some of the most talented leaders are opting not to take the top jobs of headteacher or vice chancellor, something unthinkable 20 years ago, but choose to go and find their passion in senior teaching or research roles and see out their career on a positive experience.

This is called the David Attenborough option.  As a rising star of the BBC in the 1960s, David Attenborough had stepped up from nature reporting into management, launched BBC 2 and colour television and was everyone’s obvious choice for the next Director General of the BBC. But, even back then, the job was becoming toxic and he decided not to take it but to follow his passion in natural history at BBC Bristol, for which we have all been greatly rewarded.

But we can’t all be David Attenborough and many would have contributed more by taking that leadership role, but when the reputation and personal stress risks become too high many will not step up.

We can only hope that enough of the best of midwifery continue to step up into the top leadership roles and one thing the CQC could look at in its next review of governance is whether the midwifery voice is really heard at the top table, is there a chief midwife in the unit at top management and board level?

Remember, in the East Kent case it was revealed that several years before the head of midwifery had said the unit was unsafe and should probably be closed.  She was ignored, but when the report came out, midwifery got the blame.

Neil Stewart

Editorial Director

Maternity and Midwifery Forum | MATFLIX

October 2023